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org APRIL-JUNE 2016


Critical Care
Evaluation of Pain Assessment Tools in Patients
Receiving Mechanical Ventilation
Factors Related to Successful Transition to
Practice for Acute Care Nurse Practitioners
Implementing a Mobility Program to Minimize
Post–Intensive Care Syndrome
A Clinic Model: Post–Intensive Care Syndrome
and Post–Intensive Care Syndrome-Family
Developing a Diary Program to Minimize
Patient and Family Post–Intensive Care
Peer Support as a Novel Strategy to Mitigate
Post–Intensive Care Syndrome

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Co n t e n t s

1 6 2 Evaluation of Pain Assessment Tools in Patients Receiving Mechanical

Zainab Q. Al Darwish, Radwa Hamdi, and Summayah Fallatah

1 7 3 Factors Related to Successful Transition to Practice for Acute Care Nurse

Deborah L. Dillon, Mary A. Dolansky, Kathy Casey, and Carol Kelley

Judy E. Davidson, RN, DNP, and Maurene A. Harvey, MPH,
Symposium Editors

1 8 4 Introduction: Patient and Family Post–Intensive Care Syndrome

Judy E. Davidson and Maurene A. Harvey

1 8 7 Implementing a Mobility Program to Minimize Post-Intensive Care

Ramona O. Hopkins, Lorie Mitchell, George E. Thomsen, Michele Schafer,
Maggie Link, and Samuel M. Brown

2 0 4 A Clinic Model: Post–Intensive Care Syndrome and Post–Intensive Care

Elizabeth L. Huggins, Sarah L. Bloom, Joanna L. Stollings, Mildred Camp,
Carla M. Sevin, and James C. Jackson

2 1 2 Developing a Diary Program to Minimize Patient and Family Post–Intensive

Care Syndrome
Meaghan Locke, Sarah Eccleston, Claire N. Ryan, Tiffany J. Byrnes,
Cristin Mount, and Mary S. McCarthy

2 2 1 Peer Support as a Novel Strategy to Mitigate Post–Intensive Care Syndrome

Mark E. Mikkelsen, James C. Jackson, Ramona O. Hopkins, Carol Thompson,
Adair Andrews, Giora Netzer, Dina M. Bates, Aaron E. Bunnell, LeeAnn M. Christie,
Steven B. Greenberg, Daniela J. Lamas, Carla M. Sevin, Gerald Weinhouse, and
Theodore J. Iwashyna


1 3 3 Drug Update
Medication Management to Ameliorate Post–Intensive Care Syndrome
Joanna L. Stollings, Sarah L. Bloom, Elizabeth L. Huggins, Scottie L. Grayson,
James C. Jackson, and Carla M. Sevin

1 4 1 Technology Today
Analytics 1.0, 2.0, 3.0
Linda Harrington

1 4 5 Issues in Advanced Practice

Strategies for Success: Cultivating Emotional Competence in the
Clinical Nurse Specialist Role
Elizabeth Kozub, Leah Brown, and Laurie Ecoff

1 5 2 Creating a Healthy Workplace

Shared Governance for a Healthy Work Environment in a Pediatric
Cardiothoracic Intensive Care Unit
Nida Sulit Oriza, Victoria Winter, and Flerida Imperial-Perez

1 5 8 Pediatric Perspectives
Impact of Family-Centered Care on Pediatric and Neonatal Intensive
Care Outcomes
Lori Williams

2 3 0 Clinical Inquiry
Overcoming Barriers to Using Patient-Reported Outcomes for
Clinical Inquiry
Maria Javier, Jae Youn Kim, Ellie Toone, and Bradi B. Granger

2 3 6 Ethics in Critical Care

The Ethics of Post–Intensive Care Syndrome
Judy E. Davidson and Karen Stutzer

2 4 1 ECG Challenges
2015 Advanced Cardiac Life Support Updates and Strategies for
Improving Survival After Cardiac Arrest
Gerard B. Hannibal
A d v a n c e d
Cr i t i c a l Ca r e
Mary Fran Tracy, RN, PhD, CCNS
Minneapolis, Minnesota

Earnest Alexander, PharmD Cynda Hylton Rushton, RN, PhD

Assistant Director for Pharmacy Services Anne and George Bunting Professor of Clinical Ethics
Department of Pharmacy Services Professor of Nursing and Pediatrics
Tampa General Hospital, Tampa, Florida Program Director, Harriet Lane Compassionate Care
Johns Hopkins University
Richard Arbour, RN, MSN, CCRN, CNRN, CCNS Berman Institute of Bioethics, Baltimore, Maryland
Liver Transplant Coordinator
Thomas Jefferson University Hospital Christine Schulman, RN, MS, CCRN, CNS
Philadelphia, Pennsylvania Consultant in Trauma and Critical Care Nursing
Portland, Oregon
Nancy Blake, RN, PhD, CCRN, NEA-BC
Director, PCS Critical Care Services Mary Lou Sole, RN, PhD, CCNS
Children’s Hospital Los Angeles Dean and Professor, College of Nursing
Valencia, California University of Central Florida, Orlando, Florida
Elizabeth Bridges, RN, PhD, CCNS Karen Stutzer, PhD, RN, APN-C
Biobehavioral Nursing and Health Systems, University of Washington Assistant Professor of Nursing
Seattle, Washington College of St. Elizabeth
Morristown, New Jersey
Denise Buonocore, RN, MSN, CCRN, ACNP-BC
Heart Failure Service, St. Vincent’s Medical Center Gregory M. Susla, PharmD
Bridgeport, Connecticut Associate Director of Medical Information
Medimmune, Inc, Rockville, Maryland
John Gallagher, RN, MSN, CCRN, CCNS, RRT
Clinical Nurse Specialist/Trauma Program Coordinator Lori Williams, RN, DNP, RNC-NIC, CCRN, NNP-BC
Hospital of the University of Pennsylvania Clinical Nurse Specialist, Universal Care Unit
Philadelphia, Pennsylvania American Family Children’s Hospital
University of Wisconsin Hospital and Clinics, Madison, Wisconsin
Bradi B. Granger, RN, PhD
Associate Professor, Duke University School of Nursing
Director, Heart Center Nursing Research Program American Association of Critical-Care Nurses
Associate Director, Duke Translational Nursing Institute Editorial Office
Durham, North Carolina
Publishing Manager Michael Muscat
Gerard B. Hannibal, RN, MSN, PCCN Managing Editors Melissa Jones, PhD
Staff Nurse, Progressive Care Unit
The Louis Stokes Cleveland Department of Veterans Affairs Medical Center
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Serena Phromsivarak Kelly, RN, MS, CCRN, FNP-BC Senior Publishing Associate Sam Marsella
Nurse Practitioner, Pediatric Critical Care
Oregon Health & Science University Statement of Purpose
Portland, Oregon
AACN Advanced Critical Care is a quarterly, peer-
Mary Beth Flynn Makic, RN, PhD, CNS, CCNS reviewed publication of in-depth articles intended for
Associate Professor experienced critical care and acute care clinicians at
University of Colorado College of Nursing, Anschutz Medical Campus the bedside, advanced practice nurses, and clinical and
Aurora, Colorado
academic educators. Each issue includes a topic-based
Patricia Gonce Morton, RN, PhD, ACNP-BC symposium, feature articles, and columns of interest to
Dean and Professor, Louis H. Peery Endowed Chair critical care and progressive care clinicians.
University of Utah College of Nursing AACN Advanced Critical Care contains concisely
Salt Lake City, Utah
written, practical information for immediate use and
Carol Rauen, RN, MS, CCNS, CCRN, PCCN, CEN, RN-BC future reference. Self-paced continuing nursing
Independent Critical Care Clinical Nurse Specialist & Education Consultant education units are available for selected articles in
The Outer Banks, North Carolina each issue.
AACN Advanced Critical Care
Volume 27, Number 2, pp. 133-140
© 2016 AACN

D Update
r u g Earnest Alexander, PharmD, and
Gregory M. Susla, PharmD
Department Editors

Medication Management to Ameliorate

Post–Intensive Care Syndrome
Joanna L. Stollings, PharmD, BCPS
Sarah L. Bloom, AG-ACNP
Elizabeth L. Huggins, AG-ACNP
Scottie L. Grayson
James C. Jackson, PsyD
Carla M. Sevin, MD

M ortality rates of critically ill patients have decreased markedly in recent

years thanks to advancements in care.1 Given the improved survival
rates of critically ill patients, investigators have broadened their focus from
short-term mortality to long-term mortality and morbidities that are often
underrecognized by intensive care unit (ICU) practitioners. The Society of
Critical Care Medicine (SCCM) has defined post–intensive care syndrome
(PICS) as a new or worsening decrement in mental, cognitive, or physical
health following critical illness that persists beyond the acute hospitalization.2
Many medication-related risk factors are associated with development of
cognitive impairment in critically ill patients, including glucose dysregulation,3,4
delirium,5 and medications.6 Medications have also been associated with acute
neuromuscular weakness following an ICU admission.7 In the past decade,
the increased risk of adverse drug events (ADEs) during transitions of care
has become widely known. This column focuses on how medication manage-
ment strategies in the ICU, after the ICU, and after hospitalization may prevent
or help manage PICS.

In the ICU
Glucose Dysregulation
Both hyperglycemia and hypoglycemia are associated with cognitive dys-
function in critically ill patients. Hyperglycemia decreases cerebral blood flow,
Joanna L. Stollings is Clinical Pharmacy Specialist in the Medical Intensive Care Unit (MICU) and Pharma-
cist in the ICU Recovery Center, Department of Pharmaceutical Services, Vanderbilt University Medical
Center, 1211 Medical Center Drive, BUH-131, Nashville, TN 37232 (
Sarah L. Bloom is Acute Care Nurse Practitioner in the MICU and the ICU Recovery Center, Department
of Medicine, Vanderbilt University Medical Center.
Elizabeth L. Huggins is Acute Care Nurse Practitioner, Department of Medicine, Vanderbilt University
Medical Center.
Scottie L. Grayson was a patient in the ICU Recovery Center at Vanderbilt University Medical Center.
James C. Jackson is Neuropsychologist and Assistant Director of the ICU Recovery Center, Center for
Health Services Research, Department of Medicine, Department of Psychiatry, Vanderbilt University
Medical Center, and Geriatric Research, Education and Clinical Center (GRECC) Service, Department
of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee.
Carla M. Sevin is Assistant Professor of Medicine and Director of the ICU Recovery Center, Vanderbilt
University Medical Center.
The authors declare no conflicts of interest.


injures the vascular endothelium, increases been started by SCCM to aid in the imple-
permeability of the blood-brain barrier, and mentation of the PAD guidelines in 77 hospi-
increases excitatory neurotransmitter release tals in the United States that are committed
and resultant neuronal death.8 A retrospective to improving outcomes for patients and their
study of 74 survivors of acute respiratory families.
distress syndrome (ARDS) demonstrated that Delirium. In 2013, a large, multicenter,
having a blood glucose value of 153.5 mg/dL prospective observational cohort study5 of
(to convert to millimoles per liter, multiply 821 adult medical and surgical ICU patients
by 0.0555) was associated with a 2.9 times with respiratory failure, cardiogenic shock,
greater chance of cognitive impairment.3 or septic shock, called Bringing to Light the
Additionally, a retrospective, case-control Risk Factors and Incidence of Neuropsycho-
study of 37 surgical ICU patients who had logical Dysfunction in ICU Survivors (BRAIN-
experienced at least 1 episode of hypoglyce- ICU), was reported. The researchers sought to
mia during treatment showed that cognitive estimate the prevalence of long-term cogni-
dysfunction, specifically in visuospatial skills, tive impairment following critical illness.
was higher in the hypoglycemia group than The strongest independent predictor of cogni-
in the control group (P < .01).4 tive impairment was ICU delirium, which
Hyperglycemia is also a risk factor for was found in 50% of study patients. Three
critical illness polyneuropathy (CIP) and months following hospital discharge, a Repeat-
critical illness myopathy (CIM). Insulin has able Battery for Neuropsychological Status
anti-inflammatory effects, protects endothe- (RBANS) score similar to what has been seen
lium, improves the metabolism of lipids, and in individuals with mild Alzheimer’s disease
is an anabolic hormone.7 Intensive insulin (2 standard deviations below the population
therapy (maintaining blood glucose levels mean) was found in 26% of patients, and a
between 80 and 100 mg/dL) in surgical ICU score similar to the scores seen in patients
patients decreased neuropathy from 51.9% with moderate traumatic brain injury (1.5
to 28.7%. Also, intensive insulin therapy standard deviations below the population
decreased the prevalence of CIP and CIM mean) was found in 40% of patients.5
from 49% to 25% in surgical ICU patients Pain. Inadequate pain management has
(P < .001) and from 51% to 39% in the been associated with numerous complications,
medical ICU (P = .02) in patients who had an including nosocomial infections, increased
ICU stay of at least 1 week.9,10 Moreover, the duration of mechanical ventilation, and delir-
percentage of patients receiving mechanical ium.14 The treatment of pain with opiates in
ventilation for at least 2 weeks was reduced critically ill patients has been associated with
from 42% to 32% in the surgical ICU (P = .04) an increased risk of delirium in some studies15
and from 47% to 35% in the medical ICU and a decreased risk of delirium in others.16
(P = .01).9,10 However, a subsequent study, Although other medications such as gabapen-
NICE-SUGAR,11 showed increased mortality tin (Neurontin), nonsteroidal anti-inflammatory
in the intensive insulin group (27.5%) com- drugs, and acetaminophen (Tylenol) are good
pared with conventional glucose control (< 180 adjunctive therapies, opioids are the medication
mg/dL; 24.5%; P = .02). On the basis of that class of choice for treating pain in critically
study, SCCM guidelines for the use of an insu- ill patients.13 The potential for the develop-
lin infusion in critically ill patients suggests ment of delirium highlights one of the many
that patients with a blood glucose level of reasons why pain assessment in critically ill
150 mg/dL or greater receive an intervention patients is so imperative. The PAD guidelines13
to maintain blood glucose level at less than recommend that all adult critically ill patients
180 mg/dL while avoiding hypoglycemia.12 be routinely assessed for pain. Self-reporting
of pain is considered the reference standard
Pain, Agitation, and Delirium for pain assessment. However, if a patient is
The pain, agitation, and delirium (PAD) nonverbal, the PAD guidelines13 recommend
guidelines13 were published by SCCM in 2013 use of the Behavioral Pain Scale or the Criti-
and summarize the best evidence available for cal Care Pain Observational Tool in ICU
providing physical and psychological comfort patients who are unable to self-report pain.
through management of PAD. A program Sedation. Benzodiazepines have been asso-
called the ICU Liberation Collaborative has ciated with the development of delirium in

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Drug Update

Table 1: Stop, THINK, and Medicate

Stop THINK Medicate

Do any medications need to be Toxic situations No published studies report
stopped or lowered? that haloperidol (Haldol)
Congestive heart failure,
Especially consider sedatives decreases the duration of
shock, dehydration
Is patient receiving minimal
New organ failure (liver/kidney)
amount necessary? Atypical antipsychotics may
Daily sedation cessation Hypoxemia decrease the duration of
Targeted sedation plan delirium
Infection/sepsis (nosocomial),
Assess target daily
immobilization Dexmedetomidine (Precedex)
Do sedatives need to be changed? may result in more days alive
Nonpharmacological interventions
without delirium and lower
Remember to assess for pain!
Hearing aids, eyeglasses, daily prevalence of delirium
reorient, sleep protocols,
music, noise control,
Electrolyte problems (eg,

several studies.15,16 The PAD guidelines rec- Richmond Agitation-Sedation Scale (RASS)
ommend using nonbenzodiazepine sedation were more likely to be at the target RASS score
strategies (eg, dexmedetomidine [Precedex]) with dexmedetomidine (74%) than with
in delirious patients.13 Three studies17-19 have standard care (64%).
demonstrated that patients are less likely to In a phase 3, multicenter, randomized, double-
remain delirious if dexmedetomidine is used. blind trial,19 MIDEX, researchers found that
In a double-blind, randomized, controlled the composite outcome of agitation, anxiety,
trial of 106 patients receiving mechanical and delirium occurred in 27% of patients who
ventilation, The Maximizing Efficacy of Tar- received midazolam versus 29% of patients
geted Sedation and Reducing Neurological who received dexmedetomidine (P = .69). In a
Dysfunction (MENDS) study,20 researchers second phase 3, multicenter, randomized, double-
found that the median number of days alive blind trial,20 PRODEX, researchers found that
without delirium or coma was 7 in the dex- the composite outcome of agitation, anxiety,
medetomidine group versus 3 in the lorazepam and delirium occurred in 29% of patients who
(Ativan) group (P = .01). The daily prevalence received propofol versus 18% of patients who
of delirium was lower in the dexmedetomidine received dexmedetomidine (P = .008). Overall,
group than in the lorazepam group (P = .004) these studies suggest that the use of dexme-
after the day of randomization.20 detomidine results in increased days alive with-
In a second double-blind, randomized, out delirium and reduced daily prevalence of
controlled trial of 375 medical/surgical ICU delirium compared with benzodiazepines.
patients, the Safety and Efficacy of Dexme-
detomidine Compared with Midazolam Management of Delirium
(SEDCOM) study,17 researchers found that Nonpharmacological management of delir-
60.3% of dexmedetomidine patients and ium through risk factor reduction has been
59.3% of midazolam (Versed) patients were studied in non-ICU patients, and the results
delirious at baseline according to the Confusion generalize to the ICU population. However,
Assessment Method for the ICU. During the these interventions need to be investigated
study period, the prevalence of delirium was further in critically ill patients. An example
54% in the dexmedetomidine group compared of risk-reducing strategies that can be simpli-
with 76.6% in the midazolam group (P < .001).17 fied into a simple phrase “Stop, THINK, and
A pilot, phase 3, double-blind, randomized Medicate” is presented in Table 1.
study was conducted by Ruokonen et al18 in Pharmacological interventions should be
2009 to compare dexmedetomidine with stan- considered only after nonpharmacological
dard care (midazolam or propofol [Diprivan]). strategies have been implemented and modifi-
Patients with a target score of 0 to -3 on the able risk factors have been addressed.

Beneficial effects of haloperidol (Haldol) or Table 2: Medication Strategies to Avoid

atypical antipsychotics on decreasing the Post–Intensive Care Syndrome
duration of delirium in adult ICU patients
have not been definitively demonstrated (ie, no Medications
large randomized controlled trials). In a pro- Associated With
spective pilot study,21 18 delirious patients Acute Neuromuscular
were randomized to receive scheduled que- Deliriogenic Medications Weakness
tiapine (Seroquel) and 18 delirious patients Steroids Neuromuscular
were randomized to receive placebo. All blockers
patients could receive intermittent haloperi- Antihistamines Steroids
dol. Faster resolution of delirium was found Medications for overactive
in the quetiapine group compared with the bladder Aminoglycosides
placebo group (1 day vs 4.5 days, P = .001) as Antispasmodics Clindamycin (Cleocin)
well as a shorter duration of delirium (36 days Tricyclic antidepressants
vs 120 days, P = .006). Additionally, less inter- Paroxetine (Paxil)
mittent haloperidol was required in the que- Disopyramide (Norpace)
tiapine group (3 vs 4 days). Both groups -Blockers
experienced a similar amount of QT interval
Lithium (Lithobid)
prolongation and extrapyramidal symptoms,
but more somnolence was found in the que- Diuretics
tiapine group (22% vs 11%, P = .66). Digoxin (Lanoxin)
Currently, a multicenter, randomized,
placebo-controlled, study sponsored by the Dopamine agonists
National Institutes of Health called Modifying Antibiotics
the Impact of ICU-Associated Neurological Quinolones
Dysfunction-USA (MIND-USA) is being con- Cefepime (Maxipime)
ducted in delirious medical and surgical ICU Narcotics
patients with respiratory failure or shock to
determine the effects of haloperidol versus
anti-inflammatory drugs
ziprasidone versus placebo on the number of
days alive without delirium or coma, mortal- Histamine2 blockers
ity, and long-term cognitive function. Skeletal muscle relaxants
Medications That Cause Delirium
Medications are a common yet easily Inhaled anesthetics
reversible cause of delirium, accounting for Ketamine (Ketalar)
12% to 39% of all cases. The American
Geriatric Society recently updated the Beers Theophylline (Theo-24)
criteria, listing potentially inappropriate
medications to be prescribed in elderly adults. antibiotics have weak dopaminergic activity.
In addition, the Society also published a list Morphine also increases the release of dopa-
of alternative medications to use instead of mine.24 Anticholinergic medications result
high-risk medications. Although narcotics in a cholinergic deficiency and are a modifi-
and benzodiazepines have been discussed in able risk factor for delirium. Additionally,
prior sections, many other deliriogenic medi- digoxin (Lanoxin), lithium (Lithobid), and
cations are commonly prescribed to patients histamine2 blockers demonstrate some cho-
in the ICU22 (Table 2). linergic binding activity, although they are
Excess dopamine, decreased acetylcholine, not traditionally classified as anticholinergic
and alterations in -aminobutyric acid are agents.22 The proposed mechanism behind
all mechanisms behind the development of benzodiazepine-induced delirium is altera-
delirium.23 Dopamine agonists used as anti- tions in -aminobutyric acid.24
parkinsonian agents can contribute to delir- A prospective cohort study25 of 1112 criti-
ium. If these medications are deemed necessary, cally ill patients in a 32-bed medical-surgical
a dosage reduction or change in schedule ICU for a total of 9867 days was conducted
may alleviate the problem. Quinolone to determine whether anticholinergic exposure

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Drug Update

increased the probability of a transition to visits and readmissions to hospitals following

delirium occurring. The transition from discharge have been associated with medica-
“awake and without delirium” to “delirium” tions. In response to the growing amount of
occurred on 6% of ICU days. A 1-unit data demonstrating medication errors at tran-
increase in the Anticholinergic Drug Scale sitions of care, The Joint Commission on
demonstrated a nonsignificant increase in the Accreditation of Healthcare Organizations
probability of a transition to delirium occur- declared “sustaining and properly communi-
ring the following day (odds ratio, 1.05; 95% cating correct medication information” to be
CI, 0.99-1.10). However, the authors did not a National Patient Safety Goal in 2011.
evaluate whether the dose of the medication Patients with cognitive impairment or those
affected the transition to delirium and also taking more than 5 medications per day (also
did not consider patients who were already known as polypharmacy) are 2 examples of
delirious and remained delirious while receiv- populations of patients at higher risk for an
ing anticholinergic medications.25 ADE during transitions of care.29 Addition-
Medications can also potentiate CIP and ally, the number of medications a patient is
CIM (Table 2). Neuromuscular blockers receiving is an independent risk factor for
enhance microvascular permeability, stimu- delirium.31 “Deprescribing” is defined as the
lating denervation of the muscle in addition process of tapering or discontinuing medica-
to having direct toxic effects on the nerve. tions to minimize polypharmacy and improve
Concomitant administration of steroids patients’ outcomes. The following 5-step pro-
enhances the toxic effects of neuromuscular tocol for deprescribing has been suggested:
blockers on muscles. The risk of acute myop- (1) determine that each medication has an
athy increases with coadministration of neu- indication; (2) consider the overall potential
romuscular blockers and corticosteroids for harm of the medications in determining how
longer than 24 to 48 hours.26 Additionally, many agents should be discontinued; (3) assess
hypermagnesemia, metabolic acidosis, and each individual drug to determine if it should
concomitant medications including amino- be discontinued; (4) prioritize the order of
glycosides and clindamycin promote prolonged medications to be discontinued; and (5) initi-
neuromuscular blockade.27 Studies on the ate and monitor a drug discontinuation plan.
effects of corticosteroids on CIP/CIM have Deprescribing can be further enhanced in the
yielded both positive9,10 and negative28 results. ICU by determining if medications have a cur-
The clinical situation must be considered rent indication. For example, a patient taking
when determining if the use of corticosteroids an antihistamine at home for allergies and an
is merited. anticholinergic agent for an overactive bladder
Careful review of the patient’s medication may not need these medications when admit-
list can identify potentially deliriogenic or ted to an ICU with a urinary catheter.32
CIP/CIM-inducing medications. Drug/disease A single-center study33 of 120 elderly adult
state interactions and drug/drug interactions ICU survivors evaluated the frequency of
resulting in delirium or CIP/CIM should be prescribed potentially inappropriate medica-
considered when dosing and choosing medi- tions (PIMS) and actually inappropriate med-
cations.7,24 Hepatic and renal impairment can ications (AIMs). PIMS were defined as those
lead to accumulation of medications, result- medications potentially harmful to the elderly
ing in delirium and/or CIP/CIM if the medi- according to prior research and knowledge
cation dose is not adjusted appropriately.7,24 of pharmacological effects. PIMs could then
be classified as AIMS if the benefit of the drug
Transitions of Care was outweighed by the harm after consider-
Although ADEs can occur at any time, it ing a patient’s clinical circumstances. Charts
has become evident in the past decade that a were reviewed and medications were identi-
significant risk for ADEs occurs during peri- fied as PIMS by using the 2003 Beers criteria
ods of transition of care.29 One of the first and medication safety data published since
studies that highlighted the medication errors 2003. In order to determine where AIMS were
that occur during transitions of care demon- initiated, medications were identified at 5 dis-
strated that 54% of errors were made by pre- tinct points during the hospital stay: admission,
scribers when ordering medications at hospital medical/surgical unit admission, ICU admis-
admission.30 Further, many emergency room sion, ICU discharge, and hospital discharge.


The most common categories of PIMS The risk of medication discontinuation

identified at hospital discharge were the fol- was higher in all medication groups with the
lowing: opioids, anticholinergic medications, exception of respiratory inhalers in patients
antidepressants, and drugs causing orthosta- hospitalized with an ICU admission, compared
sis. The clinical panel, consisting of a hospi- with patients hospitalized without an ICU
talist, geriatrician, and clinical pharmacist, admission. The composite risk of death,
determined that 36% of these PIMs were hospitalization, and emergency department
considered to be AIMs. At hospital discharge, visits up to 1 year after hospital discharge
the PIM categories with the highest positive in all study patients was significantly higher
predictive values for being AIMs included in patients in whom a statin or antiplatelet
anticholinergics (55%), nonbenzodiazepine or anticoagulant was discontinued. As this
hypnotics (67%), benzodiazepines (67%), study was retrospective, the clinical reasons
atypical antipsychotics (71%), and muscle why long-term medications were discontin-
relaxants (100%). The number of discharge ued could not be delineated. However, this
PIMS was independently predicted in multi- study highlights the importance of medication
variate analysis by the number of preadmis- reconciliation with changes in patients’ status
sion PIMs (P < .001), discharge to somewhere and transitions of care to prevent errors of
other than home (P = .03), and discharge from omission in the patient’s discharge medication
a surgical service (P < .001). list when leaving the hospital.
Also, nearly two-thirds of AIMs were initi-
ated in the ICU. It is likely that many of these Post-ICU Clinics
medications initiated in the ICU or at any other Fifty percent of patients who are readmitted
time during the hospital stay may have been within 30 days of discharge did not have a
appropriate for temporary or short-term use posthospitalization visit to a primary care
depending on the patient’s clinical situation. provider. Lack of understanding of home and
However, the failure to discontinue these discharge medications was a contributing fac-
medications once no longer indicated led to tor to readmissions.29 Readmissions occurred in
inappropriate and prolonged use. This study 20% of Medicare recipients within 30 days of
further highlights the need to review patients’ discharge and in 34% within 90 days of dis-
medication lists daily and during transitions charge in 1 study.35
of care to determine if deprescribing is merited. One method of smoothing the transition
In addition to the continuation of unneces- back to a primary care provider following an
sary medications following hospital discharge, ICU stay is use of a post-ICU clinic. Primary
patients’ home maintenance medications may care providers may not be familiar with the
not be initiated upon hospital admission. In specific critical care issues seen in patients
a large population-based Canadian cohort following critical illness and may not have the
study of 396 380 patients aged 66 years or tools to assess and manage these complications.
older, researchers looked at records of hospi- An interdisciplinary team of individuals in a
tal and outpatient medications prescribed post-ICU clinic can use their expertise about
from at least 1 of 5 of the following groups: specific complications related to critical care
(1) statins, (2) antiplatelet/anticoagulant agents, to aid in the diagnosis and treatment of PICS.
(3) levothyroxine, (4) respiratory inhalers, Medication therapy review, reconciliation,
and (5) gastric acid–suppressing drugs.34 and counseling should all be considered cru-
Patients were divided into 3 groups: hospital- cial parts of a patient’s visit to a post-ICU
ization with an ICU admission, hospitalization clinic. These functions are ideally performed
without ICU admission, and nonhospitalized by a pharmacist. The steps of the complete
patients (controls). Patients admitted to a medication use process are listed in Table 3.
hospital without an ICU stay were significantly
more likely to have medications discontinued Patient Testimonial
among all 5 of the medication groups com- Scottie Grayson is a 42-year-old man who
pared with control patients. Also, patients had a 30-day hospitalization after a witnessed
admitted to a hospital with an ICU stay were ventricular arrest with subsequent acute kidney
significantly more likely to have medications injury, prolonged ventilation, and heparin-
discontinued among all 5 of the medication induced thrombocytopenia who was seen
groups compared with control patients. at the ICU Recovery Center at Vanderbilt

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Drug Update

Table 3: The Complete Medication Use caddy to help organize his medications. Addi-
Process tionally, 3 medications, omeprazole, sodium
bicarbonate, and quetiapine, started for acute
needs in the hospital, were discontinued.
1. Before clinic visit: review of patient’s chart for
medical history, hospital course, and medications
2. Medication reconciliation: compare and recon- Medication management strategies in the
cile medication lists before, during, and after ICU, upon transition to the medical/surgical
hospitalization unit, and after hospitalization are critical to
3. Medication therapy review: ensure that each preventing and treating PICS. Glucose man-
medication has an appropriate indication agement strategies, delirium prevention and
4. Patient interview: identify adverse drug events, treatment, and avoidance or proper dosage
identify any untreated problems adjustment of deliriogenic or neuromuscular
weakness–inducing medications are all strate-
5. Patient counseling: review medication indica-
gies to prevent PICS.
tion, directions, potential adverse effects, and
6. Assessment: review barriers to obtaining medi- 1. Adhikari NK, Fowler RA, Bhagwanjee S, Rubenfeld GD.
cations, promote medication regimen adherence, Critical care and the global burden of critical illness in
and order any needed laboratory tests adults. Lancet. 2010;376(9749):1339-1346.
2. Needham DM, Davidson J, Cohen H, et al. Improving
7. Conclusion of visit: discuss medication changes long-term outcomes after discharge from intensive
and patient’s follow-up plan care unit: report from a stakeholders’ conference. Crit
Care Med. 2012;40(2):502-509.
3. Hopkins RO, Suchyta MR, Snow GL, Jephson A, Weaver
LK, Orme JF. Blood glucose dysregulation and cognitive
outcome in ARDS survivors. Brain Inj. 2010;24(12):
University Medical Center. The following is 1478-1484.
Mr Grayson’s testimonial regarding how tar- 4. Duning T, van den Heuvel I, Dickmann A, et al. Hypo-
geted medication interventions affected his glycemia aggravates critical illness-induced neurocog-
nitive dysfunction. Diabetes Care. 2010;33(3):639-644.
post-ICU recovery: 5. Pandharipande PP, Girard TD, Jackson JC, et al. Long-
Recently I suffered a cardiac arrest and term cognitive impairment after critical illness. N Engl
J Med. 2013;369(14):1306-1316.
spent 30 days in Vanderbilt Medical 6. Jackson JC, Girard TD, Gordon SM, et al. Long-term
Center. When I returned home I was cognitive and psychological outcomes in the awakening
shocked to learn that I was bringing and breathing controlled trial. Am J Respir Crit Care
Med. 2010;182(2):183-191.
home 11 prescriptions for a total of 7. Apostolakis E, Papakonstantinou NA, Baikoussis NG,
24 pills a day. For someone who was Papadopoulos G. Intensive care unit-related generalized
taking zero prescriptions previously, neuromuscular weakness due to critical illness poly-
neuropathy/myopathy in critically ill patients. J Anes-
it was very overwhelming. I repeatedly thesia. 2015;29(1):112-121.
had to ask my wife what all these pills 8. Jackson JC, Ely EW. Cognitive impairment after critical
were for and if I really needed them. illness: etiologies, risk factors, and future directions.
Semin Respir Crit Care Med. 2013;34(2):216-222.
Although the staff had gone over all 9. Van den Berghe G, Schoonheydt K, Becx P, Bruyninckx
these medications with my wife, I was F, Wouters PJ. Insulin therapy protects the central and
peripheral nervous system of intensive care patients.
in the dark. During my first few weeks Neurology. 2005;64(8):1348-1353.
home, I was in a fog. I don’t know 10. Hermans G, Wilmer A, Meersseman W, et al. Impact of
how much of it was the medication intensive insulin therapy on neuromuscular complica-
tions and ventilator dependency in the medical inten-
and how much of it was my body still sive care unit. Am J Respir Crit Care Med. 2007;175(5):
healing from the trauma. I believe I 480-489.
would have been less anxious and 11. NICE-SUGAR Study Investigators, Finfer S, Chittock DR,
et al. Intensive versus conventional glucose control in
overwhelmed if I personally would critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
have had a better understanding of 12. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the
use of an insulin infusion for the management of
what all the medications had been for. hyperglycemia in critically ill patients. Crit Care Med.
The complete medication review by the 2012;40(12):3251-3276.
pharmacist at the ICU Recovery Center 13. Barr J, Fraser GL, Puntillo K, et al. Clinical practice
guidelines for the management of pain, agitation, and
at Vanderbilt helped me to feel better delirium in adult patients in the intensive care unit.
about my medications. Crit Care Med. 2013;41(1):263-306.
During his visit at the ICU Recovery Center at 14. Chanques G, Jaber S, Barbotte E, et al. Impact of sys-
tematic evaluation of pain and agitation in an intensive
Vanderbilt, Mr Grayson was provided a pill care unit. Crit Care Med. 2006;34(6):1691-1699.


15. Pandharipande P, Cotton BA, Shintani A, et al. Prevalence 25. Wolters AE, Zaal IJ, Veldhuijzen DS, et al. Anticholinergic
and risk factors for development of delirium in surgical medication use and transition to delirium in critically ill
and trauma intensive care unit patients. J Trauma. 2008; patients: a prospective cohort study. Crit Care Med.
65(1):34-41. 2015;43(9):1846-1852.
16. Zaal IJ, Devlin JW, Hazelbag M, et al. Benzodiazepine- 26. Bolton CF. Neuromuscular manifestations of critical illness.
associated delirium in critically ill adults. Intensive Care Muscle Nerve. 2005;32(2):140-163.
Med. 2015;41(2):2130-2137. 27. Pandit L, Agrawal A. Neuromuscular disorders in critical
17. Riker RR, Shehabi Y, Bokesch PM, et al. Dexmedetomi- illness. Clin Neurol Neurosurg. 2006;108(7):621-627.
dine vs midazolam for sedation of critically ill patients: 28. De Jonghe B, Sharshar T, Lefaucheur JP, et al. Paresis
a randomized trial. JAMA. 2009;301(5):489-499. acquired in the intensive care unit: a prospective multi-
18. Ruokonen E, Parviainen I, Jakob SM, et al. Dexmedeto- center study. JAMA. 2002;288(22):2859-2867.
midine versus propofol/midazolam for long-term seda- 29. Hume AL, Kirwin J, Bieber HL, et al; for American College
tion during mechanical ventilation. Intensive Care Med. of Clinical Pharmacy. Improving care transitions: current
2009;35(2):282-290. practice and future opportunities for pharmacists. Phar-
19. Jakob SM, Ruokonen E, Grounds RM, et al. Dexme- macotherapy. 2012;32(11):e326-e337.
detomidine for long-term sedation I: dexmedetomidine 30. LaPointe NM, Jollis JG. Medication errors in hospitalized
vs midazolam or propofol for sedation during prolonged cardiovascular patients. Arch Intern Med. 2003;163(12):
mechanical ventilation: two randomized controlled trials. 1461-1466.
JAMA. 2012;307(11):1151-1160. 31. Inouye SK, Charpentier PA. Precipitating factors for delir-
20. Pandharipande PP, Pun BT, Herr DL, et al. Effect of ium in hospitalized elderly persons. Predictive model and
sedation with dexmedetomidine vs lorazepam on acute interrelationship with baseline vulnerability. JAMA. 1996;
brain dysfunction in mechanically ventilated patients: 275(11):852-857.
the MENDS randomized controlled trial. JAMA. 2007; 32. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropri-
298(22):2644-2653. ate polypharmacy: the process of deprescribing. JAMA.
21. Devlin JW, Roberts RJ, Fong JJ, et al. Efficacy and safety 2015;175(5):827-834.
of quetiapine in critically ill patients with delirium: a pro- 33. Morandi A, Vasilevskis E, Pandharipande PP, et al. Inap-
spective, multicenter, randomized, double-blind, placebo- propriate medication prescriptions in elderly adults sur-
controlled pilot study. Crit Care Med. 2010;38(2):419-427. viving an intensive care unit hospitalization. J Am
22. Moore AR, O’Keefe ST. Drug-induced cognitive impair- Geriatr Soc. 2013;61(7):1128-1134.
ment in the elderly. Drugs Aging. 1999;15:15-28. 34. Bell CM, Brener SS, Gunraj N, et al. Association of ICU or
23. Girard TD, Pandharipande PP, Ely EW. Delirium in the hospital admission with unintentional discontinuation of
intensive care unit. Crit Care. 2008;12(suppl 3):S3. medications for chronic diseases. JAMA. 2011;306(8):840-847.
24. Alagiakrishnan K, Wiens CA. An approach to drug 35. Jencks SF, Williams MV, Coleman EA. Rehospitalizations
induced delirium in the elderly. Postgrad Med J. 2004; among patients in the Medicare Fee-for-Service Program.
80(945):388-393. N Engl J Med. 2009;360(14):1418-1428.

CE Test Instructions

This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the
following objectives:
1. Describe medication related risk factors associated with cognitive impairment that develop in
critically ill patients.
2. Discuss medications associated with acute neuromuscular weakness following an intensive care unit
3. Evaluate the role of a post–intensive care unit clinic in providing a comprehensive medication
review for easing the transition from the critical care setting to home.
Contact hour: 1.0
Pharmacology contact hour: 1.0
Synergy CERP Category: A

To complete evaluation for CE contact hour(s) for test #ACC632, visit and
click the “CE Articles” button. No CE test fee for AACN members. This test expires on April 1, 2019.
American Association of Critical-Care Nurses is an accredited provider of continuing nursing education by the American
Nurses Credentialing Center’s Commission on Accreditation. AACN has been approved as a provider of continuing education
in nursing by the State Boards of Registered Nursing of California (#01036) and Louisiana (#LSBN12).

AACN Advanced Critical Care
Volume 27, Number 2, pp. 141-144
© 2016 AACN

T e c h n o lo g y Linda Harrington, RN-BC, PhD, DNP,

Department Editor

Analytics 1.0, 2.0, 3.0

Linda Harrington, RN-BC, PhD, DNP, CNS, CPHQ, CENP, CPHIMS

W hether you are a registered nurse, an advanced practice registered nurse,

nurse manager, director, or chief nursing officer, you most likely have
been using some form of analytics to improve patient care and outcomes. Is it
sufficient? Are the analytics you are using today transforming nursing care or
are they promoting incremental, albeit important, improvements?
Look around you at all of the technology in your work setting from infusion
pumps to patient monitoring systems, point-of-care laboratory systems, electric
beds, electronic health records (EHRs), smartphones, and more. What’s happen-
ing to the enormous amounts of data being generated by these diverse technolo-
gies, and what should be happening? How do we combine these data with data
from other sources, including genomic data and patient-generated health data?
This Technology Today column is intended to provide initial answers to
these questions, taking current data analytics to a new level by illustrating an
emerging analytics framework, outlining key milestones, and enabling a more
precise analytics strategy. Although the technology we use in acute and criti-
cal care helps us take care of individual patients, the aggregated data from
all patients, largely untapped, can be transformative not only for nursing
but for all of health care. If you have found success in today’s analytics known
as “analytics 1.0,” often illustrated in run charts and bar graphs, you can
begin to imagine the opportunities and impact of analytics 2.0 and 3.0. First
let’s look at key definitions.

Analytics is the discipline of applying mathematical sciences to data for the
purpose of making better decisions. You have most likely heard that health care
is data rich but information poor. You may also have wondered how your orga-
nization is using the abundance of data in the EHR, largely derived from man-
ual data entry by nurses and other health care professionals. Analytics serves
to convert the increasing amounts of data into actionable information for
improving practice and patients’ outcomes.

Nomenclature of 1.0, 2.0, 3.0

The nomenclature of 1.0, 2.0, and 3.0 refers to evolving versions of
something. For example, versioning of the Web or software employs this
nomenclature, using whole numbers with zero in the first decimal place. This

Linda Harrington is an Independent Consultant, Health Informatics and Digital Strategy, and Professor,
Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030 (
The author declares no conflicts of interest.
Technology Today W W W .AACN ACCON LIN E .ORG

Analytics 1.0: Descriptive Analytics

Analytics 2.0: Predictive Analytics

Traditional approach
Uses small amounts of Enabled by big data Analytics 3.0: Prescriptive Analytics
retrospective data
Provides information on trends
Does not directly yield Uses big data
Does not directly yield
actionable information Enabled by real-time, streaming data
actionable information
Optimal behaviors or actions are
suggested at the point of decision
Important for individuals involved
in self-management of their health
Drives transformation

Figure: Key differences in analytics 1.0, 2.0, and 3.0.

nomenclature has been around for years and is on collecting and preparing data for analysis
denoted as 1.0, 2.0, and so on, signifying sub- and reporting.
stantial changes in the software or program-
ming. Minor changes, updates, or upgrades are Analytics 2.0: Predictive Analytics
more often denoted as 1.1, 1.2, and so on and Analytics 2.0 is powered by big data allow-
are sometimes broken down further into 1.1.1 ing predictive analytics.2 The term big data is
and 1.1.2. The nomenclature of 1.0, 2.0, and defined as “data . . . too big to fit on a single
3.0 is similarly used here to outline significant server, too unstructured to fit into a row-and-
changes in analytic endeavors within a health column database, or too continuously flow-
care organization. ing to fit in a static data warehouse.”2(p1) It is
often described by the so-called “3 V’s” of
Analytics 1.0, 2.0, 3.0 volume, variety, and velocity or “4 V’s” if
The 3 currently recognized stages of analyt- you add value; however, this simplistic descrip-
ics are illustrated in the Figure. Each type of tion is lacking. How precisely can we define
analytic denotes significant advancements from variety and will a large volume of data today
the previous stage. As can be seen, descriptive be a large volume tomorrow?
analytics will continue but will play a smaller Big data analytics differs markedly from
and smaller role as the more valuable predictive the traditional analytics 1.0. Analytics 2.0
and then prescriptive analytics come into play. includes unstructured data, such as radiology
images and electrocardiograms, is 100 tera-
Analytics 1.0: Descriptive Analytics bytes to petabytes, deals with a constant flow
Traditional-data analytics use descriptive of data, and the data are analyzed by using
statistics that are based on a small amount technologies specific for big data that differ
of historical or retrospective data to identify from the technologies used with traditional
issues and/or generate reports.1 Data are analytics.2 An example is natural language
extracted that occur at one particular point processing used to analyze free text entered
in the past or several points over longer peri- into the EHR by clinicians.
ods of time but are predefined in terms of Predictive analytics provide illustrations
the data being captured from the past. Data of trends in data that inform users of past
extraction often uses manual processes. tendencies and can be used to predict future
Analytics 1.0 does not directly yield action- tendencies. Similar to descriptive analytics,
able information. Decisions based on the predictive analytics do not directly yield
descriptive analyses of 1.0 are identified by actionable information. Clinicians combine
using root cause analyses, best practices, or the prediction with best evidence and the
evidence-based practices affording limited individual’s unique circumstances to deter-
amounts of change. Data analysts focus largely mine what actions to take.

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Technology Today

Making the transition from descriptive ana- necessary data to provide sound answers.
lytics to predictive analytics should be part of Many decisions in patient care require addi-
nursing’s strategic plan. If an organization is tional factors that may not be readily avail-
currently using descriptive analytics, the able, such as whether or not the decision is
addition of predictive analytics is important locally obtainable, are costs incurred, who
for providing more advanced information. This pays, are there cultural or religious implica-
transition is essential not only for nursing prac- tions for the patient, does it require clinician
tice but also for advancement of the discipline. expertise and is that expertise available,
Nursing’s participation in the big and is it legal in the state in which it will
data and data science initiatives be delivered? Although analytics can move
now underway is essential to health care forward in making better deci-
ensure that the discoveries not sions, electronic analyses are limited to the
only be shaped by our profession’s adequacy of the data available.
unique understanding of the Underlying all analytics is the quality of
patient experience but also that the data being analyzed. As the saying goes,
the discoveries lead to knowledge “garbage in, garbage out.” The data should
that is useful to nursing.3(p477) be accurate, relevant, and timely.5 To achieve
quality data requires sound data capturing,
Analytics 3.0: Prescriptive Analytics removal of errors, a sound method for exam-
Analytics 3.0 makes a significant advance- ining outliers, appropriate capture and analy-
ment by adding the more beneficial prescrip- ses of free text and unstructured data, the
tive analytics at the point of decision.1,4 ability to capture data from multiple and
Prescriptive analytics are embedded in opera- sometimes disparate applications, and more.
tional and decision processes suggesting opti- It may be surprising that this column does
mal behaviors and actions both for clinicians not further define analytics 1.0 as “nursing
and for people involved in self-management analytics.” The jury may be out on this, but
of their health or illness. it seems highly unlikely that the silos of doc-
Prescriptive analytics are enabled by incor- umentation data seen today in EHRs will
porating real-time, streaming data composed continue. Data used in analytics 1.0, 2.0,
of continuous, rapid data from a variety of and 3.0 are about health care consumers and
sources. The physical data of humans is contin- are driven by patients’ goals and the contri-
uous and can change quickly and insidiously. bution of each health care discipline as well
The vast majority of real-time or continuous as the patient and the patient’s family.
data are not currently collected, stored, and Key takeaways from this column on ana-
analyzed but they will be in the future because lytics include using the analytics framework to
these continually streaming physical data are evaluate where your organization is in its ana-
what make real-time analytics for prescribing lytics journey and develop a sound strategy
decisions possible at the point of care. and operational plan for using analytics and
The ultimate benefit of prescriptive analytics for how you may contribute. Consider starting
surrounds speed and impact.4 In health care, now to acquire or develop the nursing talent to
this equates to prompt and effective preven- move analytics forward, because current oppor-
tion, early intervention, avoidance of compli- tunities are outpacing current preparation in
cations, value, and transformation. Decisions the health care industry. Nurses involved in
about individuals built on their historical quality improvement roles may be poised to
data, such as occurs with descriptive and add analytics knowledge to their repertoire of
predictive analytics, are insufficient to affect skills. The role of a chief nursing informatics
the individuals’ current situation. officer is evolving to meet the needs of health
care organizations analyzing data, including
Discussion EHR data, to meet the demands of population
Achieving the purpose of better decision health management.6 Multiple professional
making through analytics requires careful development opportunities are available
consideration. This requirement is in part through professional organizations such as
due to competing demands for resources in the International Institute for Analytics (www
building analytic systems to answer questions and continuing education or
and in part due to the accessibility of formal education/degree programs in analytics.

Technology Today W W W .AACN ACCON LIN E .ORG

The continuing addition of new and 1. Davenport TH. The Rise of Analytics 3.0: How to
Compete in the Data Economy. Portland, OR: Inter-
improved technologies, increasing interop- national Institute of Analytics; 2013.
erability, and data analytics are changing 2. Davenport TH. Big Data at Work: Dispelling the
Myths, Uncovering the Opportunities. Boston, MA:
what is possible in nursing and health care Harvard Business Review Press; 2014.
and what is possible for the people we serve. 3. Brennan PF, Bakken S. Nursing needs big data and
The promises of the digital age are truly trans- big data needs nursing. J Nurs Scholarsh. 2015;
formational but can be costly in terms of time, 4. Davenport TH. Analytics 3.0. Harv Bus Rev. https://hbr
energy, and money, especially if not effectively .org/2013/12/analytics-30. Accessed February 23, 2016.
5. Harrington L. Clinical intelligence. J Nurs Adm.
planned and managed. This Technology Today 2011;41(12):507-509.
column depicts a framework for analytics and 6. Stempniak M. More nurse technology experts
provides nurses with a roadmap for advancing move to the C-suite. Hosp Health Netw. http://www
practice and improving outcomes by success- -experts-move-to-the-c-suite. Accessed February
fully navigating the digital terrain of analytics. 23, 2016.

AACN Advanced Critical Care
Volume 27, Number 2, pp. 145-151
© 2016 AACN

Issues in
Valerie K. Sabol, RN, PhD, ACNP-BC,
Department Editor

Strategies for Success: Cultivating Emotional

Competence in the Clinical Nurse Specialist Role
Elizabeth Kozub, RN, MS, CCNS, CCRN, CNRN
Laurie Ecoff, RN, PhD, NEA-BC

T he role of the clinical nurse specialist (CNS) blends leadership and advanced
clinical practice to improve patient care, nursing practice, and organiza-
tional outcomes. Successful role implementation as a CNS is dependent on
a multitude of factors, including clinical knowledge and skills, individual and
group leadership skills, effective communication, and the ability to influence
change.1(p13) A leadership skill critical to the success of the CNS and the orga-
nization, yet often overlooked, is emotional competence. The focus of this arti-
cle is to describe the essential role that emotional competence plays in successful
CNS practice, provide tools for self-assessment and development, and discuss
implications for nurse leaders.

Emotional Intelligence Versus Emotional Competence

Emotional intelligence is the ability to assess an individual’s and others’
emotions through emotional awareness, discern the impact of those emotions,
and then use that information to positively affect behavior.2,3 Another way to
describe emotional intelligence is being aware of what you are feeling, sensing
what others are feeling, and motivating yourself to complete tasks and perform
at your optimal level.3 Emotional intelligence has been defined by Goleman4
to include self-awareness, self-regulation, motivation, empathy, and social skills.
Emotional competence is the ability to successfully apply the concepts of
emotional intelligence in everyday practice to effectively lead and influence
individuals and groups.5 As with other competencies, emotional competence
can be developed over time.3 Emotional competence includes attributes such
as self-awareness, humility, resiliency, passionate optimism, and appreciation
of ambiguity and paradox among others (Table 1).5
The attributes of emotional competence are interrelated and build on one
another. For example, an individual must be self-aware to appreciate the limit
of his or her given knowledge of a subject. The individual must exhibit humil-
ity and appreciation of knowledge to seek out other resources on the subject.

Elizabeth Kozub is Clinical Nurse Specialist, Surgical Intensive Care Unit, Sharp Memorial Hospital,
7901 Frost St, San Diego, CA 92123 (,
Leah Brown is Clinical Nurse Specialist, Medical Intensive Care Unit, Sharp Memorial Hospital, San Diego,
Laurie Ecoff is Director of Research, Education, and Professional Practice, Sharp Memorial Hospital,
San Diego, California.
The authors declare no conflict of interest.


Issues in Advanced Practice W W W .AACN ACCON LIN E .ORG

Table 1: Emotional Competence Attributesa

the CNS must have emotional awareness of
the group dynamics to optimize contribution
Self-awareness of all team members while navigating any
Humility potential controversy. In the authors’ experi-
Resiliency ence, emotional competence is vital to create
Passionate optimism effective and collaborative relationships with
Appreciation of ambiguity and paradox all members of the health care team.
Appreciation of knowledge CNSs are in a unique leadership position
to create a healthy work environment, which
Impulse control
can be accomplished through emotional com-
Willpower petence.16 The healthy work environment
Compassion (HWE) standards are evidence-based strate-
gies for creating an atmosphere that supports
Based on information from Porter-O’Grady and Malloch.5
excellent nursing practice and patient out-
comes.17 The authors propose that emotional
The individual must then display openness competence is critical to actualizing several
and appreciate ambiguity with the informa- of the HWE standards, including skilled
tion discovered. Finally, as the information communication, authentic leadership, true
is shared with colleagues, passionate optimism collaboration, and meaningful recognition.
and compassion are required to convey the For example, in the skilled communication
intended message effectively. domain of the HWE standards, skilled com-
municators must focus on finding solutions
Emotional Competence in the and hearing relevant perspectives, which aligns
CNS Role with the emotional competence attributes of
The importance of emotional competence appreciation of knowledge and openness. Fur-
in health care leadership must be fully appre- thermore, the CNS can contribute to an
ciated for organizations to thrive in its current HWE through leading by example. An emo-
changing landscape. For example, emotional tionally competent CNS is in a position to
intelligence has been correlated with positive assess the emotional competence of others
individual, nurse leader, and organizational and offer strategies for development.
outcomes.6-14 Person-specific emotional intel- The journey to emotional competence
ligence outcomes include increased job satis- involves critical self-appraisal and an assess-
faction, increased work engagement, increased ment of current level of performance before
retention, and reduced burnout.6-8 In clinical learning and growing in capability. In an effort
practice, collective emotional intelligence has to assist CNSs in developing and realizing
been associated with improved organizational emotional competence, 3 attributes will be
performance on nursing-sensitive indicators, highlighted, with key questions to assess
including decreased infections, falls, and one’s current state and strategies for expand-
improved pressure ulcer screening.9 In nurs- ing emotional competence.
ing leaders, emotional intelligence has a posi-
tive effect on quality of care, teamwork, nurse Self-awareness
satisfaction, turnover, and burnout.10-14 When Emotional competence and success in the
leaders possess high emotional intelligence, CNS role build on a foundation of self-
outcomes for patients, nurses, and organiza- awareness. In order to understand and relate
tions may improve. effectively to those within their spheres of
Emotional competence is a fundamental influence, successful CNSs must first take
prerequisite to actualizing the CNS core com- the time to thoughtfully examine their per-
petencies including consultation, systems sonal experiences and further delve into the
leadership, collaboration, and coaching. For emotions surrounding them, acknowledging
example, in systems leadership, the CNS is their impact.18 The ability to honestly feel
tasked with using “effective strategies for and admit one’s own emotions allows an
changing clinician and team behavior to individual with emotional competence to
encourage adoption of evidence-based prac- separate the emotions from the event, assist-
tices and innovations in care delivery.”15(p20) ing the CNS to navigate emotionally charged
To successfully facilitate teams and lead change, situations successfully, and also leads to the

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Issues in Advanced Practice

Table 2: Emotional Competence Self-Assessment Questionsa

Self-Assessment Questions Implications of Self-Assessment Answers

How does my mood affect my performance at work? Recognition of how emotions can drive thoughts
What situations have the potential to make me very and actions.
angry at work? Once recognized, emotions and mood can be
What are my strengths? Weaknesses? Blind spots? controlled.
When emotionally competent leaders understand
themselves, it allows them to anticipate what will
work for others.
How quickly do I ask for help with a project? Emotional competence allows leaders to maintain
How easily and/or quickly can I admit when I do not focus on the organization.
know enough about a topic? Leaders with emotional competence realize that
How willing am I to learn from others? continued growth is possible only with a constant
flow of new information.
An organization’s collective wisdom is valued over
individual talent.
Do I seek feedback when things don’t go as planned? Feedback and sharing of ideas allows an organization
Can I receive that feedback graciously, incorporating to address disappointments as a whole not as
it into future initiatives? individual failure.
Am I willing to fail when planning new projects or Emotionally competent leaders seek feedback as
anticipating a practice change? essential to growth.
Analysis of failures increases an organization’s
capacity to minimize future errors.
Based on information from Porter-O’Grady and Malloch.5

ability to sense and anticipate how a situation strengths and limitations, with appreciation
may affect others. This ability is the basis of for the experiences and emotions of others.
empathy and an important attribute of an To engage in reflection and thus grow in
effective collaborator and consultant.19 Only self-awareness, it is helpful to use a structure
with an accurate assessment of self can an or model. The model in Figure 1 may be used
individual act decisively and with authentic- to guide the CNS when examining a situa-
ity.19 The questions in Table 2 may be used tion or experience.23 For example, in con-
to prompt self-assessment and gauge an indi- sulting on a challenging situation involving
vidual’s level of self-awareness. a patient, a CNS may find himself or herself
The development of self-awareness as a assuming direct patient care without includ-
strategy to succeed in the CNS role is affected ing the bedside nurse. A confrontation may
largely by the practice of reflection. Reflection occur or there may be unspoken resentment
on practice or reflective learning is a method from nursing staff. In reflecting on the event
based on educator and philosopher John Dew- and examining what occurred in comparison
ey’s practice of purposeful and careful consid- to what the standards define, a self-aware
eration of beliefs and knowledge.20 Current CNS may recognize a desire to feel clinically
literature recommends reflective learning for relevant and demonstrate skills and knowl-
practicing nurses and nursing leaders for its edge that made the clinical staff feel excluded
effectiveness in promoting thoughtful prac- or dismissed.
tice.21 Fruitful reflection involves thinking Reflection allows an honest appraisal of
about the experience and allowing the identi- the self and the emotions and motivations
fication of emotions, motivations, and inten- involved, and it ideally results in a changed
tions, which may then lead to the uncovering perspective.21 With an accurate awareness of
of deeply held beliefs and values.20,22 Analysis self, a CNS offers honesty and authenticity
and synthesis of situations and perspectives to others. Honesty fosters humility, another
then assists a self-aware leader in uncovering important attribute of emotional competence.5

Issues in Advanced Practice W W W .AACN ACCON LIN E .ORG

their presence in others. Know when to defer

1) What 2) What did I
happened? see myself
or delegate to the gifted people surrounding
doing? you and welcome what they can teach you!
Persisting with the usual or comfortable pat-
terns of problem solving and the “same way
Experience Observation of doing things” stifles humility and hinders
success.26 Leadership is not focused on being
right, it is focused on doing the right thing,
coupled with the ability to understand that
other people may have greater insight about
Learning Reflection a situation.27 Doing so creates a CNS who is
a good role model for safe nursing practice
and a CNS on the path toward possessing
4) What will I 3) How do my emotional competence.
do differently actions relate
in the future? to standards/
As nurse leaders risk exposing their flaws
or failures by exercising humility, another
Figure 1: Reflective learning model. vital attribute of emotional competence is
Used with permission from Sharp Memorial Hospital, being developed. Resilience may be defined
San Diego, California. as the ability to move forward in a positive
manner, adapting to adversity and maintain-
Humility ing equilibrium.28 Confronting adversity in a
Humility may bring to mind self-deprecation, leadership role is often inevitable. However,
or someone of little value; however, humility emotional competence allows CNSs to main-
can be considered the epitome of self-confidence tain a sense of control over their environment,
and a major contributor to success. With measuring their responses and exhibiting a
self-awareness and an accurate appraisal of strong sense of self even when facing difficul-
knowledge, skills, and abilities, humble leaders ties. When working in the organizational
do not feel the need to boast or demand rec- sphere, barriers to optimal nursing practice
ognition for their accomplishments. An accu- or patient care may arise. Examples of barri-
rate assessment of the self is one part of the ers include medical resistance to adopting
definition of humility put forth by Smith.24 new evidence-based practices or the lack of
Other behaviors representative of humility usability of an electronic medical record.
are willingness to learn and showcasing the An emotionally competent CNS recognizes
strengths of others.5 In the leadership of that questions and resistance may allow fur-
large and successful companies, personal ther beneficial developments in practice or
humility also can take a company from that persistence in advocating for enhance-
good to great. The characteristics described ments of electronic medical records can facili-
by Collins25 include modesty, not aspiring for tate future workflow improvements.
individual success, and when assigning the The CNS actualizes the role in 3 spheres of
responsibility for poor results, never blaming influence: patient/client, nurse/nursing practice,
other individuals or external factors, looking and organizations/systems.18 The relationships
“in the mirror, not out the window.” fostered by a CNS within the spheres of
To assess one’s level of humility and ascer- influence benefit from the cultivation of resil-
tain any opportunity to cultivate this attribute ience as resistance and disappointment may
of emotional competence, ask the questions occur in the care of a patient, development
in Table 2. The last question provides a key of the nursing staff, or in working within a
tactic to cultivate humility. It is an insatiable system. Again, as a role model, the nurse leader
curiosity and constant seeking of new knowl- who exhibits resilience or hardiness helps
edge that activates the humility of a leader.24 the nursing staff to respond to challenges
Through reflection and the process used to creatively and energetically.29 Resilience can
develop self-awareness, honest leaders must also have a positive effect on organizational
admit there are things they don’t know. Admit outcomes and patients’ experience.29 To self-
these knowledge or skill deficits, and recognize assess the current state of one’s resilience,

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Issues in Advanced Practice

ask the questions in Table 2 and determine Table 3: 5 Steps to Mindfulnessa

your current state of hardiness or buoyancy
in the CNS role. 1. Mindful breathing
Fortunately, many of the practices explored 2. Concentration
in this article, especially reflection and self- 3. Awareness of your body
assessment, will build resilience in the CNS 4. Releasing tension
on the journey to emotional competence. 5. Walking meditation
In addition to building and maintaining satis- a
Based on information from Hanh.32
fying relationships with others for support
through networking, a nurse leader who team members. The authors propose that lead-
desires to become more resilient must prac- ers can influence the level of team members’
tice self-acceptance, developed through mind- emotional competence through hiring practices,
fulness.29,30 Being mindful is being aware of ongoing competency assessment, and profes-
the present moment and accepting it as it is.31 sional development activities, mentoring, and
Mindfulness assists individuals in separating (when necessary) coaching or providing cor-
themselves from events and subsequent emo- rective action.
tions. This separating assists the individual Practices for hiring CNSs include not only
CNS to notice, yet not take personally, events identifying minimum educational and experi-
or situations with patients, fellow nurses, or ence requirements but also key desirable attri-
the organization. The practice of mindfulness butes related to emotional competence (Table 1).
has 5 steps (Table 3).32 With practice, responses Once attributes are identified, questions may
can be measured and regulated without emo- be developed to elicit responses, which assist
tional outbursts or rumination that can hijack interviewers in assessing the knowledge, skills,
thoughts and decrease effective leadership.31 and attitude of a candidate. Bloom33 identified
In the pursuit of emotional competence and knowledge, skills, and attitude as the 3 domains
the reward of authentic leadership, 3 attributes or goals of learning. The attitude or affective
have been highlighted. In the journey to dis- domain addresses how individuals deal with
cover, develop, and deepen self-awareness, events or experiences emotionally. Assessing
humility, and resilience, a CNS may hone the all 3 domains (knowledge, skill level, and the
knowledge, skills, and attitudes of an essen- emotional competence or attitude) is essential
tial leadership skill. to have a complete picture of a candidate’s fit
within an organization. Behaviorally based
Implications for Nurse Leaders: interview questions can assist the hiring team
Organizational Strategies for in screening candidates on the basis of their
Fostering Emotional level of emotional competence (Table 4).5
Competence in CNSs Once a CNS is employed by the organiza-
It is equally important to address the lead- tion, it is important to continually evaluate his
er’s role in fostering emotional competence or her emotional competence. Competence in
from an organizational perspective. Leaders health care organizations is typically assessed
within an organization determine the vision upon hire and at least annually thereafter.
and standards for emotional competence of Competency tools, which integrate the tenets

Table 4: Emotional Competence Behaviorally Based Interview Questionsa

Give an example of how you established trusting relationships with members of the health care team.
Give an example of a situation where you felt you needed to modify or change your behavior. How did you
know? What did you do? What was the outcome?
Tell us about a time when you realized a conversation wasn’t going very well. What did you do? What was
the outcome?
Tell us about a particular work-related setback you have faced. How did you deal with it? What was the outcome?
Talk about a situation where some of your team members disagreed with your ideas or approach. How did
you handle the situation? What was the outcome?
Tell us about a change you have led or been involved in. What kind of resistance did you encounter and
how did you manage it? Would you do anything differently?
Used with permission from Sharp Memorial Hospital, San Diego, California.

Issues in Advanced Practice W W W .AACN ACCON LIN E .ORG

of emotional competence, are useful to evalu- Attitude (Affective)

ate employee attributes and ongoing growth. ■Affective skills to obtain information, understanding,
An effective competency format incorporates or assistance; meet need of other
all 3 domains of learning and ensures that
Novice Performance Criteria
emotional competence is evaluated. Figure 2
provides an excerpt of a competency used to (Receiving)
assess the attitude (affective) domain of an r Notices different styles of communication
emotional competence attribute. Integration r Accepts the contributions of self and others to
effective team function
of Benner’s novice to expert framework
r Focuses on being an effective team member
facilitates assessment of progressive growth r Open to continually assessing and improving
of emotional competence.34 skills as team member and leader
When an performance gap in emotional
competence is identified, it is important for
leaders to support employees to develop desired Figure 2: Excerpt of a competency used to assess
attributes. According to Daniel Goleman,35 the attitude (affective) domain.
emotional competence can be enhanced and Used with permission from Sharp Memorial Hospital,
starts with a personal commitment to change San Diego, California.
followed by an assessment of associated
attributes or competencies. Many strategies the tenets of emotional competence also facil-
exist for ongoing development of emotional itates development of emotional competence
competence and include engaging in reflective in the newly hired CNS. In these ways, indi-
learning, enlisting a mentor, attending courses, viduals and the organization in which they
reading books, and reviewing online content. function can foster emotional competence
If it becomes apparent that an employee is and contribute to successful role implementa-
unable or unwilling to demonstrate or develop tion of the CNS.
emotional competence, it is incumbent upon
a nurse leader to jointly develop a remedia- REFERENCES
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MO: Saunders Elsevier; 2007.
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process to remove the employee from the Bantam Books; 1995.
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6. Güleryüz G, Güney S, Aydin EM, Aşan O. The mediat-
ing effect of job satisfaction between emotional intelli-
Summary gence and organisational commitment of nurses: a
The importance of emotional competence questionnaire survey. Int J Nurs Stud. 2008;45(11):
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7. Sener E, Demirel O, Sarkla K. The effect of the emo-
Emotional competence increases an individu- tional intelligence on job satisfaction. Stud Health
al’s job satisfaction and work engagement Technol Inform. 2009;146:710-711.
and decreases burnout.6-8 As CNSs lead and 8. Codier E, Kamikawa C, Kooker BM, Shoultz J. Emotional
intelligence, performance, and retention in clinical staff
facilitate teams, emotional competence is nurses. Nurs Adm Q. 2009;33(4):310-316.
required to achieve desired outcomes and 9. Adams KL, Iseler JI. The relationship of bedside nurses’
emotional intelligence with quality of care. J Nurs Care
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12. Cummings G, Hayduk L, Estabrooks C. Mitigating the
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14. Bulmer Smith K, Profetto-McGrath J, Cummings GG. performance. Renaissance Executive Forums website.
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AACN Advanced Critical Care
Volume 27, Number 2, pp. 152-157
© 2016 AACN

Creating a Healthy

W o r k p la c e Nancy Blake, RN, PhD, CCRN, NEA-BC

Department Editor

Shared Governance for a Healthy Work

Environment in a Pediatric Cardiothoracic
Intensive Care Unit
Nida Sulit Oriza, BSN
Victoria Winter, MSN
Flerida Imperial-Perez, MN

A healthy work environment (HWE) is a key component of affirming the

role of nurses in promoting excellent outcomes for patients.1 In 2005,
when the American Association of Critical-Care Nurses (AACN) implemented
its HWE standards,1 a group of staff nurses from the cardiothoracic intensive
care unit’s (CTICU’s) recruitment and retention committee collaborated with
the leaders of the unit to implement the HWE standards. The impetus for
adopting the HWE standards was the unit’s staff turnover rate, which was as
high as 30%, requiring the hiring of 10 new nurses every year, a pace that
was still not enough to keep up with the staff resignations. Moreover, the fre-
quent use of agency nurses, overtime pay for regular staff, and the cost of
training and orientation of new hires had a financial impact on the organiza-
tion. The unit’s leaders believed that staff engagement was an important aspect
of achieving an HWE. The unit’s philosophy for staff employment evolved
into hiring for fit within the work values and culture.2 Consequently, a shared
governance council was formed to provide a venue for and sustain staff engage-
ment. This column describes using the HWE standards to implement a unit-
based shared governance council.

The Heart Institute of Children’s Hospital of Los Angeles (CHLA) is a world-
wide leader in the treatment of congenital or acquired heart disease in children.
The Heart Institute includes a 24-bed CTICU, a 21-bed cardiovascular acute
unit, 2 cardiac catheterization laboratories, an echocardiography laboratory,
and ambulatory practice. The CTICU is often referred to as the “heart of the
Heart Institute,” serving patients from 0 to 21 years of age. The unit provides
care for medical and surgical cardiac patients and has a mean of 900 surgical
admissions per year.

Nida Sulit Oriza is Lead Charge Nurse, Cardiothoracic Intensive Care Unit, Heart Institute, Children’s
Hospital Los Angeles, 4650 Sunset Blvd, #74, Los Angeles, CA 90027 (
Victoria Winter is Relief Charge Nurse, Cardiothoracic Intensive Care Unit, Heart Institute, Children’s
Hospital Los Angeles, Los Angeles, California.
Flerida Imperial-Perez is Clinical Manager and Clinical Nurse Specialist, Children’s Hospital Los Angeles,
Los Angeles, California.
The authors declare no conflicts of interest.

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Creating a Healthy Workplace

Shared Governance Council Develop Evidence-Based Practice Standards.

Shared governance is a care system model Staff champions developed standards of care
based on professional values and ideals of for safe sleep, prevention of hospital-acquired
autonomy, decision making, and participa- pressure ulcers, and care of patients with the
tion.3 Nurses have the freedom to participate HeartWare ventricular assist device (Heart-
fully in the practice of nursing and in shaping Ware International Inc). After deliberations
their work environment.4 An HWE must meet among council members, they assign the
6 standards: skilled communication, true col- strength of the evidence using the evidence
laboration, effective decision making, appro- rating scale of the Johns Hopkins Nursing
priate staffing, meaningful recognition, and Evidence-Based Practice Model and Guide-
authentic leadership.1 These 6 attributes were lines.5 Nurses are engaged in the review of
used as the guiding principles in implement- current research and in the development of
ing the unit-based shared governance council. clinical guidelines to better align nursing
Unit leaders and nursing staff worked practices with the best available scientific
together to transform the unit into an HWE, evidence. Working with the clinical nurse
1 standard at a time. A staff survey was devel- specialist and the rest of the CTICU nurse
oped with questions based on the 6 HWE managers, the staff nurses are empowered
standards. The staff response from the survey to identify performance gaps with the goal
confirmed the unhealthy state of the work of establishing interventions that are based
environment and served as a driving force in on best evidence.
addressing and implementing changes in the
workplace. An oversight group was developed Goal 2: Engage in Interdisciplinary
to assist with this process, and it included Interventions to Prevent Hospital-
nurses, unit nursing leaders, physicians, and Acquired Complications
respiratory care practitioners. The group devel- Objective: Achieve, Exceed, and Sustain
oped a mission statement that served as a Core Measure Targets. The unit-based inter-
guide to implementing change and achieving disciplinary performance improvement com-
the goal of providing excellent care to patients mittee defines and compares patient outcome
and their families. measures with the Centers for Disease Con-
A formalized shared governance structure trol and Prevention, AACN Healthy Work
was implemented in the CTICU to provide a Environment, and the Agency for Healthcare
venue for the CTICU staff to bring up clinical Research and Quality. Staff nurse champions
practice issues. A core group of staff nurses work closely with the unit-based clinical
met with the clinical nurse specialist to develop nurse specialist and where applicable present
a shared governance council model in align- and publish results of outcome measures
ment with the house-wide collaborative gov- studied. They continue to measure key patient
ernance council model. The CTICU’s shared outcomes, including hospital-acquired infec-
governance council structure provides nurse- tions, addressing hand hygiene compliance,
driven solutions to practice issues, evidence- ventilator-associated pneumonia, catheter-
based nursing care standards, and Lean measures related bloodstream infections (CR-BSIs),
of care delivery. It provides a forum where urinary tract and surgical site infections,
all staff can bring any concerns or questions reduction of medical errors, and improve-
related to patients. As concerns in current ment of hand-off communications. Different
practice are identified, proposed changes are staff members are involved in implementation
collaboratively developed, and strategies for of processes for monitoring compliance and
implementation of the changes are discussed improvement of current practices.
in the monthly meetings of the shared gover- One example of ongoing work is the
nance council. Every year, the shared governance implementation of evidence-based practices to
committee selects goals for the year. For 2015, decrease CR-BSIs that was started in 2005.
3 main goals were identified. The outcomes were presented at AACN’s
National Teaching Institute and Critical Care
Goal 1: Focus on Transforming Exposition in 2009, in the poster titled “The
Care at the Bedside Impact of Evidence-Based Practices in Reduc-
Objective: Develop Transformational ing Catheter-Related Blood Stream Infections
Leaders or Staff Champions Who Can in a Pediatric CTICU.” Since then, CR-BSI

Creating a Healthy Workplace W W W .AACN ACCON LIN E .ORG

rates have ranged from 0 to 1.5 per 1000 facilities have shared governance as the most
catheter days; however, by July 2015, the common structure reported. Involving nurses
CTICU had experienced an increase in CR-BSIs. in effective decision making through the use
The shared governance council engaged staff of shared governance structures also meets a
champions to address the current problem. crucial requirement of the AACN Standards
The group used the fishbone diagram, also for HWE.1 Embracing the shared governance
known as cause and effect analysis, introduced model has resulted in increased staff partici-
by Dr Kaoru Ishikawa.6 The diagram is a pation in identifying and presenting patient
graphic illustration of the relationship between care issues, identifying ways to participate in
the many potential causes and all factors that finding solutions, attending meetings, and
affect the increase in CR-BSIs. The staff providing feedback. Participation and engage-
champions assessed the knowledge and com- ment of the staff nurses on the night shift in
pliance of nursing staff and reviewed the various unit projects has also increased. Vari-
quality of our current evidence-based practices. ous structures and processes are in place in
Key causes were prioritized and action plans the unit that support an HWE and are in line
were developed. The CTICU is currently in with the AACN HWE standards. Numerous
the implementation phase of the campaign to initiatives spearheaded by the CTICU’s
decrease the rate of CR-BSIs to zero. This shared governance council are described in
program remains a collaborative effort the next section.
between the nursing staff, nursing leaders,
the physician group, and the hospital’s infection CTICU Projects Categorized by
control department. We continue to monitor HWE Standard
CR-BSI events closely, and for every confirmed True Collaboration and Effective
infection, a root cause analysis is done and Decision Making
presented to the CTICU’s performance improve- The shared governance council uses true
ment committee and the staff for follow-up. collaboration and effective decision making,
More emphasis is placed on compliance with with every CTICU staff member contributing
best practices and staff accountability. to the overall achievement of any given proj-
ect. An example is the withdrawal prevention
Goal 3: Focus on the Top 5 protocol, developed and instituted by a team
Problem List of physicians, nurse practitioners, pharmacists,
Objective: Use “I” Reports as a Platform and bedside nurses. Implementation of this
to Identify Measures to Improve Patient protocol resulted in a decrease in overall
Safety. From incident reports, the shared gov- ICU days and length of hospital stay.
ernance council can identify the top 5 prob-
lems related to patient safety in the unit. Staff True Collaboration and Skilled
members are encouraged to identify various Communication
staff champions and team members who will Another example of true collaboration is
work on the problems identified. They work the CTICU daily goal sheet (DGS). Following
on finding solutions and identifying and pre- the implementation of nurse-led daily rounds,
senting standards of care needed. Staff the DGS was developed by nursing staff
champions are currently working on stan- champions, nurse leaders, and the CTICU’s
dardization of parenteral and lipid infusions, medical team. Daily interdisciplinary rounds
interhospital transport guidelines, and a stan- allow a real-time exchange of information,
dard of care for pacer wires. making the goals and plan of care clear to
every member of the health care team. Before
Magnet and Beacon Designations this work, communication between members
CHLA is a Magnet-designated hospital of the health care team was suboptimal, but
and the CTICU is an AACN Gold Beacon communication has improved with the use
awardee. In 2002, McClure and Hinshaw7 of the structured form. Use of the DGS was
reported results of a national survey indicat- intended to close the loop of the team’s plan
ing that 55% of units surveyed had formal- of care for the upcoming 24 hours. The aims
ized shared governance structures, legitimizing of the project included (1) development of the
nurses’ decision-making control over their DGS as a tool for communicating the daily
professional practice. Magnet-designated plan of care among all of the child’s caregivers,

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Creating a Healthy Workplace

including consultants and team members who processes are examples of ways to improve
may not have been present during the daily communication and collaboration among the
rounds, (2) facilitating communication with team members and facilitate efficient patient
team members on the night shift, and (3) and unit work flow.
encouraging and reminding nurses and physi-
cians about timely interventions and altera- Appropriate Staffing
tions to the plan of care for changes in clinical Inadequate staffing is “one of the most
status. The work group has used staff input harmful threats to patient safety and the
through online surveys to revise the DGS to well-being of the nurses.”1 The CTICU pro-
make it user-friendly and to increase aware- vides care for patients with the highest mean
ness of the DGS. Through efforts such as acuity at CHLA. To meet this challenging
these, the nursing staff has opportunities to demand, a highly skilled nursing staff is
influence decisions that affect the quality of required. The AACN Staffing Blueprint:
patient care. Staff members feel that they are Constructing Your Staffing Solutions9 and
valued and committed partners in care. the AACN Synergy Model for Patient Care10
In 2005, the CTICU had a 30% turnover provide resources for best practices that guide
rate. Lack of effective communication was CTICU staffing. Patients’ outcomes are
identified as a unit problem. Reports of The optimized when patients’ needs and nurses’
Joint Commission on Accreditation of Health competencies are matched with one another.
Care Organizations8 cited inadequate com- Staffing practices are designed to meet the
munication as the most frequent root cause needs of patients and their families, address
of sentinel events. Skilled effective communi- the needs of the nursing work force, and
cation is the key to develop and ensure high- promote the health and well-being of every
quality, patient-centered care while engaging staff member involved.1 The CTICU staffing
and retaining staff. The CTICU uses multiple guidelines updated in 2015 are based on the
strategies to improve communication, team- changing conditions of patients’ acuity; nurses’
work, and patient safety. skills, training, and experience; availability
Rounding for Outcomes. Developed by the of support staff; and the physical layout of
unit nursing managers and the medical direc- the unit.
tor, weekly rounding with staff for day and The charge nurses continuously assess the
night shifts initiates discussions between staff work flow of the unit and consistently match
and unit managers regarding patient safety patients to nurses to ensure safety and best
issues and staff dissatisfiers. Feedback is outcome. They evaluate and obtain real-time
solicited in relation to concerns with unit work updates that are based on changing patient
flow, process improvement, and staff morale. acuity. The charge nurse collaborates with the
Staff members are also given opportunities to CTICU’s attending physician and the bedside
identify what is positive and working well in nurses to make adjustments in response to
the unit and recognize their coworkers who changes in patient acuity, as well as in the
have made a difference in their work. needs of patients’ families. The CTICU’s
Unit Huddles. Unit huddles are started managers are available 24 hours a day for
before each shift. Assignments are given to the support and assistance with staffing demands.
incoming nurses, and the needs of the unit and Onboarding. One strategy used by the unit
patient throughput are also presented. for recruitment and retention is the concept
Situational Awareness. A charge nurse also of onboarding. Onboarding is defined as a
leads a situational awareness session with the holistic approach that combines people, pro-
CTICU’s multidisciplinary team at the begin- cess, and technology to optimize the impact
ning of each shift. The charge nurse presents of a new hire to the organization. Onboard-
the unit census, availability of staff and beds ing requires more than just an orientation.
for admissions, discharge/transfer plans to It also requires long-term employee support
be approved, in-house patient transports for and follow-up. New hires all have a bachelor
diagnostic imaging, and planned patient pro- of science degree in nursing. Schmalenberg
cedures such as sternum closure or balloon and Kramer11 cited the reports of Aiken and
septostomy to be done at the bedside. Patients Tourangeau that hospitals with lower mortal-
who may need closer monitoring to prevent a ity rates have higher percentages of nurses with
more critical event are also identified. These bachelor’s degrees in nursing. The CTICU’s

Creating a Healthy Workplace W W W .AACN ACCON LIN E .ORG

managers have included staff bedside nurses provided to staff after they have 2 years of
in the interview process for potential nursing clinical experience in the unit. The curriculum
staff for early identification of the applicant’s includes more leadership concepts of emotional
core values, attitudes, and behavior in rela- intelligence, servant leadership, and tools for
tion to the CTICU’s mission and its values. effective communication and conflict resolution.
This process ensures early alignment and Our highly acute and fast-paced CTICU
accountability of new nurses. creates challenges that potentially impede the
Residency Program. The CTICU has a staff- growth and development of staff at all levels
driven, preceptor-based residency program of experience. We have an increase in novice
for new hires. The postorientation debriefing nurses, diverse and individualized professional
serves as a venue to discuss difficult situations development needs, and some feelings of
and to have crucial conversations to develop inadequate management support. Attention
trusting relationships. When problems are to the growth and development of each mem-
identified, strategies are discussed for resolu- ber of the nursing staff increases job satisfac-
tion and resources are identified to assist the tion and is a predictor of the nurses’ intent
new staff member. Open communication is to stay. Staff champions in collaboration with
maintained throughout the onboarding process. nursing managers developed color-coded
Advancement Programs. Another strategy professional development teams. Nurses are
to improve retention is the implementation divided into 3 color-coded teams. One team
of various advancement programs for CTICU is highlighted every 6 weeks of the current
nurses. Members of the CTICU’s education schedule. The nurses discuss with a specific
committee develop processes for recognizing manager their development needs and goals
nurses’ development from novice to expert that can be addressed during the rotation.
in providing or influencing patient care. The The goals can vary from more opportunities
CTICU’s pull-back program is a specialized to care for higher acuity patients to advance
unit-based continuing education program their clinical growth or assigning them to serve
for staff who are within 2 years of hire. This as a preceptor, shift resource nurse, or team
program addresses concerns about knowl- leader to advance their leadership skills. The
edge gaps of novice nurses. An advancement goals are accessible to charge nurses, who can
resource nurse is assigned to new staff who help provide the opportunities as they make
recently completed their orientation, to sup- assignments for the shift. This program facili-
port them in time management, prioritization tates open communication between manage-
skills, performance of CTICU standards of ment and staff. It also encourages the staff
care, delegation, and documentation. Staff- to be more accountable and empowered to
driven, 8-hour heart conferences and sympo- reflect on their own professional and personal
siums, supported by the Heart Institute and development. It offers development related to
held annually during the congenital heart advanced critical thinking skills as the nurses
disease month of February, are well attended are given higher acuity patient assignments and
by nursing staff and other disciplines. The leadership opportunities. This nurse advance-
symposium presents current innovations and ment program incorporates the 6 strategies
strategies with regard to excellent care of of the AACN HWE, creating an environment
patients with congenital and acquired heart of nurse empowerment. This program was
disease. Highlights include a continuum of presented to the Association of California
care including fetal diagnosis and surgical/ Nurse Leaders (ACNL) in February 2015,
medical interventions to discharge. Families titled “Promoting Staff Engagement and
are also invited to share the challenges of their Professional Development Teams in CTICU.”
journey as they deal with the care of their child.
New technologies of care such as the Berlin Meaningful Recognition and
Heart (Berlin Heart GmbH) and HeartWare Authentic Leadership
ventricular assist devices are also presented. Leaders in the unit are strong advocates for
A road-to-leadership training program to HWEs and they truly model the behavior they
prepare staff to take on informal leadership expect from the staff. These authentic leaders
roles in the unit by developing the knowledge do what they can on a regular basis to sup-
and skills required to meet leadership respon- port the staff and celebrate their successes.
sibilities is another advancement program They give kudos to their staff when they have

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Creating a Healthy Workplace

done something that is worthy of meaningful REFERENCES

recognition, and staff members feel supported 1. American Association of Critical-Care Nurses. AACN
standards for establishing and sustaining healthy work
as a result of this recognition. environments: a journey to excellence. Am J Crit Care.
Summary 2. Collins J. Good to Great and the Social Sectors. Boulder,
CO: A Monograph Company; 2005.
Each member of the CTICU nursing team 3. Anthony MK. Shared governance models: the theory, prac-
is committed to the principles of HWEs. The tice and evidence. Online J Issues Nurs. 2004;9(1):138-153.
4. Kramer M, Schmalenberg C, Maguire P, et al. Walk the
shared governance council has facilitated con- talk: promoting control of nursing practice and patient-
trol of their nursing practice. Shared gover- centered culture. Crit Care Nurse. 2009;29(3):77-93.
nance enables the CTICU nurses to use 5. Dearholt S, Dang D. Johns Hopkins Nursing Evidence-
Based Practice Model and Guidelines. 2nd ed. Indian-
evidence-based practices to improve the qual- apolis, IN: Sigma Theta Tau International; 2012.
ity of care they provide to patients and 6. Ishikawa K. Guide to Quality Control. 2nd ed. Tokyo,
patients’ families. Team members are respon- Japan: Asian Productivity Organization; 1986. 
7. McClure MI, Hinshaw AS. Magnet Hospitals Revisited:
sible and accountable for the shared decisions Attraction and Retention of Professional Nurses. Wash-
of the team. This arrangement affects patient ington, DC: American Nurses Publishing; 2002.
care as well as patient/family and staff satis- 8. Joint Commission on Accreditation of Health Care Organi-
zations (JCAHO). Statistics: Root Cause of Sentinel Events
faction. The CTICU has increased its recruit- (All Categories). Oak Brook Terrace, IL: JCAHO; 2005.
ment and retention rate and decreased its 9. American Association of Critical-Care Nurses. Staffing
Blueprint: Constructing Your Staffing Solutions.
turnover rate from 30% in 2005 to 5% in Aliso Viejo, CA: AACN; 1999.
2015. With progress and improvement, the 10. Hardin SR, Kaplow R. Synergy for Clinical Excellence:
challenge remains for all of the staff to be The AACN Synergy Model for Patient Care. Boston,
MA: Jones & Bartlett Publishers Inc; 2005.
accountable as a team, sustaining the success 11. Schmalenberg C, Kramer M. Clinical units with the healthi-
of having an HWE in the pediatric CTICU. est work environments. Crit Care Nurse. 2008;28(3):65-71.

AACN Advanced Critical Care
Volume 27, Number 2, pp.158-161
© 2016 AACN

P e d ia t r ic Lori Williams, RN, DNP, RNC-NIC, CCRN,

Perspectives NNP-BC
Department Editor

Impact of Family-Centered Care on Pediatric

and Neonatal Intensive Care Outcomes
Lori Williams, RN, DNP, RNC-NIC, CCRN, NNP-BC

F amily-centered care is an approach to medical care rooted in the belief

that optimal health care outcomes are achieved when patients’ family
members play an active role in providing emotional, social, and developmen-
tal support.1 Attention is shifted away from disease and toward the patient
within the context of family and community.2 The family is recognized as the
child’s primary source of strength and support. It is recognized that perspec-
tives and information provided by families and their children are essential
components of high-quality clinical decision making. Patients and their fami-
lies are viewed as integral partners with the health care team.3
Although the term was not coined then, family-centered care was the approach
for infants born in the United States in the 1800s. Most infants were born at
home with little involvement of physicians. Care was almost exclusively pro-
vided by the mother, with help from extended family members who were
usually female. This approach changed in the 1900s, when Dr Martin Couney
invented the incubator, which separated mothers from their infants. This era
also marked the beginning of the separation of the neonate from its family.
This separation continued into the 1930s as labor and delivery moved from
the home into the hospital, owing to improved health outcomes brought about
by medical inventions and infection control measures. Mother-infant care
dramatically shifted from in-home and family-focused care to the hospital.
Laboring women were separated from their family, and mothers were sepa-
rated from their infants. Stricter regulations about family presence and partici-
pation in care caused physicians to become authorities, nurses to become
gatekeepers, and families to become bystanders.4
In the 1940s, the necessity to address the family’s need for proximity in the
hospital was identified. It was not until the 1970s, however, that the family-
centered care movement began. In 1993, the Institute for Patient- and
Family-Centered Care was founded, and family-centered care concepts were
introduced.2,5 Evidence from research revealed that better clinical outcomes
could be achieved when the patient’s family was included in decision making.6,7
In 2001, the Institute of Medicine strongly recommended that health care
delivery systems become patient-centered rather than disease- or clinician-
centered. Treatment recommendations and decision making were to be tailored
to the patient’s preferences and beliefs.8 In this model, patients and their families

Lori Williams is Clinical Nurse Specialist, Universal Care Unit, American Family Children’s Hospital,
University of Wisconsin Hospital and Clinics, Mail Code C850, 1675 Highland Avenue, Madison, WI
53792 (
The author declares no conflicts of interest.


VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Pediatric Perspectives

are to be kept informed and actively involved of parents in bedside rounds and discharge
in decision making and self-management, planning rounds increases parents’ satisfac-
patient care is coordinated and integrated tion with the time spent with the team, the
across providers, delivery systems provide number of questions the team answered,
for the physical comfort and emotional sup- how well the child was respected, and how
port of the patient/family, providers have a seriously staff took parents’ concerns.15,16
clear understanding of the patient’s concept Videoconferencing technology helps families
of illness and cultural beliefs, and providers stay connected with their child and the day-
understand and apply the principles of dis- to-day changes that occur during medical
ease prevention and behavioral change appro- rounds when parents cannot be present.4
priate for diverse populations.9 Parents are no longer viewed as visitors, but
Currently, many neonatal intensive care are invited to be present at the bedside 24
units (NICUs) continue the practice of clos- hours per day. Visiting hours for other per-
ing the unit to parents, siblings, and visitors sons identified by the family as supports have
during shift changes, report, medical rounds, been expanded. Siblings are now included
admissions, emergencies and deaths. The ratio- as important visitors.12,17 When siblings are
nale for this practice is to protect the privacy allowed to visit, research has reported fewer
of the infants. Parents are often still asked to behavioral problems, decreased aggressive
step out during medical procedures despite and regressive behavior among siblings,18
evidence that parental presence can reduce and increased sense of family as a unit.15
the child’s pain and parental anxiety.1 NICU
culture is inconsistent within and among units. Implementation of Kangaroo
Parents report dissatisfaction with their oppor- (Skin-to-Skin) Care and
tunities for involvement, physician to parent Lactation Support
communication, availability of information, Support for exclusive breastfeeding or the
and planning for the transition home.10 provision of breast milk has increased. Lacta-
tion support has improved with the hiring
Impact on Unit Design and of lactation counselors and consultants in
Culture many hospitals. Kangaroo care (skin-to-skin)
Family-centered care concepts have brought has been implemented as a means to help
about many changes over the years. Unit designs mothers maintain their milk supply. Skin-to-
for pediatric intensive care units (PICUs) and skin holding contributes to a parental sense
NICUs have changed from large open bays of well-being, confidence, and competence
separated by curtains to single/private room while reducing stress.19 Skin-to-skin contact
designs. Unit design includes space for the also decreases maternal postpartum depres-
patient and space designed with amenities sion and anxiety20,21 and increases maternal
for parents to be able to stay overnight in sensitivities, affectionate behaviors, and bond-
the patient’s room. This encourages parental ing.19,22 Fathers report decreased fear of hold-
participation in daily care such as feeding ing and harming their infant when they are
and presence at procedures. Parental presence participating in skin-to-skin care.23
and participation in caregiving builds parents’
confidence long before discharge.11-13 Having Parent and Family Education
parents at the bedside decreases the child’s Resources
emotional distress, increases the child’s coping The provision of education for parents
during procedures, and improves the child’s increases their participation in discussion
adjustment during the hospitalization, after and decreases maternal stress.2,11,24 Education
hospitalization, and during recovery.3 Families can also lead to more effective use of health
are also encouraged to personalize the hospital care resources and improved follow-through
experience by personalizing the patient’s space. with the collaborative discharge plan.3 Health
Best-practice standards for NICU design information is now being provided via a
recommend provision of a family library or variety of means such as hospital kiosks and
education area.14 Medical rounds and nursing websites with a consumer focus. Classes may
shift reports have moved from conference rooms include cardiopulmonary resuscitation, sud-
to the bedside and include parents and their den infant death syndrome prevention/safe
patients as active participants. The inclusion sleep, how to have a smoke-free home, and

Pediatric Perspectives W W W .AACN ACCON LIN E .ORG

car seat safety. Many hospitals have new NICU REFERENCES

parents spend the night in a transition room 1. American Academy of Pediatrics Policy Statement.
Family-centered care and the pediatrician’s role. Pedi-
before discharge.25 atrics. 2003;112:691-696.
2. Johnson B. Family-centered care: four decades of pro-
Family Support Resources gress. Fam Syst Health. 2000;18(2):133-156.
3. Committee on Hospital Care and Institute for Patient-
Support for parents comes in a variety of and Family-Centered Care. Patient- and family-centered
forms also. Families may be provided with care and the pediatrician’s role. Pediatrics. 2012;129(2):
books, scrapbooking materials, craft projects, 394-404.
4. Phillips C. Family-Centered Maternity Care. Boston,
or journals to fill the long days. Support may MA: Jones and Bartlett Publishing; 2003.
focus on specific populations such as children 5. Conway J, Johnson BH, Edgmon-Leviton S, et al. Part-
nering With Patients and Families to Design a Patient-
with congenital heart disease, spinal muscle and Family-Centered Health Care System: A Roadmap
atrophy, or prematurity. Families may now for the Future—A Work in Progress. Bethesda, MD:
have a designated family support person to Institute for Family-Centered Care and Institute for
Healthcare Improvement; 2006.
help them navigate the health care system.26 /pages/publications/partneringwithpatientsandfamilies
The role of the family support specialist is to .aspx. Accessed January 30, 2016.
decrease parental stress and increase parent- 6. Pollack MM, Koch MA. Association of outcomes with
organizational characteristics of neonatal intensive care
ing confidence.26 Support groups or parent- units. Crit Care Med. 2003;31:1620-1629.
to-parent support offers contact with other 7. Stewart M, Brown JB, Donner A, et al. The impact of
families who have or had a child in the patient-centered care on outcomes. J Fam Pract. 2000;
NICU/ PICU. These supports have effectively 8. Institute of Medicine. Crossing the Quality Chasm: A
adapted to or integrated the experience and New Health System for the 21st Century. Washington,
DC: National Academies Press; 2001.
can be a valuable source of information, 9. Davidson JE, Powers K, Hedayat KM, et al. Clinical
advice, hope, and support.1,11,26,27 Active mes- practice guidelines for support of the family in the
sage boards with online communities offer patient-centered intensive care unit: American College
of Critical Care Medicine Task Force 2004-2005. Crit
an alternative to face-to-face support groups. Care Med. 2007;35(2):605-622.
Parents with peer support experience less 10. Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse
state anxiety, less depression, and greater JL, Berns SD. Family support and family-centered care
in the neonatal intensive care unit: origins, advances,
social support.28 impact. Semin Perinatol. 2007;35:20-28.
11. Harrison H. The principles for family-centered neonatal
Outcomes of Implementation of care. Pediatrics. 1993;92:643-650.
12. Franck L, Spencer C. Parent visiting and participation in
Family-Centered Care infant caregiving activities in a neonatal unit. Birth.
When family-centered care is implemented, 2003;30:31-35.
length of stay has decreased in many stud- 13. Örtenstrund A, Westrup B, Broström E, et al. The
Stockholm Neonatal Family Centered Care Study:
ies,13,24,29 thus decreasing health care costs.3 effects on length of stay and infant morbidity. Pediat-
A significant reduction in nonurgent visits rics. 2010;125:e278-e285.
14. White R. Recommended standards for newborn ICU
to the emergency department has also been design. J Perinatol. 2006;26:S2-S18.
reported.30 Parental satisfaction with overall 15. Landry M, Lafrenay S, Roy M, et al. A randomized,
care increased in many studies.26,31,32 Parents controlled trial of bedside versus conference-room
case presentation in a pediatric intensive care unit.
had an improved perception of the provid- Pediatrics. 2007;120:275-280.
ers’ competence.33 Staff also benefit when 16. Lewis C, Knopf D, Chastain-Lorber K, et al. Patient,
family-centered care is implemented. Many parent and physician perspectives on pediatric oncol-
ogy rounds. J Pediatr. 1988;112:378-384.
studies report improved staff satisfaction as 17. Montgomery L, Kleiber C, Nicholson A, et al. A research-
evidenced by more positive feelings about based sibling visitation program for the neonatal ICU.
work,1 a decrease in the number of nursing Crit Care Nurse. 1997;17(2):29-40.
18. Ballard J, Maloney M, Shank M, et al. Sibling visits to a
vacancies,5(pp14-15) improved job performance,1 newborn intensive care unit: implications for siblings,
and an increased ability to recruit and parents and infants. Child Psychiatry Hum Dev. 1984;
retain staff.26 19. Gayle G, Vandenburg KA. Kangaroo care. Neonat
Have we gained from implementing family- Netw. 1998;17:69-71.
centered care in our intensive and acute-care 20. Anderson GC, Moore E, Hepworth J, et al. Early skin to
skin contact for mothers and their healthy newborn
pediatric environments? Looking back over infants. Birth. 2003;30:206-207.
32 years, I say yes. The evidence also suggests 21. De Alencar AE, Arraes LC, de-Albuquerque EC, et al.
that there is much to gain when patients, par- Effect of kangaroo mother care on postpartum depres-
sion. J Trop Pediatr. 2009;55:36-38.
ents, and health care providers partner to 22. Ferber S, Makkous I. The effect of skin-to-skin contact
restore health. (kangaroo care) shortly after birth on the neurobehavioral

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Pediatric Perspectives

responses of the term newborn: a randomized, controlled 28. Preyde M, Ardal F. Effectiveness of a parent “buddy”
trial. Pediatrics. 2004;113(4):858-865. program for mothers of very preterm infants in a neo-
23. Bauer J, Sontheimer D, Fischer C, et al. Metabolic rate natal intensive care unit. CMAJ. 2003;168(8):969-973.
and energy balance in very low birth weight infants 29. Melnyk B, Feinstein N. Reducing hospital expenditures
during kangaroo care holding by their mothers and with the COPE (creating opportunities for parent
fathers. J Pediatr. 1996;129:608-611. empowerment) program for parents and premature
24. Melnyk B, Feinstein N, Alpert-Gillis L, et al. Reducing infants. Nurs Adm Q. 2009;33:32-37.
preterm infants’ length of stay and improving parents’ 30. Brousseau DC, Hoffman RG, Naltinger AB, Flores G,
mental health outcomes with the creating opportuni- Zhang Y, Gorelick M. Quality of primary care and sub-
ties for parent empowerment (COPE) neonatal inten- sequent pediatric emergency department utilization.
sive care program: a randomized, controlled trial. Pediatrics. 2007;119(6):1131-1138.
Pediatrics. 2006;118:e1414-e1427. 31. Van Rieper M. Family-provider relationships and well-
25. Broedsgaard A, Wagner L. How to facilitate parents being in families with preterm infants in the NICU.
and their premature infant for the transition home. Int Issues Neonat Care. 2001;30:74-84.
Nurs Review. 2005;52:196-203. 32. Ammentorp J, Mainz J, Sabroe S. Parents’ priorities
26. Cooper L, Gooding J, Gallagher J, et al. Impact of a and satisfaction with acute pediatric care. Arch Pediatr
family-centered care initiative on NICU care, staff and Adolesc Med. 2005;159(2):127-131.
families. J Perinatol. 2007;27:532-537. 33. Moore P, Adler W, Robertson P. Medical malpractice:
27. Nottage S. Parents’ use of nonmedical support services the effect of doctor patient relations on medical patient
in the neonatal intensive care unit. Issues Compr Pedi- perceptions and malpractice intentions. West J Med.
atr Nurs. 2005;28:257-273. 2000;173:244-250.

AACN Advanced Critical Care
Volume 27, Number 2, pp. 162-172
© 2016 AACN

Evaluation of Pain Assessment

Tools in Patients Receiving
Mechanical Ventilation
Zainab Q. Al Darwish, RN, MSc

Radwa Hamdi, MD

Summayah Fallatah, MD

Pain assessment poses a great challenge for both the BPS and the CPOT, = 0.86 for the
clinicians in intensive care units. This descrip- NVPS), and all subscales of both the BPS and
tive study aimed to find the most reliable, CPOT were highly sensitive for assessing
sensitive, and valid tool for assessing pain. pain (P < .001). The NVPS physiology (P = .21)
The researcher and a nurse simultaneously and respiratory (P = .16) subscales were not
assessed 47 nonverbal patients receiving sensitive for assessing pain. The BPS was the
mechanical ventilation in the intensive care most reliable, valid, and sensitive tool, with
unit by using 3 tools: the Behavioral Pain the CPOT considered an appropriate alterna-
Scale (BPS), the Critical-Care Pain Observa- tive tool for assessing pain. The NVPS is not
tion Tool (CPOT), and the adult Nonverbal recommended because of its inconsistent
Pain Scale (NVPS) before, during, and after psychometric properties.
turning and suctioning. All tools were found Keywords: pain, pain assessment tools,
to be reliable and valid (Cronbach = 0.95 for turning, suctioning, BPS, CPOT, NVPS

P atients in critical care settings confront a

variety of stressors that can cause pain
and suffering. Many routine procedures, such
impaired.4 Thus nonverbal pain assessment
tools are needed. Much attention has been
paid to the development of standardized pain
as turning and tracheal suctioning, are known assessment scales for critically ill patients;
to be painful to patients in intensive care units however, some of these tools show limitations
(ICUs).1 Furthermore, the pain experienced and lack generalizability.5
by critically ill patients can be complicated
by many other factors, such as underlying
disease, surgical interventions, wounds, inva-
Zainab Q. Al Darwish is Nursing Lecturer, The Saad College
sive catheters, and endotracheal intubation.2 of Nursing & Allied Health Sciences, Al Khobar 31952, Saudi
Inadequately treated pain in critically ill patients Arabia (
can lead to marked alterations in immunity
Radwa Hamdi is Assistant Professor, Department of Intensive
and cardiovascular, neurological, and pulmo- Care Medicine, College of Nursing, University of Dammam,
nary function.2 Al Khobar, Saudi Arabia.
Unfortunately, pain assessment poses a great
Summayah Fallatah is Assistant Professor, Department of
challenge for clinicians in ICUs.3 Communi- Anesthesia and Pain Management, College of Medicine,
cation barriers can exist owing to the com- University of Dammam, Al Khobar, Saudi Arabia.
plexity of patients’ conditions, as many ICU
The authors declare no conflicts of interest.
patients are either undergoing mechanical
ventilation, heavily sedated, or cognitively DOI:


Because inadequately managed pain can Tools

cause many adverse physiological effects and A data collection tool was designed to
undesirable consequences, it is important to document demographic and medical data,
investigate the reliability and validity of the including age; sex; medical diagnosis; score
existing nonverbal pain assessment tools such on the Ramsay Sedation Scale; score on the
as the Behavioral Pain Scale (BPS), the Adult Glasgow Coma Scale (GCS); hemodynamic
Nonverbal Pain Scale (NVPS), and the Critical data; onset, duration, and setting of mechani-
Care Pain Observation Tool (CPOT) in order cal ventilation; analgesic and sedative agents;
to assess pain optimally in critically ill non- and score on the Acute Physiology and Chronic
verbal patients. Health Evaluation II (APACHE II).
The reliability, validity, and sensitivity of 3
Setting and Design pain assessment tools (BPS, CPOT, and NVPS)
Setting were studied.
The study was conducted in the medical, BPS. The BPS was developed by Payen et al6
surgical, and cardiac ICUs at King Fahd Uni- to assess pain in patients who were sedated
versity Hospital in Al Khobar, Kingdom of or receiving mechanical ventilation. The BPS
Saudi Arabia. King Fahd University Hospital contains 3 behavioral domains: Facial Expres-
is one of the major health care centers in the sion, Upper Limb Movement, and Compliance
Kingdom of Saudi Arabia with 600 beds. It With the Ventilator. Each domain is rated from
includes 14 ICU beds with 6 beds and 1 iso- 1 to 4. The minimum score is 3, indicating
lation room each in the surgical and medical no pain, and the maximum is 12, indicating
ICUs. The surgical ICU provides care to neu- the worst pain. The Facial Expression domain
rosurgical, trauma, and critically ill surgical was based on a study by Prkachin,7 who divided
patients. The medical ICU receives patients the painful facial expressions into 4 catego-
with respiratory disorders such as pneumonia, ries: brow lowering, orbit tightening, closing
respiratory failure, and chronic obstructive of the eyelids, and nose wrinkling/upper lip
pulmonary disease, as well as gastrointestinal rising. The other domains were adopted from
and nontrauma neurological cases. The cardiac the COMFORT scale used to assess distressed
ICU is a 10-bed unit, providing care and mon- children in the ICU.8
itoring for critically ill cardiac patients such CPOT. The CPOT was developed and vali-
as those with heart failure or coronary artery dated by Gélinas et al.9 It has 4 subscales,
diseases and after open heart surgeries and each rated on a 3-point Likert scale from 0 to
percutaneous cardiac interventions. 2, with a total score ranging from 0 to 8. The
The study was approved by the local subscales are Facial Expression, Body Move-
committee of biomedical ethics at Dammam ment, Muscle Tension, and Compliance With
University and King Fahd University Hospi- the Ventilator or Vocalization for Extubated
tal. Informed consent was obtained from Patients.9 Each domain of the CPOT has an
each patient’s first-degree relatives during operational definition to facilitate objective
the hospital’s visiting hours. rating. Gélinas et al9 note that some subscales
and their related descriptions were derived
Design from previously established pain assessment
A descriptive research design was used tools such as the BPS and the COMFORT
for this study, and a convenience sample of scale,8,10 whereas other indicators were estab-
ICU patients was recruited during a 3-month lished on the basis of a retrospective review
period, from January 2014 through March of medical records, interviews, and focus
2014. The sample included all patients under- groups with nurses and physicians to deter-
going mechanical ventilation who were unable mine the most frequent pain indicators in
to self-report pain, were more than 18 years critically ill patients.9
old, and whose condition was hemodynamically NVPS. The NVPS was developed at Strong
stable. Patients receiving neuromuscular block- Memorial Hospital/University of Rochester,
ers and patients who were quadriplegic, validated initially by Odhner et al11 and
exhibited brain death, or had conditions that revised by Kabes et al.12 The scale was based
mask behaviors or facial expressions were on the Faces, Legs, Activity, Cry, Consolability
excluded from the study. (FLACC) scale after some behavioral indicators


that are specific to children, such as cry and points that included both turning and suc-
consolability, were eliminated.13 The NVPS tioning. Both nociceptive procedures were
consists of 3 behavioral and 2 physiological performed only if the patient’s care required
domains with specific descriptions and defini- them, with an interval of at least 30 minutes
tions. Published evidence regarding the process between them. The 3 pain assessment tools
of selection of these domains is insufficient.14 were continuously used throughout the 5
The behavioral component consists of Face, measurement points by both the researcher
Activity/movement, Guarding, and the physio- and the ICU bedside nurse simultaneously,
logical indicators include Physiology/vital signs without any communication between them.
and Respiratory. The physiological indicators Both assessors had identical, but separate
are described as any change in the past 4 hours forms that contained the printed scales, with
of more than 20 mm Hg in systolic blood consistent use in the following order: NVPS,
pressure or more than 20 beats per minute in CPOT, and BPS. The hemodynamic data and
heart rate, and respiratory indicators as a analgesic or sedative agents used were recorded
change of more than 10 breaths per minute at each point of the assessment.
above baseline or a 5% decrease in oxygen
saturation as measured by pulse oximetry.12 Statistics
Before the start of data collection, a teach- SPSS version 19 (SPSS Inc) was used for data
ing and training session was given individually analysis of descriptive and inferential statistics.
to each primary ICU nurse who was responsi- The reliability value (r) for each tool was
ble for each study patient. Twenty ICU nurses obtained from the Pearson correlation test.17
were involved during the study period. The The interclass correlation coefficient (ICC),
duration of the teaching session was based defined as the r value, was used to examine
on the individual nurse’s needs, with a mean the reliability of the subscales of each tool in
duration of 30 minutes. Teaching strategies all measurement points across the 2 raters.
included oral discussion regarding the impact Validity was established by calculating the
of pain on critical illness, description of the Cronbach to determine internal consist-
aim of the study, and explanation of the ency. The Student t test was used to examine
components of each pain assessment tool. the sensitivity of each pain assessment tool.18
The oral discussion was supported with figures Each tool and its items were evaluated for
of facial pain expression that were inspired responsiveness, which is manifested by the
from Prkachin and used by the authors of ability of the tool to respond to minor changes
the BPS and the CPOT.6,7,9 Furthermore, the in the pain level over time. Responsiveness is
published figures for BPS by Chanques et al15 calculated by the effect size coefficient; first
were used as supportive educational tools to find the difference between the mean score at
clarify the other subscales of the BPS. The rest and the score during the painful procedure,
published guidelines for the CPOT with the and then divide that difference by the stand-
facial figures in the study by Gélinas et al16 ard deviation at rest. The effect size is consid-
also were used during the teaching session. ered small when it is less than 0.2, moderate
The operational definitions of the NVPS were when it is near 0.5, and large when it is more
explored in relation to the author’s descrip- than 0.8.19 Principal-factor analysis was used
tion in the revalidated version of the scale.12 to evaluate the scale dimension, by identify-
A trial of practical performance of pain assess- ing the large contributing factors to overall
ment at rest by using the 3 assessment tools pain scores.20 All results were considered sig-
was included in the teaching session to clarify nificant when P was less than .05 and highly
any knowledge defects that could affect the significant when P was less than .001.
accuracy of the assessment.
Methods Demographics
Each patient was assessed for pain at 5 Forty-seven patients from the medical, sur-
measurement points: at rest (baseline) before gical, and coronary ICUs at King Fahd Univer-
the first procedure, during suctioning, 20 sity Hospital who were receiving mechanical
minutes after suctioning, during turning, and ventilation were recruited to the study. Most
20 minutes after turning. Each patient was of the patients (49%) were recruited from the
exposed only once to these 5 measurement surgical ICU (Table 1). Patients assessed within


Table 1: Demographic Data and Sample (1.2) on the Ramsay Sedation Scale (Table 1).
Characteristics Unconscious patients who scored 5 to 6 on
the Ramsay Sedation Scale constituted 64%
Sample Characteristics Valuea of the study sample.
Age, mean (SD), years 55.5 (20.2)
Pain Assessment
Sex All 3 nonverbal pain assessment tools were
Female 20 (43) adequately reliable and valid with both
Male 27 (57)
Cronbach and r values greater than 0.85
APACHE II score, mean (SD) 20.6 (6.3) (Table 2).
Mortality rate, No. (%) of patients BPS. The sensitivity of the BPS to the
15%-25% 22 (47) presence of pain was established by a signifi-
40%-55% 21 (45) cant increase in the mean pain scores during
75% 4 (9) suctioning and turning (P < .001). These signif-
Glasgow Coma score, mean (SD) 6.38 (2.6)
icant differences in the scores indicate that
the tool and its components are a valid instru-
Ramsey Sedation score, mean (SD) 4.77 (1.2) ment to measure pain. In addition, the BPS
Patients’ intensive care unit was adequately responsive to minor changes
Surgical 23 (49) in pain level over the period of measurement
Medical 17 (36) points (Table 3). The ICC was excellent at rest
Cardiac 7 (15) across Facial Expression, Upper Limb Movement,
Diagnosis and Compliance With the Ventilator with r
Respiratory disorder 14 (30) values of 0.95, 0.92, and 0.90, respectively.
Cardiovascular disorder 7 (15) Lowest agreement was found in the Facial
Trauma 8 (17) Expression subscale during suctioning with
Neurological disorder 8 (17) an r value of 0.77; the r value for Upper Limb
Miscellaneous 10 (21) Movement was 0.85, and the r value for
Doses of sedative and analgesic agents, Compliance With the Ventilator was 0.80.
mean (SD) During the turning procedure, the ICC was 0.88
Fentanyl, µg/h 85 (42.6) for the Facial Expression subscale, 0.94 for
Midazolam, mg/h 3.5 (1.58) the Upper Limb Movement subscale, and 0.80
for the Compliance With the Ventilator subscale.
Abbreviation: APACHE II, Acute Physiology and Chronic Health
Evaluation II.
The correlation matrix of the BPS compo-
Values are No. (%) of patients unless otherwise indicated in the first nents was positively correlated at P less than
.001. The principal contributing factor to
pain was the Facial Expression subscale with
24 hours of intubation constituted 15% of the an r of 0.84, while the Compliance With the
study sample, 21% of patients were assessed Ventilator was the lowest contributing sub-
for pain during the first 24 to 48 hours, whereas scale (r = 0.70; Table 4).
64% of patients were assessed more than 48 CPOT. The CPOT and its subscales were
hours after mechanical ventilation was started. highly sensitive (P < .001), with variable respon-
With regard to the analgesic and sedative siveness to pain, ranging from moderate to
agents used in this study, it was noted that large (Table 5), with a Cronbach of 0.95,
19 patients (40%) were not receiving any sed- and an r value of 0.93. The interrater reliabil-
ative or analgesic agents; however, these 19 ity (r value) at rest was 0.94 for Facial
patients had a mean (SD) score on the GCS Expression, 0.99 for Body Movement, 0.74 for
of 6.94 (2.09). A total of 28 patients (60%) Muscle Tension, and 0.99 for Compliance
were receiving a variety of agents that were With the Ventilator. During suctioning, the r
administered as continuous infusions only, values were 0.81 for Facial Expression, 0.92
with most (40%) receiving a combination of for Body Movement, 0.47 for Muscle Ten-
fentanyl and midazolam infusions. The patients’ sion, and 0.83 for Compliance With the Ven-
consciousness level (GCS scores) were from 3 tilator. During turning, the r values were 0.82
to 11 with a mean (SD) score of 6.38 (2.6) for Facial Expression, 0.98 for Body Move-
on the GCS and a mean (SD) score of 4.77 ment, 0.69 for Muscle Tension, and 0.89 for


Table 2: Comparison of the Psychometric Properties of 3 Pain Assessment Scales

Behavioral Critical-Care Pain Nonverbal
Characteristic Pain Scale Observation Tool Pain Scale
Reliability (r) 0.90 0.93 0.86
Validity (Cronbach ) 0.95 0.95 0.86
Interclass correlation The lowest agreement in Weak agreement in the Lowest agreement in
coefficient the Facial Expression Muscle Tension subscale: the facial expression
subscale during r = 0.47 during suctioning subscale during
suctioning (r = 0.77) and r = 0.69 during turning suctioning (r = 0.72)
Sensitivity P < .001 P < .001 P < .001 (total scale)
Physiology and Respiratory
subscales are not sensi-
tive (P > .05; seeTable 7)
Responsiveness Large responsiveness Large responsiveness Large responsiveness
(effect size coefficient) during suctioning during suctioning during suctioning (r = 1.01)
(r = 1.20) and turning (r = 1.37), moderate and turning (r = 1.20)
(r = 1.87) during turning (r = 0.77) Small responsiveness in
Small to moderate the Physiology and
responsiveness across Respiratory subscales
all subscales (see Table 5) (r = 0.20-0.40)
Principal contributing Facial Expression (r = 0.84) Facial Expression (r = 0.80) Facial Expression (r = 0.87)
factor The lowest contributor is Very low contribution from
the Muscle Tension the Physiology and Respi-
subscale (r = 0.65) ratory subscales (r = 0.36)
Comments Inconsistent psychometric The Physiology and
property of the Muscle Respiratory subscales are
Tension subscale weak, with inconsistent
Variable responsiveness sensitivity and respon-
across the tool’s siveness across different
subscales measurement points

Table 3: Psychometric Properties of the Behavioral Pain Scale

Change in Mean Scores Change in Mean Scores
From Rest to Suctioning,a a
Effect Size From Rest to Turning, Effect Size
Behavioral Pain Scale Mean (SD) Coefficient Mean (SD) Coefficient
Facial expression
Researcher 1.68 (1.12) 1.50 1.27 (1.17) 2.30
ICU nurse 1.51 (1.10) 1.20 1.10 (1.20) 2.00
Upper limb movement
Researcher 0.53 (0.68) 0.64b 0.44 (0.68) 0.77b
ICU nurse 0.48 (0.62) 0.64 0.38 (0.61) 0.79b
Compliant with ventilator
Researcher 0.85 (0.55) 0.56b 0.38 (0.61) 1.88
ICU nurse 0.78 (0.62) 0.47b 0.29 (0.65) 1.30
Total score
Researcher 3.08 (1.69) 1.20 1.97 (1.70) 1.87
ICU nurse 2.85 (1.74) 1.03 1.74 (1.81) 1.03

Abbreviation: ICU, intensive care unit.

All changes highly significant, P < .001.
Moderate responsiveness.


Table 4: Correlation Matrix of the Behavioral Pain Scale and the Principal Contributing

Facial Upper Limb Compliance Correlation

Behavioral Pain Scale Subscales Expression Movement With Ventilator Coefficient (r)
Facial expression 1 0.84
Upper limb movement 0.52 1 0.80
Compliance with ventilator 0.43 0.51 1 0.70
All correlations are significant at P < .001.

Table 5: Psychometric Properties of the Critical-Care Pain ObservationTool

Change in Mean Change in Mean
Scores From Rest Scores From
Critical Care Pain to Suctioning, Effect Size Rest to Turning, Effect Size
Observation Tool Mean (SD) P Coefficient Mean (SD) P Coefficient
Facial expression
Researcher 1.16 (0.72) <.001 1.44 0.93 (0.76) <.001 1.22
ICU nurse 0.97 (0.73) <.001 1.58 0.76 (0.75) <.001 1.43
Body movement
Researcher 0.55 (0.58) <.001 0.72a 0.21 (0.65) .03 0.28b
ICU nurse 0.46 (0.58) <.001 0.61a 0.19 (0.64) .048 0.24b
Muscle tension
Researcher 0.36 (0.52) <.001 0.81c 0.21 (0.50) .006 0.47a
ICU nurse 0.21 (0.54) <.01 0.46a 0.17 (0.54) .03 0.36b
Compliant with ventilator
Researcher 0.87 (0.53) <.001 1.60 0.38 (0.57) <.001 0.75a
ICU nurse 0.83 (0.56) <.001 1.50 0.34 (0.56) <.001 0.52a
Total score
Researcher 2.83 (1.61) <.001 1.37 1.59 (1.63) <.001 0.77a
ICU nurse 2.44 (1.53) <.001 1.29 1.15 (1.58) <.001 0.79a

Abbreviation: ICU, intensive care unit.

Moderate responsiveness.
Small responsiveness.
Large responsiveness.

Compliance With the Ventilator. The Muscle Cronbach and r values were 0.86, which
Tension subscale showed weak ICC during is lower than the values for the other 2 tools.
suctioning and lower agreement across other The ICC for all subscales ranged from 0.85
measurement points. to 0.95 across all measurement points. The
The Facial Expression subscale was the lowest ICC agreement was found in the
principal contributing factor to overall pain Facial Expression subscale during suctioning,
scores with a coefficient weight (r) of 0.80, with an r value of 0.72. The principal con-
and the Muscle Tension subscale was the least tributing factor was the facial expression
sensitive and lowest contributing factor to with an r value of 0.87. The Physiology and
overall pain scores across all measurement Respiratory subscales were inadequately con-
points (r = 0.65; Table 6). tributing to pain scores (r = 0.36) and corre-
NPVS. The psychometric properties of the lated poorly with the principal contributing
NVPS subscales were variable. Inconsistent factor (Facial Expression), with r values of
sensitivity and responsiveness were found in 0.05 and 0.01, respectively (Table 8).
the Physiology and Respiratory subscales When the psychometric properties of the
during turning and suctioning (Table 7). The 3 pain assessment tools were compared,


Table 6: Correlation Matrix of the Critical-Care Pain Observation Tool and the Principal
Contributing Factor

Critical-Care Pain Observation Facial Body Ventilator Muscle Correlation

Tool Subscales Expression Movement Synchrony Tension Coefficient (r)
Facial expression 1 0.80
Body movement 0.51 1 0.76
Ventilator synchrony 0.44 0.46 1 0.75
Muscle tension 0.28 0.38 0.37 1 0.65
All correlations are significant at P < .001.

Table 7: Psychometric Properties of the Nonverbal Pain Scale

Change in Mean Change in Mean
Scores From Rest Scores From
Nonverbal Pain Scale to Suctioning, Effect Size Rest to Turning, Effect Size
Subscales Mean (SD) P Coefficient Mean (SD) P Coefficient
Facial expression
Researcher 1.10 (0.72) <.001 1.36 0.89 (0.78) <.001 1.68
ICU nurse 1.10 (0.69) <.001 1.50 0.85 (0.78) <.001 1.61
Researcher 0.59 (0.68) <.001 0.56a 0.19 (0.39) .002 0.83
ICU nurse 0.46 (0.74) <.001 0.44a 0.31 (0.78) .008 0.65a
Researcher 0.46 (0.58) <.001 0.63a 0.38 (0.53) .000 0.78a
ICU nurse 0.42 (0.71) <.001 0.56a 0.31 (0.62) .001 0.75a
Researcher 0.12 (0.44) .06 0.34b 0.08 (0.45) .21 0.50a
ICU nurse 0.17 (0.43) .10 0.40a 0.12 (0.39) .32 0.53a
Researcher 0.14 (0.51) .51 0.22b 0.10 (0.51) .17 0.40a
ICU nurse 0.14 (0.55) .07 0.21b 0.08 (0.54) .29 0.40a
Total score
Researcher 2.46 (1.36) .001 1.01 1.93(1.68) .001 1.20
ICU nurse 2.17 (1.41) .001 0.94 1.76 (1.64) .001 1.15

Abbreviation: ICU, intensive care unit.

Moderate responsiveness.
Small responsiveness.

variations were noted when examining the across the 2 raters and across different meas-
subscales of each tool. The BPS and all its urement points (Table 2).
components were proven to be reliable, sensi-
tive, and valid in assessing pain in our sample Discussion
of nonverbal patients. The CPOT had a weak In this study, evaluation of 3 nonverbal
subscale (Muscle Tension) in terms of all psy- pain assessment tools (BPS, CPOT, and NPVS)
chometric properties. The NVPS had a lower was undertaken to determine the most sensitive,
extent of psychometric properties compared reliable, and valid tool for measuring pain in
with the other pain assessment tools. There patients receiving mechanical ventilation.
were 2 weak subscales (Physiology and Res-
piratory) of the NVPS in terms of all psycho- Psychometric Properties of the BPS
metric properties. Other subscales had The reliability and validity of the BPS were
moderate, variable responsiveness and ICCs supported by excellent Cronbach values


Table 8: Correlation Matrix of the Nonverbal Pain Scale and the Principal Contributing

Nonverbal Pain Facial Correlation

Scale Subscale Expression Activity Guarding Physiology Respiratory Coefficient (r)
Facial expression 1 0.87
Activity 0.54 1 0.77
Guarding 0.44 0.58 1 0.73
Physiology 0.05 0.22 0.07 1 0.36
Respiratory 0.01 0.23 0.07 0.35 1 0.36
All correlations are significant at P < .001.

(0.95) and ICCs of at least 0.80 for all sub- evaluated the CPOT in 96 patients receiving
scales, except for the subscale of Facial mechanical ventilation by assessing pain before,
Expression, which showed lower agreement during, and after turning. They reported results
during suctioning (r = 0.77). These results are similar to ours in terms of reliability and validity.
consistent with the work of Payen et al, who Unlike our results, Keane3 reported a low
developed and validated the BPS in a sample reliability value of the tool and low interrater
of 30 critically ill sedated patients by expos- reliability in a study of 21 patients after open
ing the patients to nociceptive procedures heart surgery. This discrepancy could be due
(suction, turning) and procedures that were to the difference in sample size; limited patient
not nociceptive. Payen et al6 used a test to characteristics because the study participants
measure the degree of agreement between were only patients who had undergone heart
raters and found a statistically significant surgery; and the study design, which included
P value less than .01. Ahlers et al21 reported 3 assessment points: on arrival from the
similar results when the BPS was evaluated in operating room, during mechanical ventila-
49 conscious sedated and 126 unconscious tion, and after extubation.3
sedated nonverbal patients. That study dem-
onstrated a good internal consistency of the Psychometric Properties of the NVPS
BPS, with a Cronbach of 0.63 for the con- When examining the psychometric proper-
scious patients and 0.66 for the unconscious ties of the NVPS, the tool showed satisfactory
patients. The interrater reliability in the study validity and reliability, but to a lesser extent
by Ahlers et al21 was excellent according to than the previous tools. The Physiology and
the value. However, the results obtained in Respiratory subscales showed poor psychomet-
our study reflect a higher Cronbach value ric properties, with weak contributions to the
than reported in other studies; this difference overall pain scores. Their described definitions
could be due to the difference in the sample were not achieved by most of the study patients
size, as well as the frequency of measurement during nociceptive procedures, even when other
in each patient and the number of assessors. subscales were scored the maximum 2 out of 2.
Payen et al6 assessed pain 3 times in each Additionally, these subscales were not sensitive
patient and involved 46 registered nurses for detecting pain, with narrow responsiveness.
during the time frame of their study, whereas This observation has not been reported in
in our study, 20 trained assessors assessed the any previous studies that validated the NVPS;
pain in all patients in the study. however, Li et al23 argued that the descriptions
in these subscales were not justified or sup-
Psychometric Properties of the CPOT ported by evidence that explained these changes
In this study, the CPOT was adequately in hemodynamic ranges.
reliable, valid, and sensitive but showed vari- Although the NVPS was sensitive and respon-
able responsiveness. Variable responsiveness sive, most subscales showed moderate to small
may result in significant changes in patients’ effect size. This variable responsiveness could
pain severity level before the changes are affect the utility of the tool for detecting
manifested in the CPOT score. Vazquez et al22 changes in pain in different clinical settings.


Patients could experience severe pain before When evaluating the 3 assessment tools that
they become agitated, rigid, or exhibit vital were used in our study, we found the BPS to be
sign changes as defined in the scale. the most valid, reliable, and sensitive tool to be
The work of Marmo and Fowler4 yielded used appropriately in our ICUs, followed by the
similar findings when both the CPOT and NVPS CPOT, which can be an alternative to the BPS
were compared in 24 patients after open heart because it showed excellent psychometric prop-
surgery. The NVPS was highly reliable with a erties despite the presence of 1 weak subscale
Cronbach similar to the values obtained in our (Muscle Tension). The NVPS was a weaker
study.4 Vranic et al24 reported contrary results tool than the BPS and CPOT in terms of all
in a study evaluating the NVPS and CPOT in psychometric properties.
66 neurosurgical patients. They reported low Systematic reviews of the nonverbal pain
and weak interrater reliability of the NVPS assessment tools have been published. Barr
scale. Although the NVPS showed statistically et al25 critically analyzed the pain, agitation,
significant results in their study in terms of and delirium guidelines that were established
sensitivity, the internal consistency as indicated by the Society of Critical Care Medicine and
by Cronbach was weak to moderate.24 ranked these recommendations on the basis
of the quality of the existing evidence. Those
Comparison of Psychometric authors considered a scale as appropriate for
Properties Among the 3 Pain clinical use when it has moderate to very good
Assessment Tools and Subscales psychometric properties with a weighted score
When examining the subscales of the BPS, of more than 12 points. They concluded that
all components were highly sensitive during both the CPOT and the BPS have moderate
both nociceptive procedures, making them psychometric properties and that they are the
valid behavioral indicators in pain assessment most valid and reliable scales for pain assess-
in nonverbal patients. The third component ment in variable ICU populations except in
of the BPS, Compliance With the Ventilator, patients with brain injury and motor dys-
has similar descriptions in its parallel in the function. The NVPS was reported to have
CPOT subscale labeled as Compliance With very low psychometric properties.25
the Ventilator. In both tools, this subscale Clade14 systematically reviewed and evalu-
was less responsive among the 2 raters. The ated all pain assessment tools including the
study by Payen et al6 yielded similar results; BPS, CPOT, and NVPS and reported findings
they found this subscale to have the smallest similar to our results. The BPS was identified
weight of contribution to pain scores. It is as the most valid among other tools, as it
unknown whether the mode of ventilation was tested in mixed clinical settings. Clade
affects the degree of responsiveness and further reported the CPOT as a promising
contribution. tool in pain assessment. However, Clade14
In our study, the Muscle Tension subscale argued that the author of the tool did not
of the CPOT was identified as the weakest examine the factor analysis adequately to
component in terms of all psychometric test the structure of the entire tool, that the
properties. When comparing this scale with studies undertaken to evaluate the NVPS
its parallel in the NVPS, labeled Guarding, were inadequate, and that the design used
the NVPS subscale also showed a lower degree by the authors was generally weak.
of responsiveness but satisfactory agreement Few reports of comparative studies that
among raters. However, in both tools, this combine these 3 tools have been published.26
subscale contains a general description and In a recent study, Chanques et al26 compared
common words such as tense, very tense, and the BPS/BPS-NI (for nonintubated patients),
rigid. Evaluation of this behavioral indicator the CPOT, and the NVPS. The psychometric
implies a subjective property, and it is unknown properties of these tools were explored in
how ICU nurses would define and quantify terms of validity, interrater reliability, respon-
these terms. Marmo and Fowler4 also reported siveness, and feasibility during turning and
the same observation when comparing the endotracheal suctioning. The study involved
CPOT and NVPS; however, they considered 30 nonverbal medical ICU patients who were
the operational definitions of the Muscle Tension either delirious, sedated, or receiving mechanical
subscale in the CPOT to be more specific and ventilation. The BPS and CPOT were deemed
reliable than was Guarding in the NVPS. as superior to the NVPS. Furthermore, the BPS


had higher responsiveness than did the CPOT, patients by using recommended pain assess-
and the NVPS showed limited responsiveness. ment tools. Further research is warranted to
The BPS was reported as more feasible for use examine the BPS and CPOT in different clini-
in clinical practice settings. However, the CPOT cal settings in a larger sample.
and the BPS were considered adequately
applicable in both nonverbal intubated and
nonintubated adults.26
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Marmo and Fowler4 reported results simi- self-report of procedural pain in the intensive care unit.
lar to ours: when the CPOT and NVPS were J Clin Nurs. 2007;16:2142-2148.
compared, the CPOT showed higher agreement 2. Pasero C, McCaffery M. No self-report means no
pain-intensity rating. Am J Nurs. 2005;105(10):50-53.
and higher psychometric properties. They con- 3. Keane K. Validity and reliability of the Critical-Care Pain
cluded that the CPOT was more appropriate Observation Tool: a replication study. Pain Manag Nurs.
than the NVPS for assessing pain in nonver- 2012;14(4):e216-e225.
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The major limitation of the current study Observation Tool for the detection of pain in intubated
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are needed to investigate the association critically ill sedated patients by using a behavioral pain
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nurses to provide sensitive and empathetic ics. Dordrecht, Netherlands: Springer; 2001.
care to patients who cannot verbalize their 19. Wright JG, Young NL. A comparison of different indices
of responsiveness. J Clin Epidemiol. 1997;50:239-247.
pain and needs. These principles cannot be 20. Kline P. A Psychometrics Primer. London, England:
attained without the use of a valid and relia- Free Association Books; 2000.
ble assessment tool. ICU nurses must be ade- 21. Ahlers SJ, van der Veen AM, Dijk MV, Tibboel D,
Knibbe CA. The use of the Behavioral Pain Scale to
quately educated and trained to assess pain assess pain in conscious sedated patients. Anesth
using behavioral indicators in nonverbal Analg. 2010;110(1):127-133.


22. Vazquez M, Pardavila M, Lucia M, Aguado Y, Margall and neurosurgical intensive care unit. Pain Res Manag.
M, Asiain MC. Pain assessment in turning procedures 2013;18(6):107-114.
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AACN Advanced Critical Care
Volume 27, Number 2, pp. 173-182
© 2016 AACN

Factors Related to Successful

Transition to Practice for Acute
Care Nurse Practitioners
Deborah L. Dillon, RN, DNP, ACNP-BC, CCRN, CHFN

Mary A. Dolansky, RN, PhD

Kathy Casey, RN, MSN

Carol Kelley, RN, PhD, CNP

The transition from student to acute care independently. Thirty-four participants were
nurse practitioner (ACNP) has been recog- recruited from a social media site for nurse
nized as a time of stress. The purpose of this practitioners. Organizational support, com-
descriptive, correlational-comparative design munication, and leadership were the most
pilot study was to examine: (1) the relation- important elements of successful transition
ships among personal resources, commu- into the ACNP role. This information can
nity resources, successful transition, and job help ACNP faculty and hospital orientation/
retention; (2) the difference between ACNPs fellowship program educators to help
with 0 to 4 years and ACNPs with more than ACNPs transition into their first position
4 years of prior experience as a registered after graduation.
nurse in an intensive care unit or emergency Keywords: acute care nurse practitioner,
department; and (3) the skills/procedures transition, practice, graduate nurse practi-
that ACNPs found difficult to perform tioner, academic, nurse practitioner fellowship

T he demand for acute care nurse practi-

tioners (ACNPs) has increased in the past
several years. This demand has been created
they have completed an advanced
practice degree program or when
they are transitioning into new clini-
by an increase in hospitalized and critically cal practice areas.4(p59)
ill patients as well as duty-hour restrictions
for medical residents implemented by the Deborah L. Dillon is Assistant Professor, University of Virginia
Accreditation Council for Graduate Medical School of Nursing, 225 Jeannette Lancaster Way, McLeod
Education.1,2 It is vital that ACNPs working Hall, Rm 4007, Charlottesville, VA (
in hospital settings be supported as they Mary A. Dolansky is Associate Professor, Frances Payne
transition into their new roles. Bolton School of Nursing, Case Western Reserve University,
The Institute of Medicine’s report3 on the Cleveland, Ohio.
future of nursing recommends transition-to- Kathy Casey is Manager, Clinical Education, Lutheran Medical
practice residency programs to address health Center, Wheat Ridge, Colorado.
care workforce shortages. The Institute of Med- Carol Kelley is Assistant Professor, Frances Payne Bolton
icine suggests that School of Nursing, Case Western Reserve University,
healthcare organizations take Cleveland, Ohio.
actions to support nurses’ comple- The authors declare no conflicts of interest.
tion of a transition-to-practice
program (nurse residency) after DOI:


Meleis model

Personal Transition
Nature of resources Subjects’
transition: well-being
situational Role mastery
transition event Well-being of
Community relationships

Personal resources
Prior experience in
intensive care unit or
Study model department
Successful transition
Student Comfort/confidence
ACNP to Patient safety Job
graduate Professional retention
ACNP Community resources satisfaction
Organizational support Job satisfaction

Figure: Meleis model and adapted study model: factors related to successful transition to practice for
acute care nurse practitioners (ACNPs).

Hospital orientation or fellowship programs interpret electrocardiograms and other diag-

can benefit by targeting interventions to nostic tests, as well as having clinical faculty
ensure successful transition. who were more experienced would improve
Although factors related to nurse practition- their readiness to practice; however, only 1%
ers’ transition to clinical practice have been of the nurse practitioners in this sample
identified, how the factors affect successful (n = 5) were ACNPs.7
transition to practice for ACNPs has not been Role development and successful transition
examined. The complexity of the acute care for nurse practitioners have been linked to
setting and the specific skills/procedures mastering the 5 elements described in the
required by ACNPs make their transition literature, which include the development of
factors unique. self-confidence,7-12 patient safety,7,13-15 organi-
zational support,9-11 professional satisfaction,14
Background and effective communication/leadership.10,16-23
Schumacher and Meleis5 defined situational The Meleis Transition Theory explains the pro-
role transition as a change in role function cess that is necessary to achieve a successful
and scope of practice. Shaping the new role outcome as well as resources that influence
involves a balance between role loss as a the transition process24 (see Figure).
registered nurse and role expansion as a nurse In the Meleis model, situational transition,
practitioner.6 Furthermore, formal education which is experienced by the newly graduated
of nurse practitioners is not sufficiently pre- nurse practitioner, is defined as a transition
paring new nurse practitioners to feel ready event. The nature of this transition event can
for practice.7 According to Hart and Macnee,7 include changes in identity, roles, relation-
recent nurse practitioner graduates (> 61% ships, abilities, and patterns of behavior.19
were family nurse practitioners) report that Personal and community resources affect
better clinical reasoning skills, ability to successful transition.


Meleis24 defined 3 global indicators for from the student role to the registered nurse
all successful transitions: (1) subjects’ well- role.21 Consistent with Casey and colleagues,
being, (2) role mastery, and (3) well-being of Newhouse et al22 also identified the new grad-
relationships. The model for this particular uate experience as stressful with high turnover
study (adapted from the Meleis model) exam- unless it was partnered with an internship. The
ined factors related to successful ACNP tran- importance of a preceptorship in developing
sition to practice. The study model corresponds a greater degree of perceived competence in
to these indicators by identifying successful development of clinical skills was examined by
transition variables as (1) comfort/confidence, Kim.23 Casey et al21 reported that newly grad-
(2) patient safety, and (3) professional and uated nurses require consistent support and
job satisfaction (see Figure). professional development during the first year
of practice. The Casey-Fink Graduate Nurse
Description of the Problem Experience Survey was developed from themes
Few reports of graduate nurse practitioners’ identified from the literature that influenced
perception of the transition experience have the graduate nurse experience and included
been published; thus little is known about consistency of role socialization support,21,26
the factors related to successful transition for the quality of the clinical orientation,27,28 and
any nurse practitioner, including the ACNP.18,25 the level of support from nursing leaders.27-30
Barnes20 explored the relationship between
experience as a registered nurse and the tran- Purpose of the Study
sition to the nurse practitioner role and found The purpose of this descriptive, correlational-
that prior nursing experience did not affect comparative design study was to identify
successful transition into practice. In an (1) the relationships among personal resources
unpublished dissertation, Duke18 used herme- (prior experience in intensive care unit [ICU]/
neutic phenomenology to examine the lived emergency department [ED] and stressors)
experience of new graduate nurse practition- and community resources (organizational
ers to hospital-based practitioners in a group support and communication/leadership), a
of 12 nurse practitioners (adult, family, and successful transition (comfort/confidence,
acute care) with at least 1 year of hospital- patient safety, and professional and job sat-
based experience. She identified a transition isfaction), and job retention experienced by
period that ranged from 6 to 18 months and ACNPs within their first 6 months of
was most intense during the first 9 months of employment; (2) the differences in personal
practice. Challenges encountered during this and community resources, successful transi-
time frame included tion, and job retention between ACNPs with
navigating and negotiating a new 0 to 4 years and ACNPs with more than 4
health care provider role, becoming years of prior nursing experience in the ICU/
integrated into a hospital system ED; and (3) skills and procedures that new
in what was a new role for the ACNPs found difficult to perform.
practitioner and often a new role
for the system, learning how to Tool Validation
function effectively as a NP [nurse No instrument is available in the literature
practitioner] while working to re- to evaluate the factors related to successful
establish themselves as proficient ACNP transition, so the Casey-Fink Graduate
clinicians with a newly expanded Nurse Experience Survey was modified, with
practice scope, building key rela- permission, to apply to the ACNP experience.
tionships, and educating physi- The Casey-Fink Graduate NP Experience
cians, hospital leaders, clinical Survey was developed to evaluate the ACNP
staff, patients and families about role transition experience. Specifically, the
the NP role.18(abstract) original instrument was modified to collect
data on personal resources (prior nursing
Registered Nurse Transition experience in the ICU/ED and stressors), com-
to Practice munity resources (organizational support
The Casey-Fink Graduate Nurse Experience and communication/leadership), and success-
Survey has been used extensively to examine ful transition factors (comfort/confidence in
various factors that affected the transition performing both clinical and relational skills/


procedures, patient safety, professional and transition to practice. The survey consisted
job satisfaction, and job retention).21 The skills of 5 sections: (1) demographic information;
or procedures in the modified instrument were (2) skills/procedure performance (drop-down
adopted from those published by Kleinpell list of 30 items); (3) subscales related to suc-
et al31 after a national survey. cessful transition (comfort/confidence, patient
After the modified survey was developed, safety, professional satisfaction, job retention);
2 expert clinical faculty members and 5 ACNPs (4) subscales related to community resources
evaluated the instrument for content validity. (organizational support and communication/
A revised survey was pilot tested on 3 ACNPs leadership); and (5) subscales related to per-
for applicability. sonal resources (stressors and prior work
experience as a nurse in the ICU/ED). All
Methods responses on subscales were added to calcu-
Design late total scores for each subscale. Table 1
A descriptive, correlational-comparative describes the concepts, gives example of items,
design was used for this pilot study. Approval and specifies the reliability and validity of
was obtained from the institutional review the study variables.
board at Case Western Reserve University and
from the group administrator of the social Statistical Analysis
media site used to recruit participants Statistical analyses were performed by
( using IBM Statistical Package for Social Sci-
ences version 22 (IBM SPSS Inc). Survey items
Sample Characteristics and demographics were summarized by using
The study included a convenience sample descriptive statistics. Bivariate correlations
of 34 ACNPs who were members of an Acute and nonparametric tests were used to exam-
Care Nurse Practitioner Network social ine the research questions.
media site. Respondents were eligible to
participate if they met the following inclu- Results
sion criteria: A description of the demographic varia-
1. Board-certified ACNP or adult-gerontology bles is displayed in Table 2. The sample was
ACNP (AG-ACNP) with more than 6 months predominantly white women between 41 and
and less than 3 years of active practice in an 50 years old. Fifteen states and Puerto Rico
ACNP or AG-ACNP role. were represented. Most participants had a
2. Member of the social media ACNP master of science degree in nursing. Eighty-
Network. two percent had more than 5 years of nurs-
ing experience, and 75% had more than 5
Data Collection and Procedures years of nursing experience in an ICU or ED.
Participants were recruited through an intro- Most had an orientation that lasted 8 weeks
ductory cover letter on the ACNP Network’s or less. Twenty-nine percent of the respond-
social media site. They were informed of the ents reported no orientation. Fifty-two per-
purpose of the web survey, what participation cent of the respondents remained in their
entailed (completion of the Qualtrics survey), first position after graduation for less than 2
and the survey length (20 minutes). Respond- years. Forty-six percent of the respondents
ents were asked to recall their first 6 months reported experiencing stress, with job perfor-
of employment as an ACNP when answering mance and personal finances reported as the
the survey questions. Voluntary consent was top 2 stressors.
implied by the participant’s completion of The relationships among personal and
the survey. Participants were assured that the community resources and successful transi-
data would be confidential and that no iden- tion and job retention are listed in Table 3.
tifiers were linked to e-mail addresses or par- Statistically significant positive correlations
ticipants’ data. were found among organizational support
and comfort/confidence (r = 0.49; P < .01),
Instrument patient safety (r = 0.38; P < .05), professional
The Casey-Fink Graduate NP Experience satisfaction (r = 0.72; P < .05), and job satis-
Survey was used for data collection and to faction (r = 0.53; P < .01). The relationship
identify factors related to successful ACNP between communication/leadership was also


Table 1: Reliability and Validity of Study Variables

No. of
Variable Definition Sample Items Items Cronbach
Successful transition
Comfort/ Perception of I was able to identify goals and outcomes for 7 0.79
confidence efficacy/ability patients
to perform I was confident in prescribing diagnostic interventions
basic skills I was comfortable in prescribing pharmacologic
required of interventions
ACNP I was able to develop a plan of care using evidence-
based guidelines
Professional Perception of I felt my work was exciting and challenging 3 0.79
satisfaction fulfillment with I felt satisfied with my chosen nursing profession
professional I felt that the nurse practitioner/physician pro-
role vided encouragement about my work
Job retention Intent to leave job I was prepared to complete my job responsibilities 2 0.89
in first 6 months I felt supported by my nurse practitioner or phy-
of ACNP sician preceptor
Job satisfaction Perception of How satisfied were you with the following aspect of 11 0.81
fulfillment in your job: salary, vacation, benefits, hours worked,
aspects of job weekends off per month, amount of responsibility,
opportunities for career advancement, encourage-
ment and feedback, on-call time, reimbursement
for on-call time, and flexibility of hours
Patient safety Perception of I was able to complete a history and physical in a 5 0.79
the ability to timely manner (<45 minutes)
perform job I felt overwhelmed by my patient care responsi-
in a timely, bilities and workload
safe, and I felt I might harm a patient because of my lack of
knowledgeable knowledge and experience
way I was comfortable formulating a differential diagnosis
I had difficulty prioritizing differential diagnoses
Personal and community resources
Prior experience Employed as a How many years of experience as a registered nurse 1 NA
in intensive care registered have you had before entering the ACNP
unit or emergency nurse in an program
department intensive care How many years of experience did you have in
unit/emergency the intensive care unit or emergency department
department before entering the ACNP program
Stressors Perception of I was experiencing stress in my personal life 1 NA
stress in one’s
Communication/ Perception of I felt comfortable communicating with physicians 4 0.79
leadership adequate I felt comfortable communicating with patients
communication and their families
with patient, I felt comfortable making suggestions for changes in
physician, and the medical plan of care
families and
feeling prepared
to complete


Table 1: Reliability and Validity of Study Variables (Continued)

No. of
Variable Definition Sample Items Items Cronbach
Personal and community resources
Organizational Perception of I felt supported by my nurse practitioner/physician 10 0.87
support support from preceptor
the nurse prac- I had opportunities to practice skills more than
titioner/physi- once in simulation
cian mentor I had opportunities to practice skills more than
and family/ once in real life
friends My preceptor helped me to develop confidence
in my diagnostic skills
I felt that the nurse practitioner/physician provided
feedback about my work

Abbreviations: ACNP, acute care nurse practitioner; NA, not applicable.

significant with comfort/confidence (r = 0.68; relationship between prior nursing experience

P < .01), patient safety (r = 0.62; P < .01), pro- (mean, 13.8 years) and the transition to the
fessional satisfaction (r = 0.44; P < .05), and nurse practitioner role. Previous nursing
job satisfaction (r = 0.57; P < .01). There was a experience is important, considering that
significant negative correlation between com- most ACNP programs require between 1 and
munication/leadership and job retention 2 years of ICU/ED experience before accept-
(r = -0.35; P < .05; Table 3). ance, and this requirement may be related to
No significant differences were found our finding that only 8 ACNPs had less than
between nurses with 0 to 4 years and nurses 4 years of ICU/ED nursing experience. The
with more than 4 years of ICU/ED experience low number of ACNPs with less than 4 years
in the measures of personal and community of ICU/ED nursing experience may have been
resources, successful transition, and retention responsible for the lack of a relationship
(Table 4). Of the 30 identified skills/procedures between these variables.
adopted from the survey results of Kleinpell The findings in our study are consistent
et al,31 only 15 were selected by the respond- with the Meleis model. Overall, the commu-
ents. The top 3 skills that were deemed most nity resources of organizational support and
difficult to perform were cricothyrotomies, communication/leadership were related to
dictation or electronic medical record docu- successful transition (comfort/confidence,
mentation of a history and physical, and bill- patient safety, and professional and job satis-
ing and coding. Table 5 identifies the top 7 faction) for ACNPs during their first 6 months
skills/procedures the participants found diffi- of practice. Support from the nurse practitioner/
cult to perform. physician mentor and their availability for new
situations and procedures was deemed impor-
Discussion tant by the new ACNPs. Feedback about their
The majority of the sample was more than work was important and helped the ACNPs
40 years old and had more than 4 years of to develop confidence in their assessment and
nursing experience in the ICU/ED before diagnostic skills. Support from families and
becoming an ACNP. We found no differences friends during this time frame was also impor-
between nurses with 0 to 4 years and nurses tant, consistent with findings identified by
with more than 4 years of ICU/ED experience Heitz et al15 in their study of nurses’ transition
in relation to successful transition and reten- into practice. New ACNPs felt supported in
tion. Contrary to the results of our study, Hart their position by their mentors, in contrast to
and Macnee7 identified that nurse practitioners new nurses, who voiced concerns about peer
with more prior experience as a nurse (mean, and preceptor relations and communication
11 years) felt more prepared in practice than with physicians.21 This difference in relation-
those with little nursing experience. Consist- ships may be related to the ACNP being per-
ent with our study, Barnes20 reported no ceived on more of a peer level as well as the


Table 2: Description of Demographic and difference between a preceptor and a mentor.

Study Variables (N = 34) Consistent with the Casey-Fink Graduate Nurse
Experience Survey, nurse practitioners also iden-
Characteristic No. (%)a tified the importance of organizational support.21
Sex No relationships were found between
Female 26 (79) personal resources and successful transition.
Male 7 (21) This may be representative of the high per-
Ethnicity centage of prior nursing experience in the
White 31 (91) ICU/ED in this sample. Although stressors
Black 1 (3) (eg, job performance and finance) were iden-
Hispanic 1 (3) tified, they did not seem to affect successful
Asian 1 (3) transition and job retention. This finding was
Area of working specialty consistent with the findings of Barnes20 that
Intensive care unit/emergency department 13 (39) organizational factors were more important
Not in intensive care unit 20 (61) than personal factors in the successful transi-
tion of nurse practitioners.
Highest level of education
Master of science in nursing
Responses to the skills/procedures items
32 (94)
Doctorate in nursing practice 0 (0)
revealed a lack of comfort in performing cri-
cothyrotomies, dictation or electronic medical
Nurse practitioner certification record documentation of a history and physi-
American Nurses Credentialing Center 29 (88) cal, and billing and coding. Cricothyrotomy
American Academy of Nurse Practitioners 4 (12)
American Association of Critical-Care Nurses 0
is not a commonly performed procedure,
which would correlate with a lack of comfort
Retention in performing. The ACNP skills survey31 lists
Time worked in first position after cricothyrotomy as a required skill, so includ-
graduation as a nurse practitioner
ing cricothyrotomy in a simulation portion
Still ongoing 14 (41)
0-6 months
of an ACNP program would improve comfort
5 (15)
7-12 months 2 (6)
for a new ACNP. Although the new ACNPs felt
13-18 months 6 (18) comfortable collecting a medical history and
19-24 months 7 (21) physical examination and doing so in a timely
manner (< 45 minutes), they were less comfort-
Feelings of leaving your job within the
first 6 months of employment
able in their ability to translate or organize
Never 15 (45)
this information into the required documen-
< Once per month 6 (18) tation. Continued exposure to the skill of
Once per month 12 (36) organizing history and findings on physical
examination and dictating/documenting in
Age, years
electronic medical records during the student
5 (15)
31-40 11 (32)
ACNPs’ clinical practicums would improve
41-50 14 (41) this skill. Billing and coding were also identi-
51-60 3 (9) fied as difficult skills. This information is
≥ 61 1 (3) similar to that found by Hart and Macnee7
Length of orientation
in their study of predominantly family nurse
Still ongoing 1 (3)
practitioners. The inclusion of billing and
0 or < 8 weeks 15 (44) coding skills in ACNP programs is unknown;
9-12 weeks 5 (15) however, including billing and coding in the
13-16 weeks 2 (6) classroom training as well as incorporating
> 24 weeks 1 (6) it into the clinical practicum would most
Did not have one 10 (29) likely increase new ACNPs’ comfort with
Prior experience in intensive care billing and coding.
unit/emergency department, years Other findings of interest were that the
0-4 8 (24) mean duration of orientation was 8 weeks
5-9 13 (38) or less and that 29% of the respondents
10-14 7 (21) reported not having any orientation. It is
15-20 6 (18) not surprising that limited orientation would
Percentages may not total 100 because of rounding. impact the transition process. This finding is


Table 3: Pearson Correlation of Personal and Community Resources and Successful

Transition and Retention

Successful Transition and Retention

Comfort/ Patient Professional Job Felt Like

Resources Confidence Safety Satisfaction Satisfaction Retention Leaving
Stressors -0.09 -0.23 0.09 -0.32 -0.08 0.07
Years of experience in
intensive care unit -0.01 -0.26 -0.25 -0.06 0.04 0.01
Organizational support 0.49a 0.38b 0.72b 0.53a -0.15 -0.34
Communication/leadership 0.68a 0.62a 0.44b 0.57a -0.35b -0.31
Correlation is significant at the .01 level (2-tailed).
Correlation is significant at the .05 level (2-tailed).

Table 4: Differences in Personal Resources, Community Resources, and Successful

Transition and Retention

Nurses’ Experience in Intensive Care Unit/

Emergency Department
Variable ≤ 4 Years > 4 Years t
Personal resources
Stressors 3.13 (0.84) 2.31 (0.75) 2.323
Community resources
Organizational support 29.62 (5.80) 29.84 (5.99) -0.083
Communication/leadership 11.50 (1.92) 12.00 (2.04) -0.556
Successful transition
Comfort/confidence 19.57 (4.23) 19.46 (3.33) 0.064
Patient safety 13.70 (1.80) 14.30 (1.88) -0.503
Professional satisfaction 10.25 (1.66) 9.76 (1.36) 0.721
Job satisfaction 37.00 (8.24) 41.33 (7.41) -1.225
Length of time in first position 2.50 (1.41) 2.62 (1.89) -0.148
How often . . . feelings of leaving 2.00 (1.06) 1.54 (.877) 1.079
Values in second and third column are expressed as mean (SD).

Table 5: Skills or Procedures Found Difficult inconsistent with the literature recommenda-
to Perform in First 6 Months of Practice tions for increased orientation/residency pro-
grams for ACNPs or all nurse practitioners.3
No. (%) of Of concern was that 52% of the respondents
Skill or Procedure Respondents
remained in their first position after gradua-
Cricothyrotomies 5 (15) tion for less than 2 years. The reason for
Documentation of history and physical 4 (12) leaving their first position was not identified
by dictation or in electronic medical in the study.
Billing and coding 4 (12)
A study limitation was the small sample
Interpreting diagnostic test results 2 (6) size; a larger number of participants may affect
(laboratory tests, radiographs) the study results. In addition, the participants
Interpreting electrocardiograms 2 (6) were asked to recall the first 6 months of
practice, and memory may have played a
Code/emergency response 2 (6)
factor in their responses.


Future Research organizational support, communication, and

Expanding the data collection method to leadership, which the results of this study
include more settings may provide a more indicate are related to successful transition.
representative and larger sample of ACNPs
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20. Barnes H. Exploring the factors that influence nurse prac-
nity to champion postgraduate NP titioner role transition. J Nurse Pract. 2015;11(2):178-183.
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grams for recent NP graduates can 22. Newhouse R, Hoffman J, Suflita J, Hairston D. Evaluat-
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Nurs Adm Q. 2007;31:50-60.
growing and important segment 23. Kim K. Clinical competence among senior nursing stu-
of the clinical workforce.34(p626) dents after their preceptorship experiences. J Prof
Nurs. 2007;23(6):369-375.
Postgraduate and fellowship training pro- 24. Meleis A. Role insufficiency and role supplementation:
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25. Reveley S, Walsh M, Crumbie A. Nurse Practitioners: 30. Pine R, Tart K. Return of investment: benefits and chal-
Developing the Role in Hospital Settings. Oxford, UK: lenges of baccalaureate nurse residency programs.
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26. Nursing Executive Center. Nursing’s Next Generation: Best 31. Kleinpell RM, Hravnak M, Werner KE, Guzman A. Skills
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A d v a n c e d
Cr i t i c a l Ca r e

Patient and Family Post–Intensive

Care Syndrome
Symposium Editors
Judy E. Davidson, RN, DNP
Evidence-Based Practice and Research Nurse Liaison, University of California San Diego Health
San Diego, California

Maurene A. Harvey, MPH

Educational Consultant
Lake Tahoe, Nevada

• Introduction
• Implementing a Mobility Program to Minimize Post–Intensive
Care Syndrome
• A Clinic Model: Post–Intensive Care Syndrome and Post–Intensive
Care Syndrome-Family
• Developing a Diary Program to Minimize Patient and Family
Post–Intensive Care Syndrome
• Peer Support as a Novel Strategy to Mitigate Post–Intensive Care
AACN Advanced Critical Care
Volume 27, Number 2, pp. 184-186
© 2016 AACN

S y m Introduction
p o s iu m Judy E. Davidson, RN, DNP
Maurene A. Harvey, MPH
Symposium Editors

Patient and Family Post–Intensive Care

Judy E. Davidson, RN, DNP
Maurene A. Harvey, MPH

F or years it has been known that many patients who survive critical illness
do not return to their original state of health, resulting in long-term
consequences of critical illness.1 Weakness acquired in the intensive care unit
(ICU) is a physical consequence occurring in 25% to 80% of patients who
receive mechanical ventilation for more than 4 days and in 50% to 75% of
patients with sepsis. Nearly all patients affected with ICU-acquired weakness
have symptoms that persist years later.1,2 Issues with cognitive function occur
in 30% to 80% of ICU survivors and include memory, planning, problem-
solving, visual-spatial, and processing problems.1,3 Cognitive consequences
may improve during the months after discharge. However, 25% of patients
with adult respiratory distress syndrome (ARDS) have long-term persistent
cognitive impairment 6 years after discharge.4 In several studies,1-3 survivors
of severe sepsis who were more than 65 years of age still had cognitive impair-
ment 8 years after hospital discharge. Anxiety, depression, and sleep distur-
bances can last from months to years.1,2 Survivors also experience posttraumatic
stress disorder (PTSD) long-term, with an incidence between 10% and 50%
and persisting for up to 8 years.2,5,6 Follow-up studies longer than 8 years
have not been reported, and for some survivors, these consequences of critical
illness may not resolve.
Together, these physical, cognitive, and mental changes may affect socioeco-
nomic status and quality of life. Caregiving assistance is required by 50% of
patients 1 year later, consisting of help with daily living activities and in some
cases a need for full care. One year following discharge, 50% of ARDS survi-
vors have not returned to work.4 One year after discharge, less than 10% of
patients who required more than 4 days of mechanical ventilation are alive
and independent.1-3,5,7
Families of survivors and nonsurvivors can have difficulty coping with the
ICU experience,8 encountering psychological and social consequences of expo-
sure to critical illness.2 Anxiety is present in 10% to 75% of families, with
symptoms of PTSD reported in 8% to 42% of families and in up to 50% of
decedents or parents of critically ill children.8 At discharge, one-third of fami-
lies are taking medications for depression or anxiety. As in ICU survivors,
these psychological consequences may remain for many years.8-11 In families
of decedents, complicated grief may occur.8,12

Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California
San Diego Health, Mail Code 8929, 200 W Arbor Drive, San Diego CA 92103 (
Maurene A. Harvey is an Educational Consultant, Lake Tahoe, Nevada.
The authors declare no conflicts of interest.

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Symposium

The Birth of Post–Intensive of care: family follow-up referrals and func-

Care Syndrome and tional reconciliation (F), good handoff com-
Post–Intensive Care munication (G), and handout educational
Syndrome-Family materials on PICS and PICS-F (H).17,18
In 2010, the Society of Critical Care Medi- To promote awareness in patients and
cine (SCCM) convened a task force to exam- families, YouTube videos have been created
ine the long-term consequences of critical by patients and their families to describe their
illness. This group of scientists and clinical experiences.19 We established a definition of
experts gathered for a summit.2 The state of PICS on Wikipedia20 and created a new PICS
the science was reviewed for outcomes asso- brochure for patients and their families that
ciated with critical illness for both patients is available through the SCCM website
and patients’ families. Participants agreed to (
refer to the new or worsening mental health,
physical, and cognitive outcomes that linger This Issue: A PICS and PICS-F
past the ICU stay as post–intensive care syn- Primer
drome or PICS. When those outcomes affect Even though the problem of PICS and PICS-F
patients’ family members, an “F” is added is clearly recognized, much more can be learned
and the term becomes PICS-F. about effective interventions to minimize
symptoms and conditions experienced by ICU
Raising Awareness survivors and their families. In this issue, we
One of the major goals of the stakeholder have invited authors to describe strategies they
conference was to identify and promote strat- are exploring to improve outcomes. It should
egies to increase awareness of PICS and PICS- be recognized that the science supporting these
F outside the critical care health care strategies is young. However, in the absence
community and among ICU survivors and of strong evidence, we have a duty to take
their families. Attendees have given presenta- action in the best interest of the health of our
tions to their peers, published in their jour- community given what is known today. To
nals, and begun initiatives toward this end. that end, this issue is designed as a primer to
It became clear to us that a transfer out of promote new ideas and programs targeted at
the ICU should include a functional reconcili- improving care in and out of the ICU to pre-
ation to assess distance from baseline condi- vent, recognize, and treat PICS and PICS-F.
tion before hospitalization.7 This checklist We have asked each team of authors to
would follow the patient’s progress through provide replicable steps for starting new initia-
their postdischarge care and serve to inform tives in care. They have also invited a survivor
caregivers of potential often-missed issues. and/or family informant as coauthor to keep
The SCCM THRIVE Initiative is a grant- the focus on the real issues and values at the
funded project to test a program of peer-to-peer forefront of why practice needs to change.
support to treat PICS and PICS-F. Demonstra- We learn most when we listen, and we hope
tion projects are in progress.13 SCCM’s ICU that the guidance offered in these articles will
Liberation Task Force is developing standard provide a compelling impetus for change.
slide sets and work tools to inform clinicians The details of implementing an early mobil-
about the efforts to reduce PICS through ity program in the ICU are described by Ramona
appropriate and minimal sedation, mobility Hopkins and her team from Intermountain
programs, and delirium prevention and assess- Medical Center in Utah. Mary McCarthy and
ment.14 During a second summit, the ABCDE her nursing colleagues from Madigan Army
bundle, which addresses the PICS risk factors Base in Tacoma, Washington, describe their
of delirium, immobility, sedation, and dura- fledging diary program and the steps needed
tion of mechanical ventilation,14-16 was endorsed to implement diaries in the ICU. Diaries have
as a method of minimizing PICS. The letters in been used in the Netherlands and Europe for
ABCDE stand for airway (A), spontaneous more than 20 years with some promising
breathing trials (B), care coordination and results for both survivors and their fami-
communication between disciplines (C), delir- lies.21-25 Use of diary programs in the United
ium assessment (D), and early mobility (E). States has not been reported before. Moving
An FGH was added to the ABCDE mnemonic outside of the ICU, Huggins and colleagues
to address issues with the family and transitions discuss how to establish a post-ICU clinic to


help patients and families who are dealing 5. Wintermann GB, Brunkhorst FM, Petrowski K, et al. Stress
disorders following prolonged critical illness in survivors
with PICS and PICS-F. Finally, Mark Mik- of severe sepsis. Crit Care Med. 2015;43(6):1213-1222.
kelsen, a leader from the SCCM THRIVE 6. Parker AM, Sricharoenchai T, Raparla S, Schneck KW,
Bienvenu OJ, Needham DM. Posttraumatic stress disor-
Initiative, describes one of the demonstration der in critical illness survivors: a metaanalysis. Crit Care
projects in progress to establish peer-to-peer Med. 2015;43(5):1121-1129.
support programs to help survivors and fami- 7. Elliott D, Davidson JE, Harvey MA, et al. Exploring the
scope of post-intensive care syndrome therapy and
lies after an ICU stay. care: engagement of non-critical care providers and
In addition to the articles in the symposium survivors in a second stakeholders meeting. Crit Care
series, 2 of the regular columns in this issue Med. 2014;42(12):2518-2526.
8. Davidson JE, Jones C, Bienvenu OJ. Family response to
also address the topic of PICS and PICS-F. critical illness: postintensive care syndrome-family. Crit
In the Drug Update column, Joanna Stollings Care Med. 2012;40(2):618-624.
9. Netzer G, Sullivan DR. Recognizing, naming, and measur-
and colleagues discuss medication manage- ing a family intensive care unit syndrome. Ann Am
ment options to ameliorate PICS. The ethics Thorac Soc. 2014;11(3):435-441.
of PICS and PICS-F are explored through a 10. Jezierska N. Psychological reactions in family members of
patients hospitalised in intensive care units. Anaesthesiol
historical case study in the Ethics column. Intensive Ther. 2014;46(1):42-45.
It was originally planned that Jessica, an ICU 11. Sullivan DR, Liu X, Corwin DS, et al. Learned helplessness
among families and surrogate decision-makers of patients
survivor whose story is publicly available on admitted to medical, surgical, and trauma ICUs. Chest.
video and in print,17,26 would coauthor that 2012;142(6):1440-1446.
manuscript. However, with much regret, we 12. Kentish-Barnes N, Chaize M, Seegers V, et al. Complicated
grief after death of a relative in the intensive care unit. Eur
report that she died this year, presumably of Respir J. 2015;45(5):1341-1352.
complications of her ICU stay many years 13. Society of Critical Care Medicine. Thrive. 2016. http://www
ago. We dedicate this issue to Jessica and all
Accessed January 29, 2016.
those who share their ICU experiences with 14. Society of Critical Care Medicine. ICU liberation. 2016.
us so that we can learn from them.
.aspx. Accessed January 29, 2016.
These articles will provide practical guid- 15. AACN. Implementing the ABCDE bundle at the bedside.
ance on how to start programs like these in
your own organization, measures of success -ABCDE-ToolKit.content?menu=practice. Accessed Feb-
ruary 2, 2016.
for quality monitoring, and a list of potential 16. Pun BT, Balas MC, Davidson J. Implementing the 2013
research questions related to addressing the PAD guidelines: top ten points to consider. Semin Respir
gap in evidence. Crit Care Med. 2013;34(2):223-235.
17. Davidson JE, Harvey MA, Schuller J, Black G. Post-intensive
In conclusion, it is our goal through this care syndrome: what to do and how to prevent it. Am
issue not only to raise awareness surrounding Nurse Today. 2013;8:32-38.
18. Davidson JE, Harvey MA, Bemis-Dougherty A, Smith JM,
PICS and PICS-F, but to stimulate adoption Hopkins RO. Implementation of the Pain, Agitation, Delir-
of strategies to enhance family-centered care, ium Clinical Practice Guidelines and promoting patient
to decrease the modifiable risk factors of PICS mobility to prevent post-intensive care syndrome (PICS).
Crit Care Med. 2013;41(9 suppl 1):S136-S145.
(immobility, oversedation, duration of mechani- 19. Society of Critical Care Medicine. New resources high-
cal ventilation, and delirium), and to study light post-intensive care syndrome.
the effects of these strategies on outcomes. -Care-Syndrome.aspx. 2016. Accessed January 29, 2016.
This is an important time for critical care 20. Post-intensive care syndrome. Wikipedia page. https://en
nurses and nurse scientists. Interventions are
Accessed January 29, 2016.
being tested to address PICS and PICS-F, and 21. Egerod I, Bagger C. Patients’ experiences of intensive care
further research is needed in all areas related diaries: a focus group study. Intensive Crit Care Nurs.
to these potentially devastating syndromes. 2010;26(5):278-287.
22. Egerod I, Schwartz-Nielsen KH, Hansen GM, Lærkner E.
The extent and application of patient diaries in Danish
REFERENCES ICUs in 2006. Nurs Crit Care. 2007;12(3):159-167.
1. Desai SV, Law TJ, Needham DM. Long-term complica- 23. Jones C, Backman C, Capuzzo M, et al. Intensive care dia-
tions of critical care. Crit Care Med. 2011;39(2):371-379. ries reduce new onset post traumatic stress disorder fol-
2. Needham DM, Davidson J, Cohen H, et al. Improving lowing critical illness: a randomised, controlled trial. Crit
long-term outcomes after discharge from intensive Care. 2010;14(5):R168.
care unit: report from a stakeholders’ conference. Crit 24. Jones C, Backman C, Griffiths RD. Intensive care diaries and
Care Med. 2012;40(2):502-509. relatives’ symptoms of posttraumatic stress disorder after
3. Brummel NE, Balas MC, Morandi A, Ferrante LE, Gill TM, critical illness: a pilot study. Am J Crit Care. 2012;21(3):172-176.
Ely EW. Understanding and reducing disability in older 25. Garrouste-Orgeas M, Coquet I, Perier A, et al. Impact of an
adults following critical illness. Crit Care Med. 2015; intensive care unit diary on psychological distress in
43(6):1265-1275. patients and relatives. Crit Care Med. 2012;40(7):2033-2040.
4. Briegel I, Dolch M, Irlbeck M, Hauer D, Kaufmann I, 26. Davidson JE, Hopkins RO, Louis D, Iwashyna TJ. Post-inten-
Schelling G. Quality of results of therapy of acute res- sive care syndrome. 2013.
piratory failure: changes over a period of two decades -Support/Pages/Post-intensive-Care-Syndrome.aspx.
[in German]. Anaesthesist. 2013;62(4):261-270. Accessed January 29, 2016.

AACN Advanced Critical Care
Volume 27, Number 2, pp. 187-203
© 2016 AACN

Implementing a Mobility Program to

Minimize Post–Intensive Care Syndrome
Ramona O. Hopkins, RN, PhD

Lorie Mitchell, RN, MSN

George E. Thomsen, MD

Michele Schafer
Maggie Link, PT

Samuel M. Brown, MD, MS

Immobility in the intensive care unit (ICU) increased ability for self-care, faster return
is associated with neuromuscular weakness, to independent functioning, improved physi-
post–intensive care syndrome, functional cal function, and reduced hospital readmis-
limitations, and high costs. Early mobility– sion and death. Factors that influence early
based rehabilitation in the ICU is feasible mobility–based rehabilitation include having
and safe. Mobility-based rehabilitation var- an interdisciplinary team; strong unit leader-
ied widely across 5 ICUs in 1 health care ship; access to physical, occupational, and
system, suggesting a need for continuous respiratory therapists; a culture focused on
training and evaluation to maintain a strong patient safety and quality improvement; a
mobility-based rehabilitation program. Early champion of early mobility; and a focus on
mobility–based rehabilitation shortens ICU measuring performance and outcomes.
and hospital stays, reduces delirium, and Keywords: early mobility, rehabilitation, inten-
increases muscle strength and the ability sive care unit, critical illness, post–intensive
to ambulate. Long-term effects include care syndrome

T he old notion that the treatment of critical

illness ends at discharge from the intensive
care unit (ICU) is no longer sufficient. The large
Ramona O. Hopkins is Professor, Department of Psychology
and Neuroscience Center, Brigham Young University, Provo,
Utah, and Clinical Research Investigator, Center for Human-
izing Critical Care, and Department of Medicine, Pulmonary
majority of adults treated in the ICU survive and Critical Care Division, Intermountain Healthcare, 5121 South
their critical illness, producing an expanding Cottonwood St, Murray, UT 84107 (
group of survivors. These survivors may have Lorie Mitchell is Nurse Manager, Shock Trauma Intensive Care
serious morbidities that are the aftereffects of Unit, Department of Medicine, Intermountain Medical Center.
both the critical illness and its treatment. These George E. Thomsen is Medical Director, Coronary Intensive Care
morbidities are associated with a substantial Unit, Department of Medicine, Intermountain Medical Center.
burden for patients, their families, and society.1,2 Michele Schafer is Member, Intensive Care Unit Patient-Family
Specifically, post–intensive care syndrome Advisory Council, Intermountain Medical Center.
(PICS),3,4 which includes physical, psycho- Maggie Link is Physical Therapist, Shock Trauma Intensive
logical, and cognitive impairments, develops Care Unit, Intermountain Medical Center.
in many ICU survivors.5-11 PICS can persist for Samuel M. Brown is Director, Center for Humanizing Critical
Care, Assistant Professor of Pulmonary and Critical Care
years after a patient leaves the ICU, adversely
Medicine, Department of Medicine, Intermountain Healthcare,
affecting patients and their families.5,6 Many and University of Utah School of Medicine, Salt Lake City, Utah.
individuals do not return to work because of The authors declare no conflicts of interest.
functional or cognitive impairments, have sub-
stantial ongoing medical problems that require DOI:


expensive treatment, and often have substan- discuss factors that may affect early mobility–
tial reductions in quality of life.12-14 Although based rehabilitation.
most survivors are glad to be alive and grate-
ful for the care of ICU clinicians, they are often Project Team
eager for ways to improve their symptoms The project team included 2 intensivists
and disabilities. involved in early mobility–based rehabilitation
A growing area of research is focused on in the ICUs described, a nurse psychologist who
patient-centered outcomes among survivors of studies ICU outcomes, the nurse manager of 1
critical illness.15 Preventing or treating PICS of the ICUs, a physical therapist who works
has become a substantial priority.16 Early in one of the ICUs, and a patient who under-
mobility–based rehabilitation—a therapy went early mobility during her critical illness.
that depends on ICU nurses, physical and
respiratory therapists, and physicians for its Early Mobility and ICU
success—has been a promising focus for efforts Outcomes
to improve PICS.17-22 The effect of critical ill- Neuromuscular complications including
ness on an individual’s overall function, qual- ICU-acquired weakness are due, at least in
ity of life, and reintegration into the home part, to immobility in critically ill patients.7,25-28
and work setting provides a strong justifica- The etiology of ICU-acquired weakness is
tion for early mobility/acute rehabilitation unclear; risk factors include immobility, long
and preventive measures, if they prove effec- duration of mechanical ventilation, high ill-
tive. Immobility in the ICU is associated with ness severity, hyperglycemia, and medications
the need for extended nursing care or treat- such as corticosteroids.29-31 Recent research has
ment in a rehabilitation facility and an inabil- begun to establish an evidence base for early
ity to walk and complete activities of daily interventions to improve patients’ outcomes,
living.23,24 To date, exercise or mobility-based including early mobility–based rehabilitation.
rehabilitation in the hospital has been reported In adult ICU populations, early mobility–based
to improve physical function for critically ill rehabilitation is safe and feasible17,19 and may
patients.18 As the evidence continues to accu- improve PICS.3,4 Researchers in a number of
mulate, key questions arise regarding how to studies have documented improvements in
implement early mobility, how it is experienced physical function with early mobility. Table 1
by patients and their families, and what bar- shows the effects of early mobility–based reha-
riers must be overcome to create and sustain bilitation on important outcomes for patients:
early mobility programs. Centrally, to what increased ability to stand, pivot, and bear
extent can early mobility programs developed weight,34 improved lower extremity muscle
in one clinical environment transfer success- strength,40 and getting out of bed sooner.41,42
fully to another? Although the studies mostly include small num-
bers of patients, a consistent trend is apparent
Evidence-Based Practice in decreasing hospital length of stay (LOS),
Project Plan days of mechanical ventilation, and time to first
In this article, we review the effects of early out of bed with an increase in activity/ambula-
mobility–based rehabilitation on ICU outcomes. tion. Early mobility increased the number of
We describe the experience in a respiratory ventilator-free days24,32 and reduced hospital
ICU (RICU), where a care practice model for readmissions.38 Early mobility increases the
early mobility was developed and implemented. number of people who ambulate, and not only
We then describe the experience with early do they ambulate, they ambulate sooner than
mobility programs in 4 other ICUs in our other ICU patients and ambulate greater dis-
corporation, exploring relevant similarities tances than do patients who do not participate
and differences regarding patient mobility in mobility-based rehabilitation.17,19,32-34,37
among these ICUs. The experience of early Studies33,34,37,38 have demonstrated that ambu-
mobility is described from the perspective lation shortens both ICU and hospital LOS.
of a patient (M.S.) who is a member of our Winkelman et al35 reported that use of an
ICU Patient-Family Advisory Council. Finally, activity protocol reduced ICU LOS, suggest-
we review the effect of early mobility–based ing that even brief episodes of low-intensity
rehabilitation on long-term outcomes and exercise may be sufficient to improve outcomes.


Table 1: Effects of Early Mobility or Rehabilitation on Outcomes in Critically Ill Patients

Patients Significant
Study Study Design Studied Sample Size Outcomes Findings
ICU Outcomes
Bailey et al,17 Prospective Acute 103 Mobility Ambulate 69%of patients
2007 cohort study respiratory > 100 feet (30 m) could ambulate
failure > 100 feet at
hospital discharge
Morris et al,19 Prospective Acute 165 Mobility Time to first Out of bed at 5
2008 randomized respiratory 165 Usual care out of bed days vs 11 days,
cohort study failure ICU LOS P ≤ .001
Hospital LOS Shorter ICU LOS
5.5 days vs 6.9
days, P = .02
Shorter hospital
LOS 11.2 days vs
14.5 days, P = .006
Schweickert Prospective Mechanical 49 Physical Delirium duration Decreased delirium
et al,24 2009 randomized ventilation rehabilitation Ventilator-free days duration 2.0 vs
controlled trial < 72 hours 55 Controls 4.0 days, P = .02
More ventilator-free
days 23.5 vs 21.1
days, P = .05
Burtin et al,32 Randomized Admitted 45 Bedside cycle Quadriceps force No difference in ICU
2009 controlled trial to ICU ergometer Berg Balance Scale LOS, quadriceps
45 Controls ICU LOS force, or score on
Berg Balance Scale
Needham and Prospective Mechanical 27 Usual care Delirium duration Reduced delirium
Korupolu,33 pre-post ventilation ICU LOS duration 53 days vs
30 Physical
2010 quality 4 days Hospital LOS 31 days, P = .003
improvement or more Decreased ICU LOS
study 7.0 days vs 4.9
days, P = .02
Decreased hospital
LOS 17.2 days vs
14.1 days, P = .03
Titsworth et al,34 Prospective Neurological 166 Mobility Global Mobility Global mobility
2012 pre-post ICU Score—IMOVE tool score 14.5 days vs
cohort study ICU LOS 44.7, P < .001
Hospital LOS Decrease in ICU
LOS 4.0 days vs
3.46 days, P = .004
Decrease in hospital
LOS 12 days vs
8.6 days, P = .01
Winkelman Prospective Medical and 55 Exercise Delirium Decreased ICU LOS
et al,35 2012 pre-post surgical ICU 20 Controls Muscle strength 19.6 days vs 14.6
cohort study Activities of daily days, P = .03
living No difference in
ICU LOS delirium, muscle
strength, or activi-
ties of daily living



Table 1: Effects of Early Mobility or Rehabilitation on Outcomes in Critically Ill Patients

Patients Significant
Study Study Design Studied Sample Size Outcomes Findings
ICU Outcomes
Dong et al,36 Randomized Mechanical 30 Rehabilitation Time to first Shorter time to
2014 controlled trial ventilation 30 Controls out of bed first out of bed 3.8
> 48 hours Duration of days vs 7.3 days,
mechanical P = .001
ventilation Decreased duration
ICU LOS of mechanical
ventilation 5.6
days vs 12.7 days,
P = .005
Decreased ICU LOS
12.7 days vs 15.2
days, P = .01
Klein et al,37 Prospective Neurological 260 Usual care Pivot, bear weight, Increase in ability to
2015 pre-post ICU 377 Exercise and ambulate pivot, bear weight,
cohort study ICU LOS and ambulate
Hospital LOS 21.2% vs 42.7%,
P < .001
Decreased ICU
LOS, 7.3 days vs
4.75 days, P < .001
Decrease hospital
LOS, 15.16 days
vs 10.21 days,
P < .001
More likely to be
discharged home
25.8% vs 31.7%,
P = .03
Post-ICU Long-term Outcomes
Schwieckert Prospective Mechanical 49 Exercise Hospital discharge: Independent func-
et al,24 2009 randomized ventilation 55 Controls Independent tional status in
controlled trial <72 hours functional status: exercise group
ability to perform 29 vs 19 patients,
activities of daily P = .02
living (bathing, Higher Barthel
dressing, eating, Index scores 75
grooming, trans- vs 55, P = .05
ferring from bed Longer distance
to chair, using the walked 33.5
toilet) and walking (0-91.4) m vs 0
independently (0-30) m, P = .004
Barthel Index scores
(activities of daily
Distance walked
Burtin et al,32 Prospective ICU 45 Bedside cycle SF-36 Physical Higher SF-36
2009 randomized ergometer Function item score Physical Function
controlled trial 45 Controls 6-minute walk test at scores 21 points vs
hospital discharge 15 points, P = .01
Greater 6-minute
walk distance 196 m
vs 143 m, P = .05



Table 1: Effects of Early Mobility or Rehabilitation on Outcomes in Critically Ill Patients

Patients Significant
Study Study Design Studied Sample Size Outcomes Findings
Post-ICU Long-term Outcomes
Morris et al,38 1-year Acute 134 Mobility Hospital readmission Lack of early
2011 follow-up of respiratory 124 Controls or death within mobility was
prospective failure 22 Lost to 12 months predictive of
cohort study follow-up hospital readmis-
sion or death,
odds ratio 1.15
(1.77-3.01), P = .04
Brummel et al,39 Pilot Medical and 22 Usual care Cognitive function No difference
2014 randomized surgical ICU 22 Physical Activities of daily between groups
controlled trial therapy only living for cognitive or
43 Physical Instrumental functional
and cognitive activities of daily outcomes at 3-
therapy living month follow-up
Quality of life No difference in
go test between
groups at 3-month
Klein et al,37 Prospective Neurological 260 Pre- Depression No difference in
2015 pre-post ICU intervention Anxiety depression,
cohort study 377 Exercise Hostility anxiety, or
hostility after
covariate control

Abbreviations: ICU, intensive care unit; LOS, length of stay; SF-36, Short Form 36 Health Survey.

In a pre/post quality improvement project to Evidence is accumulating of the short- and

reduce sedation and delirium, and increase long-term benefits of reducing sedation,
physical activity, investigators documented including decreased delirium in critically ill
that ICU LOS decreased from 7.0 to 4.9 days patients43-45 and increased ambulation.
(P = .02), and hospital LOS decreased from Data in the past 15 years have shown
17 to 14.1 days (P = .03) in the intervention that the brain-based morbidity including
group.33 In another study,37 not only did the delirium and cognitive impairments is cen-
number of patients who were able to bear tral to PICS. Several studies have shown
weight, pivot to a chair, or ambulate increase that early mobility–based rehabilitation not
from 21% to 43% after early mobility–based only affects the body, but reduces delirium
rehabilitation was implemented, the ICU LOS as well. In a landmark study, Schweickert
was shortened from 7.4 to 4.7 days (P < .001) et al24 found that an exercise program along
and the hospital LOS declined from 15.2 to with targeted sedation including daily seda-
10.2 days (P < .001). tion interruption decreased the duration of
To mobilize patients successfully, routine delirium from 4.0 to 2.0 days (P = .02) in
attention to reducing sedation, improving patients receiving mechanical ventilation.
sleep, and decreasing delirium is needed to Needham et al20 similarly reported that
facilitate mobility-based rehabilitation. Most delirium decreased from occurring in 53%
ICU mobility or physical rehabilitation pro- of patients before the quality improvement
tocols aggressively reduce sedation through project to occurring in 21% of patients
at-least daily sedation interruptions and/or (P = .003) after the physical rehabilitation
changing the sedative medications used. intervention was implemented.


Implementation of Early In a subsequent study,22 we found that the

Mobility in the ICU strongest single predictor of early mobility
Early Mobility Program in the was the ICU environment that emphasized
Respiratory ICU early mobility, more so than improvement in
The RICU—where our early mobility the patients’ physiology, as measured by scores
protocol was first developed—was initially on the Acute Physiology and Chronic Health
designed to provide protocol-driven care for Evaluation (APACHE) II or other indices.22
patients with respiratory failure, with the Further, when patients were discharged from
intent to provide outstanding clinical care the ICU and transferred to a medical/surgical
and to optimize post-ICU outcomes. A team unit, we observed a substantial decrease in
approach was used to identify areas for qual- mobility on the first day on the medical/sur-
ity improvement, which resulted in develop- gical unit: 55% of patients who ambulated
ment and implementation of care process in the ICU did not ambulate the first day
models including minimizing sedation and after transfer, even though they had a provid-
delirium reduction, daily spontaneous breath- er’s order for ambulation. This significant
ing trials coupled with explicit mechanical decrease in mobility while in the general care
ventilation protocols, and early mobility– area was unexpected and suggested that a
based rehabilitation.46 The team included culture of mobility-based rehabilitation simi-
bedside nurses, nurse practitioners, a physi- lar to that in the RICU was essential in ensur-
cian, critical care technicians, physical thera- ing that mobility was carried out every day.48
pists, and respiratory therapists. Pioneering This finding is supported by a recent study
early mobility–based rehabilitation and related that showed a decrease in ambulation after
interventions often requires a change in ICU transfer to a general inpatient care area.52
culture. The fact that these care processes Early mobility–based rehabilitation in criti-
were developed in the RICU by a multidisci- cally ill patients is intrinsically linked with
plinary team17,22,46 appeared central to our the unique culture of each ICU, the beliefs of
early success. This process for culture change the clinicians,19,22,46 available financial resources,
included the following steps: (1) identification and formal institutional support. Even in
of the problem, (2) development of goals to several ICUs within 2 institutions in 1 health
address the problem, (3) identification of the care system, there are profound differences
steps to reach the goals, and (4) measurement in unit culture and the approach to early
of whether the goals were met. This approach mobility–based rehabilitation.
engaged the entire clinical team, provided
immediate and direct feedback on progress Early Mobility–Based Rehabilitation
toward the goals, and allowed rapid changes in Other ICUs
in patient care processes.46 Organizational changes allowed us to
The RICU early mobility protocol was devel- evaluate to a certain extent the influence of
oped and implemented in 2001 and 2002. institutional culture in ICUs on early mobility
The mobility protocol47 goal was to ambulate in our institution. The hospital that housed
more than 100 feet (30 m) before ICU dis- the original RICU, a medical ICU (MICU),
charge. For patients not able to ambulate, and the shock trauma ICU (STICU) became
activity consisted of standing at the bedside, a secondary care facility when the corporation
sitting in a chair, sitting on the edge of the bed, opened a new flagship hospital in a neighbor-
or exercising in bed. Data from the RICU ing city in 2007. The RICU, thoracic ICU
showed that early mobility–based rehabilitation (TICU), and STICU at the original hospital
was feasible and safe and improved patient- moved to the new hospital, and only the
centered outcomes: on the last full day in the mixed-profile general MICU remained at
RICU, 69.4% of patients ambulated more the original hospital.
than 100 feet and 8.2% of patients ambu- With the move to the new hospital, the
lated less than 100 feet (30 m). Disposition RICU became a mixed-profile acute ICU with
of patients was as follows: 63.5% discharged a focus on patients with respiratory failure,
home or to a rehabilitation facility, 33.4% and the STICU doubled in size with a focus
admitted to a skilled nursing facility or long- on postoperative patients, septic shock, liver
term acute care hospital, and 18% died failure, and acute trauma. In parallel, the
before hospital discharge.17,22,48-51 medical director of the RICU moved to the


Table 2: Rehabilitation Practices in the Intensive Care Units at 2 Hospitals in 1 Health

Care System

Original RICU
Practice Hospital New Hospital MICU STICU TICU
Provider orders required Yes Yes Yes Yes Standing order
Consistent physician Yes Clinician Yes Clinician Yes
practice specific specific
Mobility protocol Mobility Evaluate Mobility Evaluate Mobility protocol
protocol and treat protocol and treat
Frequency of Twice daily Twice daily Twice daily Once or Twice daily
rehabilitation more daily
Physical therapy staff 2 devoted PT/ PT covers PT covers 2 PT covers PT covers
OT resources 2 units units 2 units 2 units
Nurses assist with Yes Yes Yes Yes Yes
Mobility champion(s) Yes Has varied Yes Has varied Yes

Abbreviations: MICU, medical intensive care unit; OT, occupational therapist; PT, physical therapist; RICU, respiratory intensive care unit; STICU,
shock trauma intensive care unit; TICU, thoracic intensive care unit.

TICU, an ICU that treats patients after car- range of motion). Each mobility-based reha-
diac, thoracic, or major vascular surgery and bilitation session requires a nurse, PT, RT,
patients with cardiac mechanical support and critical care technician.17 In addition to
devices. We briefly describe the early mobil- the main mobility intervention during the
ity program in each of these ICUs in the day carried out with PT, MICU nursing staff
following sections. rounds each evening to mobilize all patients
Mobility in the MICU. The MICU’s early except those with a contraindication, accom-
mobility–based rehabilitation was enhanced plished without a change in nurse staffing
following a geographic transition and subse- patterns. Currently, the culture of mobility
quent personnel changes as several RICU within the corporation is strongest in the
clinicians remained at the MICU, including MICU. Table 2 compares early mobility–
several champions of early mobility–based based rehabilitation in the various ICUs.
rehabilitation (primarily bedside nurses, Mobility in the RICU After the Unit Move.
critical care nurse practitioners, and the new Most RICU staff, including nursing leaders and
medical director).23 The MICU’s early mobil- most of the clinical staff (nurses, PTs, RTs)
ity program consists of a multidisciplinary moved to the new flagship hospital in 2007.
team that includes nurses, advanced practice Several champions of early mobility–based
providers, physicians, respiratory therapists rehabilitation moved to the RICU, including
(RTs), physical therapists (PTs), and critical the 2 PTs, the nurse manager, and key bedside
care technicians. nurses and RTs. The interdisciplinary team
The MICU continues twice-daily ambulation includes nurses, physicians, advanced practice
while minimizing sedation. Mobility requires providers, PTs, RTs, and critical care techni-
a provider’s order, as is the case in all ICUs cians. The RICU, which focuses on the acute
in the corporation because some patients treatment of individuals with respiratory
have contraindications for early mobility– failure, has a goal of twice daily ambulation
based rehabilitation. Physical rehabilitation but includes other activities (eg, sitting on
is focused on ambulation, but in patients who the edge of the bed, sitting in a chair, standing,
are not able to ambulate, attempts are made or exercising in bed) if patients are unable
to sit on the edge of the bed or engage in to ambulate. Two PTs were dedicated to the
exercises in bed (passive range of motion or RICU at the original hospital. These 2 PTs


remained with the RICU; however, with staff, including the charge nurse, RT, and crit-
changes in the physical therapy budget, these ical care technician.
PTs now cover 2 units, the same as PTs in all The STICU attending physicians developed
the ICUs. For a number of years, early mobility– exclusion criteria to guide nursing practice
based rehabilitation continued with twice regarding patients’ mobility-based rehabilita-
daily ambulation, until the 2 dedicated PTs tion. Activity exclusion criteria include the
and nurse manager retired and several other following:
key personnel left the unit for other opportu- • Unstable or uncleared thoracic, lumbar,
nities. Now, the goal for RICU is to mobilize or cervical spine until unrestricted by
each eligible patient at least once per day, physician
with an effort to mobilize twice per day when • Unstable pelvic fracture until unrestricted
staffing allows. The RICU continues to by physician
emphasize and champion early mobility. • Lower extremity fracture until unrestricted
Mobility in the STICU. The STICU moved by physician
to the new flagship hospital, including the large • Patient receiving any vasopressors unless
majority of clinical staff, and began to incor- unrestricted by physician
porate more postoperative patients along with • Patient with a head injury and intracra-
sepsis and trauma patients. The STICU was nial pressure monitoring or a score < 9 on
slower to adopt early mobility than were the Glasgow Coma Scale unless unrestricted
other ICUs, with implementation occurring by physician
primarily in 2008 and 2009. In the STICU, • Liver or spleen laceration or other poten-
the nurses and the PTs are the primary driv- tially unstable intra-abdominal bleeding
ers of mobility. More seasoned nurses have until unrestricted by physician
tended to advocate early mobility, but younger • Dialysis catheter/arterial sheath placed
nurses with less experience have often been in femoral vein unless unrestricted by
less supportive of early mobility–based reha- physician
bilitation. There is no standard approach • Fraction of inspired oxygen ≥ 0.7 or
among the physicians (eg, medical intensiv- positive end-expiratory pressure ≥ 10
ists, trauma surgeons, vascular surgeons, and unless unrestricted by physician
orthopedic surgeons), resulting in diversity in Using this guide, more experienced nurses
practice. In addition, residents, fellows, and are able to educate and assist all nursing staff
advanced practice providers are often not as by identifying patients who are eligible for
aware of early mobility, have less training and early mobility but are not receiving it. The
exposure to early mobility (which is not for- current goal is for once-daily mobility/reha-
mally part of house staff training/orientation), bilitation. Although PTs would like to sup-
and are therefore less likely to focus on mobil- port twice-daily mobility, they cover at least
ity. Although some physicians evaluate and 1 other unit in addition to the STICU, which
discuss mobility as a part of daily rounds, reduces their ability to support twice-daily
others do not. treatments. A number of barriers remain, but
The course of early mobility in the STICU the STICU continues to actively pursue early
has fluctuated over time and was the strong- mobility/rehabilitation.
est when there was a nurse champion for early Mobility in the TICU. The TICU partici-
mobility. Although the goal is for ambulation pated in early mobility endeavors subsequent
twice daily, early mobility regressed somewhat to development of the early activity program
because of the absence of a nurse champion in the RICU. A key source of this participation
in the STICU. As such, leaders recognized has been through nursing staff who worked
the need for more nurse champions and have in both units. The PTs in the TICU became
identified 5 nurse champions who are currently involved in early mobility after the RICU
receiving early mobility training. The charge published their results.17,22,46 The TICU uses
nurse also rounds daily with the bedside nurse the Intermountain Heart Institute Open Heart
to ensure that appropriate activity is provided. Rapid Recovery Activity Protocol, which is
If a PT is unavailable for early mobility, the activated by a standing postoperative order
bedside nurse has the responsibility to mobi- for all heart surgery patients (Figure 1).
lize the patient with the assistance of other Physician involvement occurs through


ACTIVITY ASSESSMENT Criteria (to be evaluated by RN or PT/

cross-coverage by critical care physicians on
Cardiac Rehab): BP < 170/95 & > 90/50; HR < 120 & > 50; RR < 28; weekends. Additionally, one of us (G.T., prior
SaO2 ≥ 90; SvO2 ≥ 55 (if available); CI ≥ 2 (if available); CT output < 100
cc/hr x 2 consecutive hours; Pain adequately controlled (consider pre- medical director of the RICU), moved his
medication before activity); no angina, no uncontrolled atrial or primary practice location from the RICU
ventricular arrhythmias; absence of pallor, cyanosis, lightheadedness,
unresolved nausea & vomiting, shortness of breath, or diaphoresis to the TICU in 2007.
The TICU has internal programs that
promote early activity and minimize sedation.
Recently the Society of Thoracic Surgeons
(STS) has made time to extubation after heart
Does patient
N Reevaluate surgery a major quality metric.53 As a conse-
meet Activity
Assessment for reentry quence, the TICU undergoes careful scrutiny
Criteria? of the postoperative respiratory management
of cardiac surgery cases. To achieve rapid
Y postoperative extubation, a coordinated team
(nurses, physicians, advanced practice pro-
viders, PTs, and RTs) evaluates each patient
with an emphasis on reducing sedation and
promoting early mobility–based rehabilitation.
Any This attention has resulted in increasing suc-
contraindications cess with early extubation in postoperative
to activity? ie, RN PROM* q cardiac surgery patients (Figure 2).
1 hr until The TICU cares for postoperative cardiac
femoral line, pt awake & patients who have respiratory complications
open chest, responsive
muscle flaps,
and prolonged ICU courses. These patients’
etc respiratory care and sedation management
* Supine ankle, knee, are similar to those specified in the guide-
hip, and arm flexion/
extension for 1 min lines originally developed in the RICU.23 In
each extremity the TICU, physical therapy with a focus on
early ambulation is conducted twice daily
RN or RT verbal with patients who meet activity criteria (Fig-
Y stimulation until pt ure 1). The TICU PTs are trained in ambu-
awake & responsive lating patients with a variety of mechanical
Activity per
devices, including ventilators (Figure 3), left
MD order
ventricular assist devices, and total artificial
heart consoles. For patients who are not able
If at any time the patient becomes
A to ambulate, attempts are made to have them
hemodynamically unstable, stop the
protocol, put the pt on bed rest, sit on the edge of the bed or exercise in bed.
notify the MD if appropriate. Assess
and reevaluate pt for reentry into the
protocol when appropriate. Continued Summary of Mobility in the ICU
In our review of these 5 ICUs, we found
Figure 1: The Open Heart Rapid Recovery Activity marked variability in mobility across 2 hos-
Protocol used in the thoracic ICU. pitals in 1 health care system. Although all
Abbreviations: BID, twice daily; BP, blood pressure; units were engaged in mobility-based rehabil-
BRP, bathroom privileges; cc, cubic centimeters; CI, itation, there were differences in the frequency
cardiac index; CPS, cardiopulmonary support; CT, chest of rehabilitation, use of a mobility protocol,
tube; ET, exercise therapist; HR, heart rate; hr, physician practice, and presence of a mobility
hour; IAB, intra-aortic balloon; ICU, intensive care unit; champion. The variable penetration of mobility-
MD, medical doctor; N, no; PA, physician assistant; based rehabilitation suggests that, like any
PROM, passive range of motion; PRN, as needed; practice (eg, hand washing), there needs to
PT, physical therapist; pt, patient; q, every; Rehab, be a process of continuous training and eval-
rehabilitation; reps, repetitions; RN, registered uation in order to maintain best practices. The
nurse; RR, respiratory rate; RT, respiratory therapist; biggest differences between the ICUs are the
Sao2, arterial oxygen saturation; Svo2, venous oxy- culture, the leaders who support and empha-
gen saturation; Y, yes. Reprinted with permission of size early mobility, and the presence or absence
Intermountain Medical Center, Murray, Utah. of a mobility champion. Similar findings come


Activity for Y N Activity for

the extubated Is the pt the intubated
patient extubated? patient

RN, ET, or PT dangle within 1 hour of RN or PT dangle with calisthenics**

extubation with calisthenics** If stable, stand and march in place
If stable, stand & march in place 30 sec 30 seconds

Up to bedside chair (30 min to Up to bedside chair

1 hour) within 2 hours of extu- (30 min to 1 hour)
bation, for all meals, & PRN BID & PRN

Has the
pt tolerated N Return to dangle.
Has the pt activity and Consider PT
tolerated activity been up in evaluation
& been up in the chair Notify PA on call
chair ≥2X? ≥2X?

Consider PT Y
Notify N
Can the
PA on call pt tolerate
**Ankle dorsi/plantar flexion 5 reps each foot,
hold 3 sec. Knee flexion/extension 5 reps each
leg, hold 3 sec.

C Continued

Figure 1: The Open Heart Rapid Recovery Activity Protocol used in the thoracic ICU (Continued).

from a recent study54 in which mobilization Even in 2 hospitals in the same city and health
practices in 9 Scottish ICUs and 10 Australian care system, mobilization varies markedly
ICUs were compared. Mobilization occurred across ICUs.
in 40% of patients in Scottish ICUs and 60%
of patients in Australian ICUs; however, Effects of Early Mobility on
fewer patients were receiving mechanical Long-Term Outcomes
ventilation in the Australian ICUs (16.3%) Most research to date has focused on the
than in the Scottish ICUs (41.1%). Barriers effects of early activity programs on short-term
to early mobilization included sedation, outcomes. The effect of acute in-ICU mobility-
endotracheal tube, and cardiovascular or based rehabilitation on long-term outcomes
respiratory instability, suggesting (not surpris- and functional independence is a growing field
ingly) considerable variability in mobiliza- of research (Table 1). Morris et al38 reported
tion practices across ICUs in 2 countries.54 that during the first year after ICU discharge,



Has Do not ambulate pt, Has

N continue with previous N
pulmonary artery pulmonary artery
catheter been activity, up to bedside chair catheter been
removed? BID & PRN removed?


RN, ET, PT Ambulate pt at Ambulate as pt

least BID, as tolerated per tolerates per activity
activity assessment, assessment
including chair 30 min-
1 hr for meals & PRN
BRP with assist as needed

Stop activity.
Reassess pt, call MD PRN
Did the pt Did the pt
N After patient again meets Activity N
tolerate tolerate
Assessment Criteria, restart activity
ambulation & ambulation &
at previous level or consider ambu-
activity? activity?
lating for a shorter distance/time.
Consider PT


Continue progressive Continue progressive

ambulation BID & PRN ambulation and activity as
per cardiac rehab protocol tolerated

Figure 1: The Open Heart Rapid Recovery Activity Protocol used in the thoracic ICU (Continued).

lack of early exercise/mobility was a predic- outcomes, or quality of life in ICU survivors.
tor of hospital readmission or death (P = .04) Burtin et al32 reported that patients who
among ICU patients. Early exercise in the ICU participated in bedside cycle ergometry had
improved patients’ abilities to complete activ- higher scores on the Short Form 36 Health
ities of daily living (bathing, dressing, eating, Survey (SF-36) Physical Functioning Scale
grooming, transferring from bed to chair, and than did patients in the control group. The
using the toilet) and increased the distances Physical Functioning Scale is used to assess
they were able to walk compared with a con- functioning in 10 mobility activities, such as
trol group.24 Similarly, in a study that used a walking specified distances, bending, stoop-
bedside cycle ergometer, researchers found that ing, kneeling, carrying groceries, and bathing
patients in the intervention group walked an or dressing. The patients’ quadriceps forces
average of 53 m farther than patients in the correlated with both walking performance and
control group walked.32 SF-36 Physical Function scores, suggesting
In only 3 studies32,37,55 did researchers assess that increased strength affects not only walk-
the effects of early mobility–based rehabili- ing but the perception of physical function.33
tation on cognitive function, psychological Thus, improvements in physical strength were


Percentage of patients





2009 2010 2011 2012 2013 2014

Time to Extubation
< 5 hours
< 7 hours
< 24 hours, excludes patients with > 3-day ICU stay
< 24 hours, all patients

Figure 2: Time from surgery to extubation for postoperative cardiac patients in the thoracic intensive care
unit (ICU). The category “Time to extubation < 24 hours all patients” includes all patients regardless of whether
their stay in the ICU was short or long (> 3 days). Most patients in the thoracic ICU have shorter ICU stays
because they are primarily there after cardiac surgery.

reflected both in a task of physical function

(longer distance walked on the 6-minute walk
test) and in patients’ assessment of their func-
tional abilities (SF-36 Physical Function scores).
Researchers in the other 2 studies37,55 assessed
the effects of early mobility–based rehabilita-
tion on 2 important components of PICS,
cognitive impairment and psychological mor-
bidities. In a pilot study by Brummel et al,55
87 critically ill patients were randomized to
usual care, once-daily physical therapy, or
once-daily early physical therapy plus cogni-
tive therapy that included orientation, atten-
tion, memory, and problem-solving tasks.
At 3 months, the patients did not differ signifi-
cantly in functional abilities or cognitive func-
tion. Another prospective pre-post cohort
study37 of 637 neurological ICU patients
showed that an early exercise program in
the ICU did not reduce symptoms of depres-
sion or anxiety at ICU discharge. Some data
indicate that physical exercise/activity improves
Figure 3: A patient ambulating in the thoracic cognitive function and decreases depression
intensive care unit while intubated. and anxiety in both healthy and non-ICU


clinical populations.56 Additional research is Patient’s Perspective

needed to understand fully the effects of early One of the authors (M.S.) had a long stay
mobility–based rehabilitation on the cogni- for acute respiratory distress syndrome in
tive and psychological morbidities associated the RICU and is now a member of the STICU
with PICS. Patient and Family Advisory Council. We
report here her memories of the experience
Partnering With Families for of early mobility in the recovery phase, which
Early Mobility extended from several months in the RICU
Having a loved one in the ICU is difficult to 1 month in a long-term acute care hospi-
at best, as the ICU environment can be a tal to a readmission to the TICU for a post-
threatening and disorienting place. Both the acute complication.
severity of illness and the invasive therapies When you are in the ICU you
can contribute to dehumanization and isola- lose all your dignity, and you are
tion for both patients and their families.57 at the mercy of the hospital staff. I
Engagement of both patients and their fami- don’t remember most of the early
lies is increasingly recognized as a priority months, as I was in a coma and
in contemporary critical care.58 Families can intubated. By the time I was out of
participate as members of the clinical team the coma, physical therapy was
in representing the patient’s values and prior- ordered. My hands and feet were
ities and in direct participation in bedside so swollen that I basically had no
care.59,60 Early mobility–based rehabilitation feeling in them, making it difficult
provides opportunities for family to partici- to stand. The physical therapist
pate in education about the need for and the would come by once or twice a
benefits of mobilizing their loved one.61 When day. At first it was just dangling
invited, family members are often happy to my legs on the side of the bed.
participate in care of their loved one.62,63 When they would try to stand me
Family members could participate in early up, I would sometimes lose con-
mobility–based rehabilitation in various ways, trol of my bowels, which fright-
including providing information about their ened me. In addition, my oxygen
family member, supporting their family mem- levels would drop so low they
ber, walking alongside, providing encourage- would have to lay me down most
ment, communicating the importance of early of the time. Eventually they were
mobility, assisting with passive and active range able to get me into a chair, which
of motion exercises, and coaching their fam- was so uncomfortable. I couldn’t
ily members.61 Rukstele and Gagnon61 used even sit upright in the chair. I just
the following steps to engage patients’ fami- wasn’t strong enough. I was finally
lies in early mobility: inviting them to par- able to take a few steps, and the
ticipate in early mobility, education (about nurses and respiratory therapists
PICS morbidities, showing them how to do would take me to the shower in a
mobility, and about the importance of the wheelchair. I walked a few steps
task), and supporting the families. Staff in and they would have the chair
The University of Michigan Health System’s right behind me. The doctors on
surgical ICU used these 3 steps and reported their visit would tell the staff to
that compliance with mobility increased from get me up today. I was glad to
64% to 99% during a 6-month period, sug- hear that the doctor wanted me to
gesting the importance of including patients’ get up. The therapist’s approach
families.60 Our experience has been that really matters. One of the physical
patients’ families are excited to participate therapists was kind and would
in early mobility, feeling like their loved one coach me and explain each step in
is making progress and that they are able to getting up and walking. Another
participate. Such participation, where fami- was more brusque and didn’t help
lies desire it, has become routine in all Inter- me to feel motivated, so our treat-
mountain ICUs. ments together didn’t really work


well. The nurses would come by protocol increased mobilization from 22%
twice a day to try to help me get before implementation to 82% after imple-
up and walk. It is so important to mentation (P < .05).65 Further, numerous
work as hard as you can and try studies17,24,40,46,66 support the important role
to stand as soon as you can. Get- that ICU culture plays in early mobility–
ting up in the RICU helped me based rehabilitation in critically ill patients.
be ready for rehabilitation at the
long-term acute care hospital. Factors Associated With
Once I was in the long-term acute Successful Practice Change
care hospital, I was totally com- Care bundles and professional society
mitted to getting stronger again. endorsements may help with the culture
I would even sign up for extra change required to support early mobility.4,67,68
PT appointments if other patients Programs such as the Society of Critical Care
couldn’t do them. I am so very Medicine’s ABCDE bundle were designed to
grateful for all the staff in the improve modifiable risk factors of adverse
RICU as well as the staff at the outcomes. The ABCDE bundle includes daily
long-term acute care hospital. sedation awakening trials, breathing coordi-
nation, assessment, preventing delirium and
Overcoming Obstacles: implementing early mobility–based exercise/
Barriers to Early Mobilization rehabilitation.69 As Clemmer70 noted, manage-
Changes in clinical care should be evidence ment of sedation, delirium, and sleep are
based. Minimizing sedation, facilitating spon- interdependently necessary in order to mobi-
taneous breathing, delirium screening, and lize patients. Implementing new practices,
early mobility–based rehabilitation are safe especially ones (eg, early mobility) that are
and feasible, improve important patient- diametrically opposed to old ones (eg, seda-
centered outcomes, and are practice priorities tion and bed rest) can be a monumental task.
in adult ICUs.49-51 Data to date suggest that Important and dramatic changes in clinical
early mobility–based rehabilitation is associated practice are exactly what the ABCDE bundle
with positive short- and long-term outcomes, is designed to address.
supporting incorporation of early mobility– A report of the ICU Clinical Impact Interest
based rehabilitation as a standard of care in Group, who participated in implementation
the ICU. of the ABCDE bundle, stated that a multidis-
Consistent implementation of early mobil- ciplinary team was required to implement
ity is influenced by a variety of factors such the ABCDE bundle.19,21,25 Factors that were
as low census with flex staffing (PTs have to associated with better implementation of the
cover more units, fewer nurses, etc), unit-level ABCDE bundle included (1) ICUs that had
knowledge of early mobility, implementation good organizational characteristics, including
of a mobility protocol, administrative support, strong and stable ICU leadership and consist-
and funding. Some of these issues can be ent staff for physical and respiratory therapy;
addressed at the unit level (eg, education), (2) an ICU culture focused on patient safety
whereas others will be outside the direct con- and quality improvement; (3) ICUs that had
trol of the unit (eg, funding for rehabilitation a clinical champion focused on implementing
staff). A recent review of early rehabilitation early mobility; and (4) ICUs that used multi-
in ICU survivors revealed that barriers to suc- modal training for clinical staff during imple-
cessful mobility-based rehabilitation included mentation of the ABCDE bundle.69
insufficient or lack of availability of physical A recent article71 listed 7 guiding principles
and occupational therapy, physiological or for implementing new evidence-based practices,
neurological instability, and an ICU culture such as the ABCDE bundle. The principles
that did not support early mobility.64 For include the following: (1) PICS-associated
example, researchers in one study40 found morbidities are modifiable, and modifiable
that early mobility–based rehabilitation was causes and risk factors should be the focus
not provided to critically ill patients more of interventions; (2) invested interdisciplinary
than 50% of the time because of a shortage teams who use evidence and a team approach
of rehabilitation staff. Implementation of to improve care delivery are needed; (3) inter-
mandatory mobility orders and a mobility disciplinary teams should use bidirectional


feedback and good communication for success- death. Factors that influence early mobility–
ful change; (4) the evidence-based ABCDE based rehabilitation include an interdiscipli-
bundle should become standard clinical nary team, a strong and stable ICU leadership,
care; (5) patients will wake up, breathe on access to physical, occupational, and respira-
their own, and participate in early mobility– tory therapy, an ICU culture focused on patient
based rehabilitation with implementation of safety and quality improvement, a champion
the appropriate care processes; (6) measure- of early mobility, and a focus on measuring
ment of goals and outcomes is necessary to performance and outcomes.
track progress and identify areas in need of
improvement or change; and (7) processes REFERENCES
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delirium, breathing, and mobility-based outcomes, health care use, and costs of survivors of
rehabilitation. Without such practices, there acute respiratory distress syndrome. Am J Respir Crit
Care Med. 2006;174(5):538-544.
is no way to assess improvement in mobility- 2. Iwashyna TJ, Cooke CR, Wunsch H, Kahn JM. Population
based rehabilitation.71 burden of long-term survivorship after severe sepsis in
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CE Test Instructions

This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the
following objectives:
1. Describe 2 components of implementation of early mobility–based rehabilitation.
2. Describe the effects of early mobility–based rehabilitation on intensive care unit and long-term outcomes.
3. List 3 barriers to early mobility–based rehabilitation.
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Pharmacology contact hour: 0.0
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AACN Advanced Critical Care
Volume 27, Number 2, pp. 204-211
© 2016 AACN

A Clinic Model: Post–Intensive Care

Syndrome and Post–Intensive Care
Elizabeth L. Huggins, AG-ACNP

Sarah L. Bloom, AG-ACNP

Joanna L. Stollings, PharmD, BCPS

Mildred Camp
Carla M. Sevin, MD

James C. Jackson, PsyD

The number of patients surviving critical ill- have been used to address the complications
ness in the United States has increased with of post–intensive care syndrome for some
advancements in medicine. Post–intensive time. However, the interprofessional clinic at
care syndrome and post–intensive care syn- Vanderbilt University Medical Center is among
drome–family are terms developed by the the first in the United States to address the
Society of Critical Care Medicine in order to wide variety of problems experienced by inten-
address the cognitive, psychological, and sive care survivors and to provide patients
physical sequelae emerging in patients and and their families with care after discharge
their families after discharge from the inten- from the intensive care unit.
sive care unit. In the United Kingdom and Keywords: critical care, post–intensive care
Europe, intensive care unit follow-up clinics syndrome, follow-up clinic, rehabilitation

T he number of patients surviving critical

illness in the United States has increased
with advancements in medicine. The long-term
Elizabeth L. Huggins and Sarah L. Bloom are Adult-Gerontology
Acute Care Nurse Practitioners, Department of Medicine,
Vanderbilt University Medical Center (VUMC), 1161 21st Ave S,
consequences of critical care survivorship have Suite AA-1214, Nashville, TN 37232-2102 (elizabeth.huggins
become evident. The implications of critical,
illness on patients’ short- and long-term health Joanna L. Stollings is Clinical Pharmacy Specialist in the Med-
are vast and include consequences not only ical Intensive Care Unit (MICU) and Pharmacist in the ICU
for patients, but also for their loved ones.1 Recovery Center, Dept of Pharmaceutical Services, VUMC.
Evidence suggests that one-third of intensive Mildred Camp was a patient in the MICU at VUMC.
care unit (ICU) survivors have depression,2 Carla M. Sevin is Assistant Professor, Director of the ICU
one-half have cognitive impairment,3 and Recovery Center, Department of Medicine, Division of Allergy,
physical disability is common.4 Mental health Pulmonary and Critical Care, VUMC.
outcomes have been reported among disease- James C. Jackson is Neuropsychologist and Assistant
specific groups of critical illness survivors, such Director of the ICU Recovery Center, Center for Health
as those with acute respiratory distress syn- Services Research, Departments of Medicine and Psychiatry,
drome and sepsis.5 At 3 months after discharge, VUMC, and Geriatric Research, Education and Clinical
Center (GRECC) Service, Department of Veterans Affairs,
cognitive testing performed on survivors of Tennessee Valley Healthcare System, Nashville, Tennessee.
critical illness has shown that an astonishing
The authors declare no conflicts of interest.
one-third of patients experience cognitive
deficits similar to those seen in Alzheimer’s DOI:


disease and an additional third have cogni- Critical Care Recovery Center (CCRC) at the
tive impairment similar to that seen after a Indiana University School of Medicine was
traumatic brain injury. Delirium was indepen- the first post-ICU clinic to open in the United
dently associated with a spectrum of cognitive States in 2011. The CCRC targets geriatric
impairments affecting patients after hospitali- patients with depression and psychological
zation for critical illness.3 Older adults who disorders and aims to improve the long-term
survive critical illness have a significantly higher health of ICU survivors, reduce readmissions,
mortality rate in the 1-year period following and provide care to optimize psychological
discharge when compared with other hospital- wellness.10 Patients qualify for the CCRC if
ized patients and the difference is even greater they were receiving mechanical ventilation
when compared with the general population. or experienced delirium that lasted more than
The mortality rate in patients discharged to 48 hours. The clinic is operated by an inter-
a skilled nursing facility remains greater, at professional group that includes physicians,
24.1%, than the rate in patients discharged registered nurses, and social workers.10
to home, which is 7.5%.6 These statistics may The ICU Recovery Center at Vanderbilt
reflect a cohort of patients with a higher opened in 2012 with the objective of improving
severity of illness and may highlight the need the long-term health and outcomes of patients
for improved care delivery to all survivors who have survived critical illness through an
of critical illness owing to the unique prob- interprofessional team approach. The Vander-
lems afflicting this population. bilt Model employs providers with expertise
Post–intensive care syndrome (PICS) is a in critical care in an outpatient setting, a unique
term recently coined by the Society of Critical approach to deliver care that addresses the
Care Medicine to encompass the cognitive, sequelae of critical illness and its associated
psychological, and physical issues that patients increased mortality. Teaching caregivers about
face after an ICU admission. The term post– their loved ones’ recovery and supporting them
intensive care syndrome-family (PICS-F) refers through this often-difficult transition are
to the response to critical illness by families integral parts of the model. In addition, the
and describes the development of a cluster of clinic is designed to gain subjective and objec-
physiological outcomes such as posttraumatic tive information about the lives of patients after
stress, depression, complicated grief, and anxi- critical illness to guide research that will affect
ety, among others.7 Post-ICU clinics have been treatment guidelines in the ICU. The inter-
proposed as a strategy for improving long- professional team works together to recruit
term care and outcomes for ICU survivors.8 and screen patients on the basis of established
In the United Kingdom, post-ICU clinics have criteria and to provide comprehensive follow-
been in existence for more than 20 years; the up care in an outpatient setting. Patients’
first clinic opened there was in Reading in family members are invited to attend the clinic
1993. In the United Kingdom, a national sur- appointment at the discretion of the patient.
vey reported that of the 288 ICUs nationally, At this time, the Vanderbilt ICU Recovery
80 of them had an associated post-ICU clinic.9 Center does not screen or treat these family
Despite the wide use of these clinics in Europe, members for PICS-F. As the outreach of
few data are available to demonstrate efficacy the center grows, resources to address PICS-F
and guide further practice. Therefore, no con- will be a priority.
sensus on the ideal model of care delivery has
been established. Within the United States, The ICU Recovery Center Team
clinics remain a novel way to improve the The Vanderbilt ICU Recovery Center team
health of ICU survivors. Clinics at Indiana consists of a medical ICU (MICU) nurse prac-
University and Vanderbilt University are titioner, a pharmacist, a pulmonary intensivist,
among the first in the United States with the a case manager, and a neurocognitive psychol-
goal of improving post-ICU quality of life ogist. The team is modeled after the interpro-
and reducing hospital readmission rates fessional team composition used within the
among medical and surgical ICU survivors.10 MICU. Each individual clinician is responsi-
ble for a component of the patient’s visit, and
The Post-ICU Clinic information is shared among team members
Since 2011, 2 ICU follow-up clinics have during the clinic appointment for the purpose
been developed in the United States.11 The of forming a collaborative treatment plan.


• Discusses work status and supports persons involved in care

• Ensures that services arranged for at discharge are received; for example, access
to medications and/or home heatlh (notifies case manager as indicated)
Medical Intensive Care
• Educates patient and patient’s family, health promotion, tracheostomy/
Unit’s Nurse Practitioner
wound care, nutritional assessment
• Reviews level of independence for activities of daily living with patient and
patient’s family

• Medication reconciliation
Clinical Pharmacist
• Vaccine review/recommendation (eg, influenza and pneumococcal)

Neurocognitive • Screens for presence of anxiety, depression, and/or posttraumatic stress disorder
Psychologist • Therapeutic dialogue, referrals for ongoing therapy

• Reviews and interprets 6-minute walk and spirometry results with patient and
Pulmonary Critical patient’s family
Care Physician • Compiles recommendations from each clinician and reviews final plan with
patient and/or patient’s family

• Accesses medications and durable medical equipment as indicated

Case Manager • Follows up with home health services if needed

Figure 1: Roles of various clinicians in constructing patients’ plan of care.

Each individual clinician has a unique role and the majority of referrals to the clinic. These
perspective that is considered in constructing a referrals are then screened for the presence
patient’s plan of care (Figure 1). of inclusion and exclusion criteria.
The MICU nurse practitioners review the
Recruitment of Patients chart for inclusion and exclusion criteria
To understand better how survivors of criti- (see Table). If the patient meets criteria for
cal illness and their families can best be served appointment scheduling, the patient is fol-
by a PICS clinic, a database is maintained to lowed throughout the hospital stay until
capture both patient referrals and the status discharge planning is underway and outpatient
of their appointment scheduling. Family mem- follow-up can be arranged. One of the initial
bers are encouraged to attend the clinic, but barriers to successful scheduling of a clinic
currently they are not recruited separately appointment has been a patient or family’s
for evaluation of PICS-F. The recruitment and familiarity with the ICU Recovery Center’s
scheduling processes described here reflect a function. One strategy to increase compliance
strategy that has evolved in the 3 years since with appointment scheduling is rounding on
the clinic’s formation. patients and their families before discharge.
Patient referrals to the Vanderbilt ICU This visit is used to encourage follow-up in
Recovery Center come from all of the institu- the clinic and educate patients about the clin-
tion’s adult ICUs. However, the majority of ic’s function. With additional resources and
referrals come from the MICU, most likely personnel, introducing the clinic to all patients
because the clinic team is made up of MICU and scheduling an appointment before dis-
providers. Any member of a patient’s health charge will become standard.
care team can make a referral, which is done
by notifying the MICU nurse practitioner or Scheduling of Patients
by requesting a consultation via the elec- The Vanderbilt ICU Recovery Center has a
tronic order entry system. In the MICU, the dedicated appointment scheduler who is noti-
clinical pharmacist and case manager make fied when appointment scheduling is needed.


Table: Inclusion and Exclusion Criteria for Recruitment and Attendance for the Post–
Intensive Care Syndrome Clinic

Inclusion Criteria Exclusion Criteria

Primary Preexisting dementia or cognitive deficit
Adult (> 18 years old) with critical illness Life-limiting illness with anticipated life expectancy
(adult respiratory distress syndrome or sepsis) < 6 months
Managed primarily by different subspecialty service
Secondary (1 or more of the following):
(eg, liver/renal transplant)
Delirium > 48 hours
Primary diagnosis in intensive care unit with specialty
Received neuromuscular blockade, high-dose
resources in place after hospitalization (eg, stroke
steroids, and/or bed rest > 3 days
or cardiac rehabilitation)
Prolonged course (> 7 days) in intensive care unit
Long-term resident of skilled nursing facility or
Multiple new deficits anticipated at discharge
long-term acute care facility
Shock (> 6 hours)
New organ dysfunction(s) with prolonged recovery

Ideally, the clinic’s aim has been to arrange results of these performance metrics are used
for outpatient follow-up before the patient’s to determine the patient’s physical capacity
discharge, so that the visit is listed on the in comparison to the predicted ability. Each
patient’s discharge letter. Again, the referral allows an objective measure of the patient’s
and scheduling process described has been physical capacity and can be used to track
reformed on the basis of the clinic team’s improvement throughout the patient’s
experience and may not reflect the ideal recovery.
strategy for other institutions. The MICU nurse practitioner completes a
A secure database that can be accessed detailed history and physical examination as
online can assist in storing data and gaining it pertains to the patient’s resolving critical
insight into features of a patient’s hospitaliza- illness. Special attention is focused on trache-
tion, including when the patient moves out ostomy care, persistent respiratory insufficiency,
of the ICU and the anticipated discharge dis- indwelling vascular catheters, neuromuscular
position. As previously mentioned, patients weakness, and skin breakdown. Key features
and their families are often unfamiliar with of a patient’s hospital course are reviewed.
the purpose of the PICS clinic and thus are A comprehensive health interview involving
unwilling to schedule in the face of multiple the patient and family (if present) details nutri-
appointments. Frequently patients are fearful tional intake, activity tolerance, independ-
of returning to the hospital, or lack the social ence in daily living, and return to work status.
support, finances, or transportation to return Patients are asked to explain how their post-
for multiple appointments. Tracking the ICU life is different from their lives before
reason(s) that patients/families cite for declin- hospitalization. The nurse practitioner then
ing to schedule an appointment can provide tailors the interview to investigate specific
insight into improving the scheduling process. complaints further depending on the patient’s
Using a data collection tool during the response. Complications, new deficits, and
creation of a PICS clinic is necessary to gain support systems are evaluated in every patient
valuable insight into trends associated with and then discussed with the clinic team. A
referrals of patients, appointment scheduling, clinical pharmacist completes a full medication
and reasons observed for why patients do not review and provides medication education and
attend the clinic. The model for referrals and reconciliation. Additionally, indications and
recruitment of patients that is most successful eligibility for an annual flu shot and pneumo-
will vary by institution, and internal review coccal vaccine are reviewed and offered to
for quality improvement should be considered. the patient at this time.
A neuropsychologist meets with the patient
Initial Clinic Visit to evaluate and screen for cognitive impair-
At the initial ICU Recovery Center visit, ment, posttraumatic stress disorder (PTSD),
each patient is asked to complete spirometry anxiety, and depression. Validated tools are
testing and a 6-minute walk test (if able). The used in the psychological assessment portion


of each visit, per recommendations from will have access to ongoing follow-up. The
experts in PICS.12 These tools include global clinic’s goal is not to replace a patient’s pri-
measures of cognition, such as the Montreal mary care provider. Rather, the clinic strives
Cognitive Assessment13 and Trail Making Tests to bridge the gap between the ICU and out-
A and B.14 These tools are augmented by tests patient care as a patient makes the transition
of psychological functioning such as the Beck from critical illness to home.
Depression Inventory II15 or the Hospital
Anxiety and Depression Scale16 and the PTSD Measuring Success and
Checklist.17 Results from the cognition and Future Research
psychological functioning tests are quickly Data on the effect of Vanderbilt’s ICU
interpreted by the neuropsychologist adminis- Recovery Center remain anecdotal to date.
tering them and then used in both therapeutic Currently this clinic is unable to report on the
conversations with patients and their families outcomes of interest with quantitative findings.
and for purposes of treatment planning. Future projects designed to grow the limited
Additionally, smoking status is reviewed, body of research are in the early stages. The
and cessation education and resources are value of the aforementioned model and the
discussed. A case manager is available should interprofessional team composition have not
a patient need additional resources like home been established as the standard of care for
medical care, durable medical equipment, PICS clinics. Additional specialties, not pre-
medications, primary care access, and afford- viously mentioned here, may also provide
able community health resources. We have value for both patients and their families.
found that many of the items that are addressed For example, palliative care and primary care
during the first clinic visit (eg, physical ther- providers may play an important role (Figure
apy, medication reconciliation, health, nutri- 2 conceptualizes the many disciplines that
tion) were in place before discharge, but for can improve patient care through involvement
various reasons are not appropriately in in a PICS clinic). The feasibility of any team
place weeks after discharge. We not only must be considered when developing a group
verify these support services and equipment, of providers for a PICS clinic.
but also often set them up, reorder what is The specific research questions the ICU
appropriate, and assist patients and caregiv- Recovery Center is focused on are evaluating
ers with communication with social services. the effectiveness of this post-ICU clinic on
reducing hospital readmissions and improving
Treatment Plan long-term health. The interventions employed
The clinic team completes the visit with a are screening for and treating psychological
collaborative review of pertinent findings and ailments associated with critical illness, reduc-
the proposed assessment and plan. The treat- ing the number of adverse medication effects,
ment plan often includes referrals to support and promoting health and safety. Currently
services such as physical therapy, occupational the ICU Recovery Center has received approval
therapy, or specialty providers. Survivors of from the institutional review board for data
critical illness have a variety of special needs collection that focuses on readmission rates
following ICU discharge, all of which cannot for ICU survivors who attend the clinic versus
be mentioned here. Health promotion and ICU survivors who do not, as well as approval
education on topics like immunization, for medication review and adverse outcomes,
smoking cessation, and weight management long-term psychological ailments from critical
can help reduce further complications and illness, and data that help to evaluate factors
readmissions to the hospital in these vulnera- that contribute to clinic attendance.
ble patients. A pulmonary critical care attend- The following are steps to initiate and apply
ing physician meets with the patient and the the research process to determine the value
patient’s family to conclude each visit. Perti- of PICS clinics. The first will be establishing
nent findings are summarized and plans for a clinic model that efficiently screens, tracks,
future health care resources are agreed upon. and recruits patients to be seen in the clinic.
A summary of the patient’s hospitalization The next step is to systematically evaluate and
and clinic appointment is sent to the patient’s study a large group of PICS patients, identify
primary care provider in an effort to improve major issues, and gather resources to treat
communication and ensure that the patient them. Third, important research questions


Advance Practice Nurse/Physician Assistant

Critical Care Nurse Dietitian

Physical Therapist Neuropsychologist

Occupational Therapist Clinical Pharmacist

Primary Care Provider(s) Palliative Care Specialist

Speech Language Pathologist Social Work/Case Manager

Patient &
Rehabilitation Medicine Specialist Pulmonary Critical Care Physician

Figure 2: Stakeholders in a multidisciplinary team approach to outpatient post–intensive care syndrome

clinics. All team members work in the medical intensive care unit at Vanderbilt University Medical Center
and in the clinic.

will focus on the efficacy, the value and the and financial constraints must be considered
impact that the PICS clinics have on long-term when offering a follow-up appointment.
outcomes, allowing development of the ideal Once patients do return, basic resources
model. Finally, the knowledge gained through needed for specialists to identify and treat
research of PICS can be used to establish the problems associated with critical illness,
PICS clinics and to prevent the development such as a physical clinic location and labora-
of PICS while patients and their families are tory capabilities, are necessary. Additional
in the ICU. resources such as access to pulmonary func-
tion testing, radiography, and further subspe-
Overcoming Obstacles cialty care are desirable.
Despite continued efforts, barriers to Most of these barriers can be addressed with
effective post-ICU care are still evident. Two additional resources, personnel, and funds.
of the most prominent obstacles experienced The process of recruiting and tracking patients
at Vanderbilt University Medical Center are can be streamlined with a dedicated staff mem-
the logistical challenge of recruiting and ber who is able to recruit and track patients on
screening patients and the availability of a daily basis. In addition, a physician champion
adequate resources. who is willing to advocate for patients and
Patients who meet inclusion criteria for the their participation in the clinic is key. As
ICU Recovery Center often have long and com- technologies advance and the electronic med-
plicated hospital admissions. Tracking their ical record is consistently used, the tracking,
transition from the ICU to a step-down unit ordering and scheduling process for patients
and then to discharge is time-consuming and will become more efficient. Additional educa-
requires personnel who have access to the tion and time spent with patients and their
electronic medical record and can interpret families describing the sequelae of critical
the chart to estimate when discharge is likely. illness tend to improve participation of patients
Therefore, a strong foundation of knowledge and their families. Once the range of difficul-
about critical care and illness trajectory is ties that survivors of critical illness may encoun-
needed. Anecdotally, the clinic team has ter is reviewed, patients and family members
observed face-to-face recruitment for appoint- can better understand the potential importance
ments to be effective. However, patients may of attending a PICS clinic.
feel overwhelmed when their anticipated long
recovery process is described. Patients frequently Patient’s Perspective:
cite a high number of providers or inability to Millie Camp
return to the hospital as a reason for not sched- In 2013, Mildred Camp, a previously
uling an appointment. Barriers such as trans- healthy woman in her 60s, was admitted to
portation, portable oxygen, family support, Vanderbilt University Medical Center with a


new diagnosis of thrombotic thrombocytopenic Of the ICU Recovery Clinic, she says,
purpura. Her initial treatment plan included The ICU Recovery Center was a
high-dose steroids and rituximab. Although great resource—answering every
she was discharged after 2 weeks, the treat- question, helping me recognize my
ment of the disease left her body weakened progress, validating my efforts,
and susceptible to opportunistic complications. and checking for post-ICU decline
Soon after, Mrs Camp was readmitted to the in physical, cognitive, and psycho-
hospital and transferred to the MICU with logical realms. The clinic provided
acute respiratory distress syndrome. She much-needed information, direc-
received mechanical ventilation for 17 days tion, and encouragement. I wanted
and was in the ICU for a month. Mrs Camp to sing again but lacked the breath
has little recollection of her time in the ICU, and vocal range. [I was referred
but recalls feeling frightened and helpless as to] The Vanderbilt Voice Center,
she lay in bed unable to communicate her [which] gave me vocal and breath-
needs. The memory of looking out of the ing exercises, which benefited my
window into the hallway to see her nurse overall breathing capacity. [A year
working at a computer sticks out in her mind. after I fell ill] I returned to my bar-
She recalls feeling powerless and vulnerable bershop chorus to sing, a major
to her caregivers’ ability to remain aware of goal in my recovery.
her needs. Mrs Camp’s family was by her Today, it has been more than 3 years since
side and has helped her to grasp the pro- Mrs Camp was admitted to the MICU. She
found experience she endured. They clung to reminds us that recovery is a long process,
updates from the nurses and doctors, watched one that requires not only physical endurance
her monitor with intent, and prayed faith- but mental and emotional endurance. She
fully in the waiting areas when her condition urges fellow survivors not to succumb to the
became critical. She tells us, moments of pain, fear, weakness, fatigue, con-
I was so swollen that my wedding fusion, doubt, hopelessness, and depression.
rings would not come off. So my However, she adds, “I was very lucky to not
husband of 41 years (longer than struggle with pain, depression, or anxiety
most of my caregivers had been after my critical illness as I recognize these
alive) began the arduous hour-long ailments do suspend progress.” In closing, she
process of cutting off my rings. You says, “I battle to moderate my expectations
can imagine his pain and sorrow as I continue my journey to optimal health
with this difficult task. ICU illness and delight in each new day.”
impacts the whole family.
Mrs Camp left the ICU and spent months Conclusion
in long-term acute care and rehabilitation, With an aging population and a growing
where she worked tirelessly to rebuild her number of patients surviving critical illness,
strength. The magnitude of her weakness was the implications of post-ICU deficits are pro-
difficult to grasp; her physical capacity was found. The ICU Recovery Clinic at Vanderbilt
so severely diminished upon leaving the ICU University Medical Center is one example of
that she lacked the strength to sit up or roll how critical care providers can use a PICS
over in bed without assistance. Mrs Camp clinic to improve the care of patients. Patients
was discharged after 3 months in hospitals, and families benefit from the support of criti-
with portable oxygen and outpatient physical cal care clinicians outside of the ICU as a
therapy scheduled for another 3 months. She way to manage the transition of their care to
was also scheduled in the ICU Recovery Clinic. a general practitioner. Future research is
She was committed to regaining her strength needed to determine the ideal model for PICS
both mentally and physically but was plagued clinics in the United States and to quantify
by “brain fog” and inattention. Three months the effects such clinics have on quality of life
after discharge, she was able to be weaned after discharge and readmission rates.
off of supplemental oxygen and had regained
much of her physical strength with intense REFERENCES
physical therapy, hiring a trainer after her 1. Desai SV, Law TJ, Needham DM. Long-term complica-
outpatient therapy was complete. tions of critical care. Crit Care Med. 2011;39(2):371-379.


2. Jackson JC, Pandharipande PP, Girard TD, et al. Depression, 10. Khan BA, Lasiter S, Boustani MA. Critical care recovery
post-traumatic stress disorder, and functional disability in center: an innovative collaborative care model for ICU
survivors of critical illness in the BRAIN-ICU study: a lon- survivors. Am J Nurs. 2015;115(3):24-31.
gitudinal cohort study. Lancet Resp Med. 2014;2(5):369-379. 11. Society of Critical Care Medicine. THRIVE. http://www
3. Pandharipande PG, Girard TD, Jackson, JC, et al. Long-
term cognitive impairment after critical illness. N Engl J Accessed February 12, 2016.
Med. 2013;369(14):1306-1316. 12. Needham DM, Davidson J, Cohen H, et al. Improving
4. Herridge MS, Tansey CM, Matté A, et al. Functional long-term outcomes after discharge from intensive
disability 5 years after acute respiratory distress syn- care unit: report from a stakeholders’ conference. Crit
drome. N Engl J Med. 2011;364(14):1293-1304. Care Med. 2012;40(2):502-509.
5. Davydow DS, Desai SV, Needham DM, Bienvenu OJ. 13. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Mon-
Psychiatric morbidity in survivors of the acute respira- treal Cognitive Assessment, MoCA: a brief screening
tory distress syndrome: a systematic review. Psycho- tool for mild cognitive impairment. J Am Geriatr Soc.
som Med. 2008;70(4):512-519. 2005;53:695-699.
6. Wunsch H, Guerra C, Barnato AE, et al. Three-year out- 14. Reitan RM. Validity of the Trail Making Test as an indi-
comes for Medicare beneficiaries who survive intensive cator of organic brain damage. Percept Mot Skills.
care. JAMA. 2010;303(9):849-856. 1958;8(3):271-276.
7. Davidson JE, Jones C, Bienvenu OJ. Family response 15. Beck AT, Steer RA, Brown GK. Beck Depression
to critical illness: postintensive care syndrome–family. Inventory-II. San Antonio, TX: Psychological Corp;
Crit Care Med. 2012;40(2):618-624. 1996.
8. Stollings JL, Caylor MM. Postintensive care syndrome 16. Zigmond AS, Snaith RP. The hospital anxiety and
and the role of a follow-up clinic. Am J Health Syst depression scale. Acta Psychiatr Scand. 1983;67(6):
Pharm. 2015;72(15):1315-1323. 361-370.
9. Griffiths J, Barber V, Cuthbertson B, Young J. A 17. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris
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AACN Advanced Critical Care
Volume 27, Number 2, pp. 212-220
© 2016 AACN

Developing a Diary Program to

Minimize Patient and Family
Post–Intensive Care Syndrome
Meaghan Locke, RN-BC, BSN, CCRN

Sarah Eccleston, RN, MSN, ACCNS-AG, WCC

Claire N. Ryan, RN, BSN

Tiffany J. Byrnes, RN, BSN

Cristin Mount, MD

Mary S. McCarthy, RN, PhD, CNSC

A series of evidence-based interventions this article is to explain the education of all
beginning with an intensive care unit diary stakeholders; the introduction of the diary,
and a patient/family educational pamphlet video, and educational pamphlet; and the
were implemented to address the long- evaluation of the acceptance of these inter-
term consequences of critical illness after ventions. This process began with an infor-
discharge from the intensive care unit, bun- mal evaluation of the educational products
dled as post–intensive care syndrome and and overall perception of the usefulness of
post–intensive care syndrome–family. An the diary by patients, family members, and
extensive literature review and nursing staff. The efforts described contribute to the
observations of the phenomenon high- evidence base supporting diaries as an adjunct
lighted the potential for this project to have to intensive care.
a favorable impact on patients, their fami- Keywords: intensive care, diary, post–intensive
lies, and the health care team. The goal of care syndrome

P ost–intensive care syndrome (PICS) is an

increasingly confronted phenomenon
that encompasses physical, neurological, cog-
Meaghan Locke is a Consultant, Critical Care Nursing Section,
Madigan Army Medical Center.
Sarah Eccleston is Critical Care Clinical Nurse Specialist,
nitive, and emotional issues affecting patients Center for Nursing Science & Clinical Inquiry, Madigan
long after their stay in the intensive care unit Army Medical Center.

(ICU). The prevalence of this syndrome is Claire N. Ryan is Intensive Care Unit (ICU) Staff Nurse, Critical
Care Nursing Section, Madigan Army Medical Center.
variable but can be high, occurring in 15% to
Tiffany J. Byrnes is ICU Staff Nurse, Critical Care Nursing
more than 50% of ICU survivors.1-3 In addi- Section, Madigan Army Medical Center.
tion, patients’ family members experience Cristin Mount is Chief, Department of Medicine, Madigan
psychological and emotional trauma at a high Army Medical Center.
rate, so the PICS definition has been broad- Mary S. McCarthy is Senior Nurse Scientist, Center for
ened to include family members (PICS-F).2 Nursing Science & Clinical Inquiry, Madigan Army Medical
Patients may have survived their critical Center, 9040 Jackson Ave, Tacoma, WA 98431
illness, yet they face considerable challenges
to reach a full recovery. These challenges The authors declare no conflicts of interest. The ICU Diary
Program received a small grant award from the Army Surgeon
include ICU-associated posttraumatic stress General’s System for Health Initiative.
disorder and anxiety disorders, neurocogni-
tive deficits that are new or worse than they DOI:


were at baseline, extreme muscle weakness that According to Garrouste-Orgeas et al,6

limits activities of daily living, decreased pulmo- various studies have elucidated the following
nary reserve that also limits activity, chronic strategies designed to help family members
pain syndromes, and any lingering effects of actively provide support to themselves and the
the disease process that initially required ICU patient: flexible visitation policies, involvement
admission.1 Unfortunately, patients and their in nursing care, and participation in maintain-
families are often not educated about what ing a diary during the ICU stay. ICU diaries
to expect upon surviving a critical illness or have been widely used in European countries
injury because transitions from the ICU to as a low-cost technology to improve the qual-
the general care area and from there to home ity of life after critical illness.7,8 Qualitative
or another facility are usually focused on the studies reveal that the diary enables patients
acute care needs of the patient. to evaluate their recovery and improves com-
Additionally, the phenomenon of PICS has munication with their families about their
only recently been recognized by the critical experiences, thus sustaining family-centered
care community, and many non-ICU provid- care.6,7,9-13 Diaries may also enable patients
ers are unaware of the impact that PICS and to make sense of their intensive care encoun-
PICS-F may have on patients and their family ter, which they previously may have failed
members after discharge from the hospital.3 to understand.7
Patients are unsure of whether or not these Critically ill patients can have both negative
symptoms are expected, and non-ICU provid- and positive experiences during their time in
ers may not recognize that a focused evalua- an ICU. These experiences are due to a variety
tion is needed. If health care providers could of factors, but one that stands out is the loss
address the gap in PICS/PICS-F care by first of time for patients who have been sedated
educating patients and their families about or otherwise confined in the ICU. Critically
what to expect after surviving an ICU stay, ill patients also often suffer from disorienta-
accompanied by an ICU diary to help patients tion and delirium, thus creating a “void” of
remember what occurred and trigger follow-up what transpired during their stay. These “voids”
discussions with primary care providers, they are then filled in by what the patient thinks
could potentially increase satisfaction of patients might have happened; by what they were told
and patients’ families and improve transitions happened by staff, family, and friends; or by
of care from the ICU to acute care teams. past experiences.13 Nurses can assist patients
by addressing the risk for PICS/PICS-F upon
Literature Review admission and throughout the ICU stay,
Each year, millions of patients are admit- using the diary to help promote a more posi-
ted to the ICU, and one-third of them require tive reflection on their illness episode. Nurses
mechanical ventilation.2 These patients are can also help manage expectations regarding
also often unconscious or sedated. ICU sur- the future plan of care goals with sensitive
vivors have a high incidence of a variety of and meaningful communication via the diary.
mental health symptoms that may affect their The critical care community is aware of
recovery, including nightmares, unwanted evidence suggesting that the struggles faced
thoughts and memories, anxiety or depres- upon discharge from the hospital are often
sion, and posttraumatic stress syndrome.4 complicated by insufficient recovery and
These memories contain actual events that rehabilitation resources for both patients
occurred during the ICU stay, as well as delu- and family members, including a lack of spe-
sions. ICU survivors describe memories and cific knowledge on the part of primary care
dreams that they are often unable to compre- providers who interact with and follow up
hend and that often lead to a reduction in with survivors and close family members
their quality of life.5 Affected patients and after the hospitalization.14 Specific inpatient
their family members may benefit from a interventions to address individual elements
written document to reflect on their experi- of PICS and PICS-F include delirium screen-
ence of critical illness. This record of events ing and prevention protocols, early mobility
may allow them to move slowly past the protocols, detailed management of sedation
delusional memories and misconceptions regimens, and ICU diaries.1,14,15 Our evidence-
that formed in the disoriented mind during based practice (EBP) project team proposed
the ICU stay. that a combined ICU diary and patient/family


educational pamphlet might reduce symptoms and a nurse researcher with an interest in this
of PICS/PICS-F and improve satisfaction of project met every 2 weeks for 2 months to
patients and their families with respect to prep- discuss the EBP model selection, review the
aration for discharge from the ICU and even- literature, and develop a strategy for intro-
tual discharge from the hospital. The team was ducing the new program. Once those tasks
optimistic that this project would also benefit were accomplished, the group set a “kick-off”
the health care team by encouraging them date and arranged a nursing grand rounds
to be more engaged with the patient and the presentation to introduce the program to
patient’s family, demonstrating their commit- potential stakeholders throughout the hospital.
ment to the best possible outcomes for the The team invited Dr Judy Davidson, a nation-
patient along his or her illness trajectory. ally recognized nurse and subject matter expert
on PICS and PICS-F, to speak. The focus of the
EBP Program Plan presentation was the biopsychosocial implica-
Guiding Questions tions of PICS and PICS-F and EBPs that pre-
The ICU diary program was implemented vent or diminish the long-term effects, such
as an EBP project using the Iowa Model of as judicious sedation, early mobility, and use
Evidence-Based Practice to Promote Quality of an ICU diary. The audience included medi-
Care.16 The setting for this program is a 20- cal and nursing staff as well as ancillary sup-
bed mixed medical-surgical ICU in a 198-bed port staff, such as the chaplain. This discussion
level II trauma center. It is the second largest provided the motivation needed to move for-
military medical center and serves 25 000 ward with the ICU diary program.
active duty service members on the fourth
largest military base, with an additional 110 000 Project Team
beneficiaries in the surrounding Pacific After determining that the EBP project was
Northwest community. Efforts at this time a priority for the organization, the next criti-
are focused on evaluating the processes and cal step was assembling a team.16 Selecting a
outcomes of the project in terms of feasibility, dedicated group of professionals to lead the
sustainability, and staff and patient/family EBP project was viewed as crucial to its suc-
satisfaction within the facility. The background cessful implementation. The team leader hired
questions for this EBP change project were was an ICU nurse previously on staff at the
1. Given the complex care environment hospital who had developed an excellent
of the ICU and the highly mobile status of rapport with coworkers and interdisciplinary
military nurses, is it feasible to implement a team members. Her credibility and advocacy
program designed to prevent PICS and PICS-F for patients were undeniable, and she easily
for select patients and their families in our garnered widespread support from staff and
level II medical center? leaders. She immediately set about building
2. Given the frequent turnover of medical the team and identifying champions. Devel-
and nursing staff in a military ICU environ- oping the educational tools and the curriculum
ment in a teaching hospital, can we achieve for in-service training followed. The final team
sufficient staff and patient/family engagement included a team leader, 2 ICU nurse managers,
to support adoption of an ICU diary program? a critical care clinical nurse specialist, 2 ICU
3. Can we achieve a high level of patient staff nurse champions, 2 ICU physician direc-
and family satisfaction with the educational tors, 2 staff nurse champions from the step-
products (pamphlet, video, and diary) and down unit and 6 from the medical-surgical
staff interactions surrounding implementation unit, and a nurse researcher. The chaplain
to sustain an ICU diary program? and the palliative care team were also strong
4. What tools and interventions will be advocates and actively engaged in the pro-
needed to formally evaluate the impact of the gram. The team could not have developed or
ICU diary on long-term biopsychosocial out- purchased the educational tools and other
comes once adoption of the practice has occurred? materials without the support of the ICU
(Research question for future protocol) supply specialist, the information manage-
ment/visual information teams, logistics staff,
Preparation the administrative officer from the Center for
Before implementation of the ICU diary Nursing Science and Clinical Inquiry, and
program, ICU nurses, clinical nurse specialists, staff from the Public Affairs office.


Project Tools care unit or once they returned home. While

The diary is an 18-page packet contained on the acute care unit, patients and loved
in a clear covered binder. Using a clip binder ones continued to document the patient’s
allowed the nursing staff to easily add pages, illness and recovery journey, if desired.
if necessary. The diary began with “Get to
Know Me” pages dedicated to the patient’s Implementation
personal information such as name, nickname, The ICU diary program procedures adopted
birth date, and general preferences, with space from the literature suggested that nurses typ-
for other relevant details or patient and family ically initiated diaries on patients who were
photographs. The next section defined PICS, intubated for longer than 24 hours, and/or
talked about the transition to other nursing rated positive for delirium on the Confusion
units, the discharge process, and posthospital- Assessment Method for the ICU (CAM-ICU)
ization follow-up. tool. For this program, the primary nurse
The team, with coordinated efforts from was responsible for completing the initial diary
hospital support services and constructive entry, which included a brief explanation of
feedback from the nursing staff, developed why the patient was admitted to the ICU.
several educational tools to augment imple- Subsequent entries were written throughout
mentation of the ICU diary program. The the shift by the patient’s nurse, physician
packet also contained a section describing team, and/or ancillary services (eg, respira-
what to expect regarding the ICU stay and the tory therapists, social workers, and chaplains).
purpose of devices and equipment in a typical Participation in the ICU diary program was
ICU suite. Along with the diary, families were voluntary. Nurses were encouraged to contrib-
provided an educational brochure entitled ute at least 1 entry per shift. Patients’ families
“PICS & The ICU Diary: A Guide for Families and friends were invited to complete entries
and Patients.” The primary nurse initiating as well; the team believed that their participa-
the diary also arranged for the family to view tion in the diary would help patients better
a short video on PICS/PICS-F that had been appreciate the support they provided through-
filmed in the ICU, featuring unit champions out the illness experience. (For examples of
and choreographed by marketing experts from diary entries, see Table.) The diary remained
our Public Affairs office. The video was availa- with the patient when the patient was trans-
ble on the patient education channel or on a ferred to an acute care unit or discharged to
portable DVD player. The new channel was a skilled nursing facility or home.
projected for programming on in-room televi- A tracking tool was maintained by the team;
sions and will eventually offer around-the-clock unit champions rotated the task of checking
access hospital wide. The video was also made in with nurses, patients, and family members
available on the hospital’s Facebook page for to assess diary utilization, provide feedback
viewing by any military beneficiary/health care on diary entries to the nurses, and answer
consumer interested in knowing more about any questions. This tool listed the patient’s
PICS or PICS-F. This multimodal approach initials, the date of admission, the date that
served to educate current and future patients the diary was initiated and by whom, the date
and their family members. when the patient was transferred from the
In addition to the program tools, families ICU, the unit to which the patient was trans-
were provided with an opportunity to use a ferred, the name of team member following
Polaroid camera to take pictures of visitors, the up with the patient/family and unit champion,
patient, or the patient’s room, if they wanted to and the date when the patient was discharged
include photos in the diary. Health Insurance from the hospital. All nurses were informed
Portability and Accountability Act (HIPAA) of the tool and its secure central location in
concerns were addressed and cleared by the the ICU in order to enroll new patients and
hospital’s legal office before the cameras were update the tool upon transfer from the ICU
purchased. Photos taken by family members and discharge from the hospital. When patients
did not include details beyond the individual were transferred to one of the acute care units,
patient’s room. The intent was for the patient an ICU diary program champion attempted
and family to keep this diary upon transfer to follow up with them at least once before
from the ICU and encourage them to review discharge from the hospital. Nurses identified
it at their convenience, either on the acute as unit champions on the medical-surgical


Table: Diary entries by various roles

Date Role Diary Entry

October 29, 2015 Student nurse You were very cool today, sir. You were very calm and you were able
to effectively communicate with me and CPT Andrews (Terri) despite
being intubated. We were pretty busy with you today; we had x-ray
come in and out; you had a PICC line put in (it’s like an IV); we
repositioned you multiple times, and asked for a lot of ice chips.
But even through all that, you were very cooperative and helpful.
Also, I thought it was cool when you asked me if I passed my NCLEX
yet and said (wrote) that you were pulling for me. That was really
awesome. And when I told you that I passed, you cheered and gave
me a thumb up. I had a great time with you today!
PFC Baconawa
October 22, 2015 Physician Yesterday we talked for a long time about your lung disease and pneumo-
nia history, and what the ICU could do to help. You were very aware
of the severity of your lung disease and were tiring rapidly because
of difficulty breathing. We intubated you and looked inside your lungs
to get a good sample. You went on a “road trip” to get a CT scan that
gave us good info. Today we may have an answer to the pneumonia
as a new bacteria is growing, so we changed antibiotics. You’re doing
well otherwise, and we’re feeding you by a tube in your stomach.
Dr Jette
October 28, 2015 Nurse Chass, I was one of the other nurses working with you today. Let me
tell you, you have a wonderful family. They brought in tons of cookies
for the staff. Your grandmother and grandpa were adamant about us
giving you the best care. They love you so much, and you have such
a great support structure around you. As you can see from Jamies’
entry, you had a very busy day. CT took a pretty long time downstairs
and then they decided to do a bronchoscopy to check your lungs. We
are trying to keep you as comfortable as we can. It was great to see
your parents hang some pictures of you. You are a very pretty girl, and
the picture of Buster is adorable! Keep fighting! We’ll get you better!
Claire RN
October 31, 2015 Grandmother Nice costume! Sleeping Beauty of course… I am here with you tonight
so Mom and Billy can take Jenna and Wyatt trick-or-treating. You just
got back from MRI and they took you for a CT scan, next is x-ray.
Your nurse calls it your road trip. Keep getting better so we can have
our road trip! Love you so much!
October 21, 2015 Spouse Hi Honey, today is much better now, good to be able to talk to you. You
went through a lot this time. Everybody wants to know how you are
every day. I’ll be able to give them good news now. Precious and
Silky miss you, always staring at the door, waiting for you to come
through. Prayers have been from everyone thanks to Susan. Hang in
there, and be good. We’ll be home in a while. My love to you, honey.

and step-down units received education about from the acute care units outside the ICU
the ICU diary program and were instrumental was imperative for continuation of the
for follow-through on their units. Although diary, including patient participation in com-
the diary was started in the ICU, the nurse pleting entries. The unit champions on the
from the medical-surgical or step-down unit medical-surgical and step-down units also
was most likely responsible for introducing helped ensure that the diary accompanied
the diary to the patient after their critical the patient or family member upon discharge
illness and confusion had resolved. Support or transfer.


Measuring Success and Overcoming Obstacles

Future Research The first obstacle in implementing a hospital-
For the pilot phase of the program, assess- wide, multidisciplinary project was the need
ing the knowledge and support of ICU staff for widespread education about a new pro-
(registered nurses, licensed practical nurses, cess. Having identified program champions
physicians) for the ICU diary initiative was early in the pilot phase, staff awareness chal-
the primary interest. In order to solicit feed- lenges were overcome with one-on-one or small
back on the educational efforts to date, the group in-service training sessions. Knowing
resources created, and the introduction of what to write in the diary was one of the
the ICU diary, we interviewed individual greatest struggles for the ICU nurses. Using
nurses and physicians and simultaneously examples from the literature or developed by
distributed a 10-item staff perspective survey the team, nurses gained confidence in writing
during a 2-week period. The survey used a about day-to-day events, messages of caring,
Likert-type scale for 7 statements, as well as and progress notes without describing clini-
3 open-ended questions to address the pro- cal details typical of the medical record. As
gram’s biggest barriers, greatest benefits, and mentioned previously, educating the nurses
aspects needing improvement. We placed sur- on the acute care units was vital to ensuring
veys in staff mailboxes and provided an opaque follow-through after the patient left the ICU
ballot box for the return of anonymous sur- and ultimately to achieving project goals.
veys. The low response rate was disappointing, These unit champions became responsible for
and the team resorted to 12 informal individ- engaging and educating their coworkers about
ual interviews of nurses and physicians. Over- the project as it moved forward. On the acute
all, feedback from nurses and physicians was care units, we encouraged the nurses, during
very positive. Noticeable improvements in hand-off or change of shift, to write “ICU
nurses’ initiating diary entries were seen each diary” on the white communication board
week as knowledge and comfort level increased. posted in each room detailing daily goals.
In the past 3 months, 17 diaries were initiated, Logistics hurdles occurred frequently, and
compared with 3 in the preceding 2 months. the project team met to decide on sustainable
More diaries were implemented without solutions. One hurdle faced was identifying a
prompting from the unit champions, and specific location for all the program supplies
more nurses and physicians were contribut- and devices, as well as the diary itself. In some
ing entries on a regular basis. The diaries had instances, the family seemed protective of the
a mean of 10 to 15 entries each, with 3 or 4 diary, keeping it with their personal belongings.
entries per day. A recent briefing to department Other times, the diary was hidden among all
chiefs in the surgical services line resulted in the other supplies in the ICU suite. The team
an invitation for a surgery grand rounds developed a simple solution and had plastic
presentation about the program in order to file holders mounted on the outside of each
engage more surgeons and surgical residents patient’s ICU room. This provided a stand-
in the diary process for their ICU patients. ardized location, as well as a visual cue, for
Acute care units have welcomed the ICU diary nurses and other staff to be mindful of con-
program’s team leader for unit in-service train- tributing to the patient’s diary. Family mem-
ing sessions, and the number of volunteers bers could easily retrieve it from that spot as
willing to be a part of the ICU outreach plan well. Project supplies such as additional dia-
exceeded all expectations. ries, pens, and the cameras and DVD players
Team discussions have focused on next steps were maintained on a mobile cart secured in
for the program, which would involve meas- the ICU supply area.
uring the psychological impact of diaries on Implementing a project of this magnitude
outcomes for patients and patients’ families does require institutional resources and funds.
at intervals recommended in the literature, The team had the support of nursing leaders
possibly testing different methods and timing at all levels and a small grant to cover project
of diary debriefing after discharge to see expenses including team leader salary, the new
which lead to the best outcomes, and explor- education channel, DVD players, cameras,
ing responses of patients and patients’ fami- and a color printer. The team also purchased
lies to the diary program in the ICU with customized pens with the hospital logo and a
formal qualitative or experimental methods. window to display 1 of 6 reminder messages


reflecting what to include in diary entries. These nurse said it was “tedious, like the updating
were provided to staff and family members. of care plans,” and commented that “some
Examples of the messages include What noises nurses participated while others did not”
are in your room?, Who visited you today?, (J.L., oral communication, November 2015).
and What happened in the world today? As A few staff members felt that writing in a
mentioned previously, an experienced team diary posed a potential legal threat and that
leader was paramount to ensure adherence it might be used against them if a lawsuit
to program objectives, achievement of goals, occurred. Despite reeducation emphasizing
and program adoption. We found the best that this was not a part of the patient’s medi-
way to deal with obstacles was to anticipate cal record, they still felt that it could be used
them and use the team’s energy to develop against them and were reluctant to participate.
innovative solutions. These feelings were amplified after a camera
was offered to family members to take pic-
Perspective of Staff, Patient, tures of their loved ones while in the ICU,
and Patients’ Families specifically for posting in the diary. It did
Staff Perspective not seem to matter that this idea was derived
Attaining staff buy-in is an inherent prob- from published reports and was vetted through
lem of any EBP initiative on a busy clinical the hospital’s legal department with approval
unit. A multitude of tasks already must be granted to proceed as long as photos included
completed in a 12-hour shift, so adding another only the immediate ICU suite and patients
project that required education, training, and and their family members.
follow-up to ensure that it was implemented Despite the aforementioned issues, the
effectively was a challenge. Staff members majority of nurses interviewed for feedback
provided insightful comments during differ- felt that the ICU diary program was a good
ent phases of the project rollout. Although idea overall. As far as its effect on the nursing
these comments (listed in the following para- staff, some felt that writing diary entries was
graphs) highlight feedback specific to imple- a helpful way of sharing their support and
mentation of this ICU diary program, they feelings. Other comments included, “I can see
may serve to inform implementation processes if someone passes away, it could be a closure
at other health care facilities considering thing for family members and they can recount
adoption of a similar program. just how sick they were” (J.L., oral communi-
Even after initial training was provided, cation, November 2015). She added, “and
staff members voiced that they did not have the diary provided the family members some-
enough knowledge about the ICU diary pro- thing to do and focus on rather than staring
gram to start a diary on a patient. Nurses at the monitors for 24 hours” (J.L., oral com-
expressed that they did not know what to munication, November 2015). Another regis-
write in the diary and requested that sample tered nurse stated, “It also provides the family
entries be provided during the initial educa- and patient a means of helping them remem-
tion process, rather than later as had been ber or reflect on events that occurred while
done in this project. However, if a diary was in the ICU” (J.K., oral communication, Novem-
already started and entries were already ber 2015). The nurses who participated felt
written in it, they felt it was easier for them that the patients’ families responded favora-
to contribute. The nurses who contributed bly to the project. One nurse stated, “I think
reported that the time required to write in it gives the family a job to help in their loved
the diary was minimal and was not perceived ones’ recovery. [It] kind of gives them a bit of
as a burden on their day. Several months after control or input in [their] care” (B.W., oral
the project was underway, some staff nurses communication, November 2015).
remained apprehensive. Other nurses consid- The diary also provided a level of emotional
ered diary entries to be one of their last pri- support as family members read entries from
orities, especially when staffing was low or the staff and other friends and relatives. One
the patient load was increased. “If a nurse is staff nurse commented that it was nice to see
busy and trying to catch up with charting the interest and enthusiasm of family members
[and it’s shift change], the last thing I want to when they heard about the diary. She contin-
do is stay after to write a journal entry” (L.B., ued, “It gives me hope that both patients and
oral communication, November 2015). One family will benefit from simply keeping a daily


journal for them” (T.B., oral communication, patient’s mother was especially thankful that
November 2015). Another nurse summed up the diary was started for her and stated she
his thoughts like this, “If I had any family or learned a lot about her daughter’s care before
friends in the ICU, I would hope someone her arrival by reading the diary. Both the
would start an ICU diary for them” (J. S., oral patient and mother loved the added pictures
communication, November 2015). taken of her child in the NICU. Overall, they
were extremely appreciative of the accounts
Patient/Family Perspective of her illness written in the ICU diary (S.M.,
One positive experience relayed to an ICU oral communication, November 2015).
diary champion came from a 20-year-old Other comments received from patients
woman who had a baby via cesarean section and/or their family members support the idea
at 26 weeks’ gestation. Her child was imme- that knowing who visited and that they were
diately taken to the neonatal ICU (NICU) for not alone was very comforting:
care. A few days after the birth of her child, it is good to just tell about your
she was admitted to the ICU and intubated day, and what their day was like.
for sepsis from a postoperative infection. She They might think no one came to
remained intubated for 4 days. During this visit them, but then realize that
time, an ICU diary was started. The husband they did come to visit because it is
was oriented to the ICU diary, as he went written down. It helps him to
back and forth from our ICU to the NICU know that he had support while he
to spend time with his wife and also his new- was here (R.Z., oral communica-
born child. During her intubation, the ICU tion, November 2015).
patient remained lightly sedated and aware In another instance where the family was
of her surroundings. She was able to write dealing with a sudden and devastating condi-
her care needs on a clipboard and frequently tion involving their young adult daughter, the
asked about her child. After getting written mother stated,
approval from the father and explaining the Me, personally, I find it very diffi-
mother’s current situation in the ICU to the cult to write in the book. I am
NICU nurse manager, a unit champion was still very emotional and it’s hard
able to educate and include the NICU nurse, to write in it, but other family
who began writing entries in the ICU diary members have used it and I think
in order for the mom to have updates. Her it will be very helpful later down
nurse also obtained pictures of her child, with the road for both myself and for
permission, that were placed in her ICU diary her. We have been reading the
so she could see her child. This was met with diary to her at the bedside, and it
great appreciation and approval. is a nice resource for us (S.M.,
After speaking with the patient, her hus- oral communication, November
band, and her mother after extubation, it 2015).
was evident that the ICU diary was going to
help tremendously in her recovery. Her mother Conclusion
arrived from out of town and was able to For more than a decade, the Institute of
read the entries to her; the patient felt that Medicine has advocated for the inclusion of
this helped her understand what had happened patient- and family-centered care in the defi-
while she was intubated. The patient stated nition of health care quality because we now
that she remembered some of the nurses, but have evidence that this care is associated with
after reading the entries she felt she remem- better outcomes and greater patient satisfac-
bered exactly who took care of her. She was tion.17 In a recent publication, Auriemma et al18
also happy to find out that the diary was hers describe their efforts to develop a framework
to keep and stated she was thankful she would for patient- and family-centered care outcomes
be able to go back and read about what hap- for critical care. The most salient themes for
pened during her ICU admission. After read- both patients and family members included the
ing the diary entries, she said they answered following: sick, caring, suffering, comments
a lot of her questions that she was not able about medical staff, description of emotional
to ask while she had a breathing tube and states, and physical qualities of the ICU (eg,
was under the influence of medications. The environment, medical equipment, and noise).


These researchers, and others who performed policy of the Department of the Army, the
similar research, agree that the expressed Department of Defense or the US Government.
themes are most likely related to satisfaction
of patients and their family members with
the ICU experience and care.14,18,19 Because of
1. Hopkins RO. Strategies to ensure long-term quality of
the similarities found in the perceptions and life in ICU survivors. Crit Connect. 2013;12(4):1.
experiences of patients and their family 2. Davidson JE, Hopkins RO, Louis, D, Iwashyna TJ. Post-
members, it is important to include both in intensive Care Syndrome. My ICU Care. Society of
Critical Care Medicine website. 2013. http://www
any initiative that addresses the phenomenon
of critical illness.17-19 -Care-Syndrome.aspx. Accessed February 11, 2016.
3. Pandharipande PP, Girard TD, Jackson JC, et al. Long-
Although this ICU diary program was devel- term cognitive impairment after critical illness. N Engl
oped to help mitigate the negative effects of J Med. 2013;369(14):1306-1316.
PICS/PICS-F, a secondary effect was that it 4. Griffiths RD, Jones C. Seven lessons from 20 years of
follow-up of intensive care unit survivors. Curr Opin Crit
was a source of inspiration to the patient, Care. 2007;13:508-513.
the patient’s family, and staff members. Writ- 5. Löf L, Berggren L, Ahlström G. Severely ill ICU patients’
ing daily entries about the patient’s progress recall of factual events and unreal experiences of hospital
admission and ICU stay: 3 and 12 months after discharge.
in the ICU was viewed as therapeutic, espe- Intensive Crit Care Nurs. 2006;22:154-166.
cially when what was written included the 6. Garrouste-Orgeas M, Coquet I, Périer A, et al. Impact of
an intensive care unit diary on psychological distress
eventual removal of the ventilator and, ulti- in patients and relatives. Crit Care Med. 2012;40(7):
mately, transfer from the unit. The program 2033-2040.
was, and continues to be, a means for patients’ 7. Egerod I, Christensen D, Schwartz-Nielsen KH, et al.
Constructing the illness narrative: a grounded theory
families to cope with the circumstances of exploring patients’ and relatives’ use of intensive care
their loved ones; it provided an outlet to deal diaries. Crit Care Med. 2011;39(8):1922-1928.
with the daily struggles surrounding clinical 8. Ullman AJ, Aitken LM, Rattray J, et al. Intensive care
diaries to promote recovery for patients and families
progression or regression. after critical illness: a Cochrane systematic review. Int
One of the great satisfactions in the critical J Nurs Stud. 2015;52(7):1243-1253.
9. Perier A, Revah-Levy A, Bruel C, et al. Phenomenologic
care nursing profession is saving the lives of analysis of healthcare worker perceptions of intensive
patients and seeing them leave the ICU, but care unit diaries. Crit Care. 2013;17(1):R13.
it is vital to understand that this is only one 10. Garrouste-Orgeas M, Périer A, Mouricou P, et al. Writ-
ing in and reading ICU diaries: qualitative study of
step in the healing and recovery process. As families’ experience in the ICU. PLOS One. 2014;9(10):
this program continues to expand and improve, e110146.
it will be crucial to create a mechanism to 11. Bäckman CG, Orwelius L, Sjoberg F, et al. Long-term
effect of the ICU diary concept on quality of life after
get feedback from patients and their family critical illness. Acta Anaesth Scand. 2010;54(6):736-743.
members so that we can understand how 12. Hale M, Parfitt L, Rich T. How diaries can improve the
experience of intensive care patients. Nurse Manag.
the ICU diary assisted in their recovery and 2010;17(8):14-18.
return to everyday life. Numerous gaps remain 13. Engstrom A, Grip K, Hamrén M. Experiences of intensive
in our understanding of the strategies most care unit diaries: “touching a tender wound.” Nurs Crit
Care. 2009;14(2):61-67.
likely to favorably influence the adjustment 14. Needham DM, Davidson J, Cohen H, et al. Improving
of patients and their family members to the long-term outcomes after discharge from intensive
consequences of critical illness. More research care unit: report from a stakeholders’ conference. Crit
Care Med. 2013;40(2):502-509.
by interdisciplinary ICU teams is needed to 15. Barr J, Fraser GL, Puntillo K, et al. Clinical practice guide-
build an evidence repository for interventions, lines for the management of pain, agitation, and delirium
in adult patients in the intensive care unit. Crit Care Med.
such as an ICU diary, that will reduce physi- 2013;41(1):263-306.
cal, cognitive, and mental health comorbid 16. Titler MG, Kleiber C, Rakel B, et al. The Iowa Model of
conditions and allow patients to regain their Evidence-Based Practice to Promote Quality Care. Crit
Care Nurs Clin North Am. 2001;13(4):497-509.
quality of life. 17. Institute of Medicine, Committee on Quality of Health
Care in America. Crossing the Quality Chasm: A New
ACKNOWLEDGMENTS Health System for the 21st Century. Washington, DC:
National Academies Press; 2001.
The authors wish to thank K. Taylor Blair, 18. Auriemma CL, Lyon SM, Strelec LE, Kent S, Barg FK,
Halpern SD. Defining the medical intensive care unit in
BA, RN, for her critical review of this manu- the words of patients and their family members: a
script, as well as writing, editing, and format- freelisting analysis. Am J Crit Care. 2015;24(4):e47-e55.
ting assistance, without compensation. 19. Jones C, Bäckman C, Capuzzo M, et al. Intensive care
diaries reduce new onset post-traumatic stress disor-
The views expressed in the article are those der following critical illness: a randomized, controlled
of the authors and do not reflect the official trial. Crit Care. 2010;14:R168.

AACN Advanced Critical Care
Volume 27, Number 2, pp. 221-229
© 2016 AACN

Peer Support as a Novel Strategy to

Mitigate Post–Intensive Care Syndrome
Mark E. Mikkelsen, MD, MSCE Aaron E. Bunnell, MD

James C. Jackson, PhD LeeAnn M. Christie, RN, MSN

Ramona O. Hopkins, PhD Steven B. Greenberg, MD

Carol Thompson, PhD, DNP, ACNP Daniela J. Lamas, MD

Adair Andrews, RN, MATD Carla M. Sevin, MD

Giora Netzer, MD, MSCE Gerald Weinhouse, MD

Dina M. Bates, MD Theodore J. Iwashyna, MD, PhD

Post–intensive care syndrome, a condition state of critical care survivorship is described,
defined by new or worsening impairment and postdischarge care delivery in the
in cognition, mental health, and physical United States and the potential impact of
function after critical illness, has emerged the present-day fragmented model of care
in the past decade as a common and life- delivery are detailed. A novel strategy that
altering consequence of critical illness. New uses peer support groups could more
strategies are urgently needed to mitigate effectively meet the needs of survivors of
the risk of neuropsychological and func- critical illness and mitigate post–intensive
tional impairment common after critical ill- care syndrome.
ness and to prepare and support survivors Keywords: critical illness; survivorship;
on their road toward recovery. The present quality of life; resilience; peer support

Mark E. Mikkelsen is Assistant Professor, Department of Aaron E. Bunnell is Assistant Professor, Department of
Medicine, Center for Clinical Epidemiology and Biostatistics, Rehabilitation Medicine, University of Washington, Seattle.
Perelman School of Medicine at the University of Pennsyl- LeeAnn M. Christie is Research Scientist, Dell Children’s
vania, Gates 05042, 3400 Spruce Street, Philadelphia, PA Medical Center of Central Texas, Austin.
19104 (
Steven B. Greenberg is Clinical Associate Professor, North-
James C. Jackson and Carla M. Sevin are Assistant Professors, Shore University HealthSystem, Evanston, Illinois.
Department of Medicine, Vanderbilt University School of Daniela J. Lamas is Clinical/Research Fellow and Gerald
Medicine, Nashville, Tennessee. Weinhouse is Assistant Professor of Medicine, Division of
Ramona O. Hopkins is Clinical Research Investigator, Pulmonary and Critical Care Medicine, Brigham and Women’s
Department of Medicine, Center for Humanizing Critical Hospital, Boston, Massachusetts.
Care, Intermountain Medical Center, Murray, Utah and Theodore J. Iwashyna is Associate Professor, Department of
Professor, Psychology Department and Neuroscience Internal Medicine, University of Michigan, Center for Clinical
Center, Brigham Young University, Provo, Utah. Management Research, Department of Veterans Affairs, Ann
Carol Thompson is Professor, College of Nursing, Arbor, Michigan, and Australian and New Zealand Intensive
University of Kentucky, Lexington. Care Research Centre, Department of Epidemiology and Pre-
ventive Medicine, Monash University, Melbourne, Australia.
Adair Andrews is Quality Implementation Program
Manager, Society of Critical Care Medicine, Mount The work was supported in part by the National Institutes of
Prospect, Illinois. Health, National Heart, Lung and Blood Institute Loan Repay-
ment Program, Bethesda, MD (M.E.M.) and the Health Ser-
Giora Netzer is Associate Professor, Division of Pulmonary
vices Research and Delivery Service of the Department of
and Critical Care Medicine and Department of Epidemiol-
Veterans Affairs (T.J.I., IIR 11-109). The 6 inaugural Society of
ogy and Public Health, University of Maryland, Baltimore.
Critical Care Medicine Peer Support Collaborative sites were
Dina M. Bates is Assistant Clinical Professor, Division of awarded seed grants.
Pulmonary, Critical Care, and Sleep Medicine, University
of California San Diego School of Medicine. DOI:


P ost–intensive care syndrome (PICS), a

condition defined by new or worsening
impairment in cognition, mental health, and
activities of daily living (ie, activities that
allow a person to live independently such
as finances and medication management),
physical function after critical illness,1,2 has afflicts 27% of survivors at 12 months.5 The
emerged as a common and life-altering conse- result is that the majority of survivors of
quence of critical illness.3-6 Unfortunately, PICS critical illness appear to suffer from PICS.1-6
is also resistant to change, with several rand- In addition to cognitive, mental health, and
omized controlled trials showing no benefit physical impairments, critical care survivor-
of various promising strategies.7-12 New strat- ship frequently encompasses chronic pain,20,21
egies are urgently needed to mitigate the risk sexual dysfunction,22 disability, financial
of neuropsychological and functional decline loss,23 and inability to return to work,9,23-25
after critical illness and to prepare and sup- all of which culminate in reduced health-
port survivors on their road toward recovery. related quality of life in survivors.23,26
In this article, we outline the present state Qualitative studies of patients with severe
of critical care survivorship. We focus on the sepsis and acute respiratory distress syndrome
impairments and vulnerabilities of this popu- and their caregivers have illuminated the
lation of patients. We then detail postdischarge present-day experience of critical care survi-
care delivery in the United States and the poten- vorship.27-29 Survivors and their caregivers
tial impact of the present-day fragmented crave information at each step of recovery,29
model of care delivery. To bridge the gap yet frequently lack the knowledge required
between what survivors currently experience to understand what they have experienced
and what is needed, we offer a novel strategy and what to expect. Survivors struggle with
that uses peer support groups and may more the enduring impact of critical illness on their
effectively meet the needs of survivors of own health and the impact on caregivers.
critical illness. They lament the lack of support after discharge
to tend to or learn to cope with their ongoing
Critical Care Survivorship health needs and lack of independence.27,28
In the United States alone, approximately Although additional studies are necessary to
5.7 million adult patients are cared for fully grasp the challenges experienced by sur-
annually in an intensive care unit (ICU),13 vivors, and to identify strategies that facilitated
and nearly 1 million of these patients will recovery, the available evidence provides a
require mechanical ventilation.14 Advances blueprint for what survivors need.
in care have improved survival, resulting in
millions of critical care survivors being dis- Post-ICU Follow-up
charged back into the community each year. Contemporary follow-up of ICU survivors
Many survivors experience new or worsening in the United States is fragmented and unco-
functional impairments, leading some experts ordinated.30-32 The fragmentation is charac-
to herald these developments as a “hidden terized by poor communication between care
public health disaster”15 even as they praise providers,29-31 a reality exacerbated by the
the remarkable success of critical care medi- multitude of discharge destinations for survi-
cine in reducing short-term mortality. vors and high rehospitalization rates.32-35
While strategies evolve to improve communi-
PICS Sequelae cation between acute care and primary care
At the time of hospital discharge, 46% providers,31 and integrated electronic health
to 80% of survivors experience cognitive records should facilitate this important pro-
impairment.16,17 At 3 and 12 months after cess improvement, PICS and other sequelae
discharge, 40% and 34%, respectively, of of critical illness remain underrecognized,
previously healthy survivors remain impaired understudied, and underfunded. A small
to a degree that would be consistent with mod- number of ICU follow-up clinics have been
erate traumatic brain injury.3 At 12 months, established in the United States to combat
clinically significant symptoms of anxiety, this fragmentation.36 These clinics draw on
depression, and posttraumatic stress disorder 2 decades of experience from the United King-
are present in 20% to 30% of survivors.4,18,19 dom37 and incorporate into clinical practice
Functional impairment, defined as impairment the identification of neuropsychological and
in activities of daily living and instrumental physical problems and timely referral to other


health care providers. Although conceptually about recovery. We define ICU survivors in
appealing, the effectiveness of nurse-led ICU this context—in contrast to our technical use
follow-up clinics in the United Kingdom was above—as patients and their loved ones who
not demonstrated when tested.38 More proxi- have emerged from critical illness. We believe
mally, in a separate trial, increasing physical that the continuum of survivorship begins at
and nutritional rehabilitation during the ICU admission and may continue for years or
post-ICU acute hospital stay did not result decades afterward. We define peer support as
in improved physical recovery or quality of the process of providing empathy, offering
life as measured by the Short Form 36 Health advice, and sharing stories between ICU sur-
Survey.11 However, germane to the constructs vivors. Peer support is founded on the princi-
of preparation and support, the intervention ples that both taking and giving support can
that was paired with informational content be healing if done with mutual respect. Peer
delivery led to improved patient satisfaction support is centered on the notion that survi-
with physical and nutritional support, coordi- vors can help each other through problems
nation of care, and preparation at discharge.11 and have the willingness to do so. Peer sup-
Additional studies drawing on the lessons port is not a clinician-centered model; the role
learned from these seminal trials are needed. of clinicians is to help provide the safe space
Issues of survivorship are rarely addressed in which survivors can work together to dis-
during the period of critical illness.39 As knowl- cover what they share to help each other.45,46
edge translation is notoriously slow, outpa- The potential benefits of peer support
tient providers are most likely unaware of emanate from the establishment of a commu-
PICS and thus are even less likely to address nity that promotes health and well-being
issues of survivorship. The result is that mil- through the shared experience of illness and
lions of survivors of critical illness are being recovery. The potential benefits, applied to
discharged into the community, unprepared survivors of critical illness, are many: mental
and uneducated about what to expect and reframing (hope, optimism), effective role
how best to cope, adjust, and recover. Impair- modeling, information sharing, and practical
ments will therefore frequently go unrecog- advice that is not readily available to health
nized and/or undermanaged. A substantial care professionals at present.45,46 Peer support
burden will fall on their informal caregivers,23 has proven effective in people with mental
many of whom may be struggling with their health disorders and substance abuse issues,45,46
own emotional sequelae from their ICU in the self-management of diabetes,47 and
experience. Family members and caregivers among cancer survivors.48,49 It can lead to
are not immune to the psychological trauma empowerment, self-advocacy, and improved
of the ICU; in fact, they are also vulnerable outcomes. However, although “authentic
to developing a form of PICS known as post– empathy,” “validation,” and “acceptance”
intensive care syndrome–family (PICS-F),40-42 are important contributions offered by the
which includes mental health consequences peer support model,45 programs that formally
and may include physical symptoms and integrate education into the program appear
social isolation. to be the most valuable.50 In the near future,
Novel strategies to augment survivors’ social sharing effective coping and compensation
support structure may be important to pro- strategies by health care providers and peers
moting a culture of resilience.43,44 These strate- may accelerate recovery further.51-53
gies would complement initiatives that aim As survivors and their caregivers have
to improve survivors’ physical and neuropsy- first-hand experience of the challenges that
chological well-being. Additionally, these strat- survivors face, these individuals are well suited
egies could also facilitate coordination between to educate and prepare peer survivors for
inpatient and outpatient settings. Peer support certain aspects of the recovery process. In
has the potential to fulfill these imperatives. addition, because spirituality and religion
appear to be important in survivors’ support
Peer Support networks,6 and given the reluctance of health
We propose that peer support for ICU care providers to engage in the spiritual aspects
survivors may serve a crucial role in both of illness and recovery,54 peer support groups
improving the recovery of current survivors may be a vehicle through which these aspects of
and in accelerating the progress of knowledge recovery can be explored and acknowledged.


Table 1: Structural Principles Recommended for Incorporation Into Models of Peer

Support for Survivors of Critical Illness

Voluntary participation
Open to all who self-designate as survivors of critical illness
Led by health care providers and/or survivors with a firm grasp of the emerging survivorship literature
Free-standing or designed to complement follow-up clinics after discharge from intensive care unit
Designed to provide educational content in addition to support
Creativity to try group activities to foster support and relationships
Flexibility to adapt the meetings to the needs of the assembled group

Although the challenges experienced may mentorship. This area is one of the many in
differ between the adult, pediatric, and neo- need of empirical evidence.
natal populations, the principles of peer sup- Meetings should be held at a mutually con-
port and the inherent potential of this strategy venient time for survivors, peer support leads,
apply to each group, including hundreds of and clinical staff who may serve as coordi-
thousands of pediatric and neonatal survivors nators and/or moderators. The anticipated
of critical illness. duration of the meetings is 60 to 90 minutes.
Engaging facilitators who have experience with
Structure and Process of peer support in other venues (eg, oncology
Survivor Support Groups patients) early in the process may be useful to
The ideal structure, process, and timing of align expectations and guide design strategy.
support groups for survivors of critical illness Given the frequency of psychological distress
is unknown—a fact that bears emphasis. We among survivors of critical illness, holding
remain at a fluid, innovative stage of discov- meetings away from the ICU—possibly even
ery as to how peer support is best used after away from the hospital—may be preferable.
critical illness. An urgent need and opportunity The format of meetings most likely begins
for creative practitioner/survivor combina- with general introductions and explanation
tions exists to invent a new layer of post-ICU of ground rules (eg, confidentiality), followed
support and then evaluate it rigorously. Some by shared experiences and encouraging survi-
general structural principles we recommend, vors to share what would be most helpful to
drawn from the general peer support litera- them. To draw survivors in, a dedicated lon-
ture45-40 and applied specifically to survivors gitudinal curriculum that addresses various
of critical illness, are included in Table 1. aspects of the survivor experience should serve
Whether and how the needs of former as the foundation for meetings. However, to
patients and caregivers would be expected facilitate shared group discussion, moderators
to differ is unknown. It is conceivable that should aim to encourage open dialogue and
stress experienced by one group (ie, caregiv- be open to go where the experience of those
ers) may be the result of impairments incurred present leads the group. The frequency of
by the other (ie, survivors) or vice versa. If meetings will depend on the target audience,
so, distinct support groups may be ideal. logistics, and the availability of volunteers
Yet it is plausible that combined meetings, and staff. For example, peer-to-peer support
in the presence of those further along the groups embedded within ICU follow-up clinics,
path of recovery, could be therapeutic and or juxtaposed to clinical settings (eg, long-term
beneficial and mitigate both PICS and PICS-F. acute care hospitals), may stimulate the demand
Alternative options include a combined to schedule one or more meetings per month.
model in which both patients and their family
members meet together for part of the meet- Unique Challenges in
ing and then separately for part of the meeting Survivors of Critical Illness
to address the unique needs of the patients The precise problems that create the need
and caregivers or individual peer-to-peer for in-person peer support can make attending


Table 2: Challenges of Survivors of Critical Illness and Possible Mitigation Strategies

for Use in Peer Support Groups

Challenges Possible Mitigation Strategies References

Cognitive impairment Awareness, adjustment, and coping strategies for 1-4, 16, 17, 25, 27-30
survivor and caregiver
Empathy toward survivor and caregiver
Encourage rehabilitation and compensation training
Practical advice for obtaining a referral to a
Practical advice on use of memory aids, ways to
break complex practical problems (doing the
shopping) into easier tasks
Anxiety Awareness, adjustment, and coping strategies for 1, 2, 4, 5, 18, 19,
Depression survivor and caregiver 27-30
Posttraumatic stress disorder Empathy toward survivor and caregiver
Practical advice for obtaining a referral to a psychol-
ogist or psychiatrist to discuss medication and
nonmedication (cognitive-behavioral) therapy
Physical impairment, includ- Awareness, adjustment, and coping strategies for
ing immobility, impairments survivor and caregiver 1-5, 20, 21, 27-30
in activities of daily living Empathy toward survivor and caregiver
and instrumental activities of Practical advice for obtaining a referral to receive
daily living, and chronic pain physical and/or occupational therapy
Shared experience with assistive devices (eg,
showerheads and chairs, stools, walkers)
Negative financial impact Empathy toward survivor and caregiver
Practical advice for obtaining a social work or 23, 27-30
community health referral
Connection to local charities

in-person support group meetings challeng- critical illness is that it is frequently acute and
ing. A brief list is provided in Table 2, along unexpected. In its wake, therefore, critical ill-
with potential mitigation strategies to discuss ness often leaves survivors with new impair-
at meetings. Moreover, after critical illness, ments that they are not equipped or prepared
many survivors are in and out of various forms to handle. This unique challenge must be
of health care venues, including long-term acknowledged within critical care survivors
acute care hospitals or skilled care facilities. broadly and peer support models specifically.
Frequent readmissions to the hospital or Sustainability of peer support groups
ICU32-35 and high short-term mortality55-57 requires engaged and active peer support
further this challenge. leadership. Given the frequency and severity
For survivors with functional impairments, of impairments, some if not many survivors
which may include problems with mobility will be physically, mentally, or emotionally
and driving, caregiver involvement and par- unable to serve in this role. For those survi-
ticipation will frequently be required to per- vors who are physically and mentally able to
mit the survivor to attend in person. Further, serve as leads, they may not be able to relate
as noted previously, survivors with anxiety completely or to coach survivors with more
and posttraumatic stress disorder may be severe injuries and disabilities as effectively
reluctant to attend meetings if scheduled at as those with lesser impairments. Given the
or near the ICU or hospital where the patient economic consequences of critical illness and
was admitted. Unlike other populations (eg, the toll that it takes on survivors and their
cancer survivors), who may have had time to caregivers,23 the ability to attend meetings in
process their illness and their recovery and a voluntary fashion may be cost prohibitive.
to perform advanced planning, the nature of For these reasons, virtual support is a plausible


alternative that warrants investigation; however, to invent this future together. It is, by design,
its utility in other populations has not been improvisational. In some ways, the collabora-
established.58 If centers of recovery emerge tive is a support group for usually evidence-
as an effective and financially solvent model, based clinicians busy working in an area
incorporating ICU staff and survivors into without any evidence yet. The collaborative’s
peer support staff as full-time employees or start-up culture is balanced by reporting to
volunteers, as done successfully in mental the broader SCCM Thrive initiative and to
health clinic models,45 may be prudent. SCCM’s executive committee. Each year, the
collaborative will share its current state of
Design and Development of a the art at SCCM’s annual congress and work
Peer Support Collaborative to codify best practice in ways that can be
In 2015, the Society of Critical Care Medi- scaled up and shared broadly.
cine (SCCM) initiated the Thrive Supporting We expect that in several years the evidence
Survivors of Critical Illness initiative. Thrive base will be sufficient to propose definitive
has 3 pillars: a peer-support collaborative, clinical trials to evaluate alternative models
expanding research into recovery, and edu- of peer support. However, premature conduct
cation within and outside the ICU around of such evaluative trials—before the techniques
PICS.59 The peer-support collaborative began of peer support have developed sufficiently
with an international call for applications, to warrant testing—is not part of the collabo-
the first action of the Thrive group. In the rative’s mandate.
fall of 2015, 6 inaugural sites were awarded
on the basis of their innovative and team- What to Expect
oriented design to implement, collaborate, Based on the experience in the support
and assess the effectiveness of peer-to-peer group context and otherwise at the Vander-
support groups applied to survivors of critical bilt Recovery Clinic, Intermountain Medical
illness and their caregivers. The 6 sites include Center,60 and Toronto General Hospital,29,30,61,62
5 adult hospitals and 1 pediatric hospital. several recurrent themes should be anticipated
We expect to expand the collaborative by 5 when implementing a peer-support group.
new sites each year for at least 2016 and 2017, Chief among these relates to identity—that
balancing the needs of group cohesion with is, survivors grapple with questions related
tremendous interest in participation. to who they are after intensive care. Acutely
The aim of the collaborative is to catalyze aware of new cognitive deficits, personality
the development of a network of pioneer changes, and physical limitations, survivors
in-person support groups, testing the feasibil- frequently struggle in a quest to cope with
ity of peer support and amassing a body of loss and to define and eventually embrace a
proven experience and skills to grow and “new normal.” Even as they look ahead and
support survivors of critical illness. The under- brace for an unfamiliar future, they are regu-
lying model of the peer-support collaborative larly buffeted by feelings of frustration, guilt,
is itself a form of collaborative peer support— and regret—sometimes for poor health deci-
that the leaders of the 6 sites convene monthly sions that led to critical illness and sometimes
to share successes and challenges and to brain- for contributing to the distress of family mem-
storm solutions. The site leaders are joined bers. Regardless of prior health status, they
on the monthly calls by SCCM staff and an tend to be preoccupied with health concerns,
international group of experts to be available leading to vigilance, social disengagement, and
as a resource for the sites. As the collaborative withdrawal. In many cases, they feel powerless
matures, the aim is for formal monthly com- and victimized by circumstances, a dynamic
munications to parallel frequent and informal that can result in decreased self-efficacy and
idea exchanges and mentoring between sites. a burgeoning sense of helplessness.
These efforts at group cohesion are facilitated Facilitating support groups made up of
by annual site visits by SCCM staff and a mem- individuals struggling with the aforementioned
ber of the Thrive initiative, and in-person issues is both satisfying and challenging.
meetings at SCCM’s annual congress. Although successful group facilitators share
A basic principle of the peer-support collab- certain characteristics regardless of the patient
orative is that no evidence base for providing population in question—traits such as the abil-
peer support to ICU survivors exists. We need ity to forge close connections and to relate to


others in a nonjudgmental fashion—effective This work does not necessarily represent

leaders of post-ICU support groups should the official views of the US Government or
possess specialized knowledge. In particular, the Department of Veterans Affairs.
facilitators need to anticipate the natural his-
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AACN Advanced Critical Care
Volume 27, Number 2, pp. 230-235
© 2016 AACN

P e Cld i na t i c r i a c l
Perspectives Bradi B. Granger, RN,
Department Editor

Overcoming Barriers to Using Patient-Reported

Outcomes for Clinical Inquiry
Maria Javier, RN, BSN
Jae Youn Kim, RN, BSN
Ellie Toone, AD
Bradi Granger, RN, PhD

A patient-reported outcome (PRO) is a report or assessment of the status

of a patient’s health or health care experience that comes directly from
the patient.1 One common example used in acute and progressive care settings
is the Hospital Consumer Assessment of Healthcare Providers and Systems
(HCAHPS) survey, which assesses patients’ satisfaction with care in the hospital
setting.2 Beyond providing a measure of satisfaction with previously delivered
care, the broad array of available PROs represents a compendium of valuable
tools for identifying patients’ future expectations for health-related goals, health
engagement, or expectations for communication with health care providers,
for example. Nationally, the Patient-Centered Outcome Research Institute has
led the way in encouraging patients to engage actively with their health care
team, in part through PRO surveys that ascertain, measure, score, or prioritize
individual-level health beliefs, health goals, symptom perceptions, satisfaction
with care and the care environment, and many other factors associated with
the personal experience of health and illness.3
As nurses, we are increasingly focused on understanding and incorporating
patients’ perspective in developing care plans and tailoring treatment regimens.
To measure the effect of these efforts on the patient’s perceived quality of care,
and to develop new knowledge for more effective patient-centered care plan-
ning, PROs are an important tool for clinical inquiry. The ability of PROs to
serve a dual purpose, functioning both as a tool to guide care and as a measure
of the quality of care delivered, enables these publicly reported scores to be
particularly well suited for measuring change and evaluating improvements
in quality. And yet, in clinical practice, a number of factors pose barriers to
broad-scale use of PRO surveys as tools to guide care and evaluate outcomes
in real time. Chief among these is the limitation of time itself. The purpose

Maria Javier is Clinical Nurse II, Duke University Health System and a Family Nurse Practitioner,
Duke University School of Nursing, Durham, North Carolina.
Jae Youn Kim is Clinical Nurse II, University North Carolina Health Systems, Chapel Hill, North Carolina
and Family Nurse Practitioner, Duke University School of Nursing.
Ellie Toone is Nursing Student Intern, Duke University School of Nursing and Duke Heart Center,
Durham, North Carolina.
Bradi Granger is Director, Heart Center Nursing Research Program, Duke University Health Systems
and Associate Professor, Duke University School of Nursing, 307 Trent Dr, Durham, NC 27710
The authors declare no conflicts of interest.


VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Clinical Inquiry

Table: Examples of Tools for Documenting Patient-Reported Outcomes in Patient Care


Opportunities for Integration of a Validated

Usual Care Assessment Assessment Survey (Patient-Reported Outcomes)
Assessment of presenting problem or symptoms: Emotional impact of disease
“What brings you here today?” or “How do feel?” Diabetes (PAID)
(eg, regular checkup; pain, problems, issues?) Heart failure (KCCQ)
Symptoms and impact of illness on quality of life: Symptom assessment and impact on quality of life
“What symptoms or physiological problems, if any, General (HRQOL)
affect or impede your daily activities?” General (PROMIS)
Specific (KCCQ)
Medication use and management assessment: Medication use patterns
“What side effects, unanticipated effects, or reactions Morisky Medication Adherence Scale (MMAS)
do you experience with your medications?” Belief in medications scale (BMQ)
Educational level and ability to read assessment: Health literacy
“What was the last grade you attended in school?” REALM
and “What is your preferred learning style?” TOFHLA
Evaluation of self-management strategies: Motivation, health behavior change
“Do you weigh yourself each day?” PAM-13
“How do you usually monitor your blood pressure?”
Knowledge about the current illness: Disease-specific tools
“What is your understanding of your disease?” DCP (diabetes)
Activity (current) and activity progression: Current activity
“Tell me about your physical activity in a usual day.” Stanford Questionnaire
Barriers to self-management of illness at home Assessments of physical environment and external
(including transportation, access to food, medications, social resources
or in-home care)

Abbreviations: BMQ, Brief Medications Questionnaire; DCP, Diabetes Care Profile; HeLMS, Health Literacy Management Scale; HRQOL, Health-
Related Quality of Life; KCCQ, Kansas City Cardiomyopathy Questionnaire; PAID, Problem Areas in Diabetes; PAM-13, Patient Activation Measure-13;
PROMIS, Patient-Reported Outcomes Measure Information System; REALM, Rapid Estimate of Adult Literacy in Medicine; TOFHLA, Test of
Functional Health Literacy in Adults.

of this article is to describe the value of PROs his/her social and environmental support,
for patients and nurses and to propose strate- and the perceived quality of financial and
gies to overcome common barriers to using community-based resources that might be
PROs in clinical settings. tapped to achieve his/her respective health
goals. The added value of using PROs is the
Value of Patient-Reported opportunity to elicit individuals’ health care
Outcome Measures decisions and choices in a meaningful, measur-
Resistance to using PROs in clinical practice able, and reproducible way so that feedback
can be attributed in large part to the “newness” can be given to patients and comparisons
of PROs and underappreciation of these mea- can be made over time.
sures as a core value in patient care excellence.4
Although more than a decade of evidence has What Is the Added Value for Patients?
been generated to support the use of PRO data Patient-reported outcomes quantify patients’
in usual patient care delivery, the value of perspectives about the frequency and severity
collecting and using patient-generated data of symptoms, how disease affects physical
in clinical practice remains underappreciated. functioning, and the degree to which illness
At the unit or hospital level, PROs can be used limits quality of life.5 Both generic and disease-
to identify short- and long-term goals for health specific forms of PRO surveys have been
and to develop a treatment plan that incorpo- developed (see Table) and represent valid,
rates the patient’s understanding of the illness, reproducible measures that are stable over

Clinical Inquiry W W W .AACN ACCON LIN E .ORG

time and sensitive to clinical changes as for resolving those concerns across settings
they occur.1 As such, they provide opportuni- of care and over time.
ties for better data capture on the patient’s Examples of these opportunities to use
perception of health care and well-being. PROs to elicit patient-reported outcome data
When used as a standard part of care include assessment and care planning for
delivery, the time involved in obtaining PRO patient literacy, patient-perceived quality of
data is time well spent because it allows the life, emotional impact of illness, medication-
patient to communicate measurable priori- taking skills, patient goals for care including
ties, concerns, and perceptions to the health priorities, knowledge, skills, and ability to
care team. Nurses and other care providers self-manage health conditions, or the social
can then integrate direct patient input into and psychosocial factors influencing patients’
the plan of care, the education plan, and plans self-management. Documentation of each of
to prepare for discharge. For example, assess- these key components of the patient assessment
ing health literacy by using a standardized is required for high-quality care, and yet, the
PRO tool may highlight opportunities for use of valid and reliable PRO tools to collect
educational delivery method, such as the patients’ responses to these important assess-
use of pictures rather than words, or the ment questions is far from “standard.” As a
use of alternative medication information result, the patient’s response cannot be reliably
rather than standard pamphlets from the compared across patients’ experiences or even
Food and Drug Administration.6 In addi- within an individual patient’s experience, pre-
tion, issues that are of particular concern to venting nurses from assessing improvement
the patient or the patient’s family can more at the individual level over time.9
easily and systematically be identified and Powerful incentives to increase awareness
addressed, including knowledge gaps about of the value of PROs and encourage their use
the plan of care or gaps in the patient’s in clinical settings are emerging. For example,
understanding of self-management expecta- health care providers participating in account-
tions after discharge.7 able care organizations are now expected to
Despite more than a decade of encourage- provide evidence that the care they delivered
ment to improve the quality of patient care produced value for the patient, as determined
by including PROs as a part of standard and reported by the patient.10 These new indi-
clinical assessment and clinical practice, cations for use of PROs parallel suggestions
these types of assessments of directly cap- that The Joint Commission and National Qual-
tured, PROs are still not routinely used.8 ity Forum may require use of PROs in order
PROs are not typically integrated in usual for organizations to be accredited.11 And yet,
care delivery or standard assessments of thus far, real-time clinical applications of PROs
patients. In current clinical practice, we fail have been limited.
to assess PROs as an integral component of To date, the most commonly used and
baseline information on patients, informa- recognized examples of PROs in standard
tion that could be used to drive care delivery practice patterns include pain assessments
and develop a more patient-centered plan (eg, the postoperative pain assessment, chest
of care. pain assessment, pediatric pain scales, and
others) and assessments of satisfaction with
What Is the Added Value for Nurses care (eg, HCAHPS).12 Despite incentives for
and Providers? these examples and other use cases, PROs in
The value of PROs for nurses and provid- clinical settings have major drawbacks, not the
ers can be broken down into 4 opportunities: least of which are that they take considerable
(1) enabling better data capture on patients’ nursing time to administer to patients and
perceptions of care, (2) allowing the nurse or that they are not reportable and actionable
provider to focus on the patient’s perceived in real time. These drawbacks create a signifi-
concerns without wasting time on issues about cant disincentive for PRO use for hospital
which the patient may not be concerned, (3) nurses and a burden for ambulatory care
providing structure for the nursing assessment nurses, where it can be challenging to find the
to address and prioritize patient-centered con- results in the electronic health record (EHR)
cerns, and (4) improving communication and and difficult to maintain continuity and
continuity of patients’ concerns and the plan alignment with the plan of care.

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Clinical Inquiry

Overcoming Barriers to Using

• Huddle with charge nurse: use PROs to
PROs in Practice set priorities and acuity levels
Barriers in clinical practice settings present • Handoff between nurses: use PROs in
challenges for nurses who seek to improve 7 AM
shift report
practice quality and patients’ outcomes • Morning weights and vital signs
through clinical inquiry projects that depend • Distribute morning medications
on PROs. These barriers, though somewhat
unique across patient populations and clinical
sites, can be broadly grouped into 3 catego-
• Before serving meals, verbally reassess
ries: (1) barriers to work-flow integration, key PROs:
(2) lack of real-time reporting for actionable Pain score, comfort
metrics, and (3) technology-based barriers Noon Satisfaction with meal, environment
that prevent interoperability. Next we of care
describe 3 brief solutions that highlight the Expectations for communication
promise of how these PROs can be used more regarding plan of care
effectively to contribute important data for
clinical inquiry projects.
• Before administering evening medica-
Work-Flow Integration tions, taking evening vital signs, or
Although the opportunity to obtain impor- shift change, reassess key PROs for
tant patient-centered clinical information 7 PM
changes during shift
(not available via any other mechanism or
any other location in the EHR) is recognized
by the health care team, the opportunity to Figure 1: Work-flow integration of patient-reported
obtain and use the information is not easily outcomes (PROs) on day shift.
integrated into a unit’s work flow. The first
step in addressing this challenge is through
a shared governance platform, a meeting with staff does not usually receive scores and
a performance-services or Six Sigma process trends on admission, during patient handoff,
engineering team, or through a unit clinical or even before the patient is discharged. The
practice council. Identify the decision-making time delay makes using the survey responses
informal leadership team in place, and use difficult. The immediate opportunity for
these leaders to evaluate work flow to accom- evaluation of the health care experience and
modate PRO collection. The process of initi- communication between patients and pro-
ating change in established unit work flow can viders about that experience is lost. Without
be difficult and is best addressed by partner- the ability to obtain results of PROs in an
ing with established leadership groups such actionable, real-time format, the value of
as these.13 the tools is diminished. One solution is to
The second step in ensuring that work hardwire reports of actionable PROs into
flow accommodates PROs is to map not patient handoffs using an SBAR (situation,
only the patient day, but also the entire background, assessment and recommenda-
course or plan of care. For example, the tion) reporting process for communication.14
acute care nurse, discharging nurse, and Using SBAR for communication of PROs
follow-up nurse each have unique responsi- during patient report ensures that the results
bilities that can be mapped across a shift as and actionable trends will be integrated into
well as across the entire course of care or care planning and priority setting and will
trajectory of illness. One example of a suc- maintain integrity and continuity across
cessful approach is shown in Figure 1. shifts (Figure 2).
Although the opportunity exists to find
Reporting Trends trends in scores over time, send these trends
Reporting PRO scores and trends in real to the clinic or referring provider, and print
time is another challenge that can stymie the out these trends for patients to take home,
use of PROs for clinical inquiry. Although scores are not always easy to find trends in
the benefits of collecting and using these and translate. One solution is to adopt crite-
data are many, at a local level the front-line ria for selection of PROs to be used for a

Clinical Inquiry W W W .AACN ACCON LIN E .ORG

SITUATION: At each handoff, the nurse optimizes

immediately during use and does not require
patient-centered priorities and addresses key extensive programming to get a score during
patient-specific PROs: (a) preexisting PROs, a given shift; (3) efficient to use, meaning
(b) PROs specific to the current plan of care, and minimal time is required for the nurse to
(c) PROs in preparation for discharge administer the survey or tool; (4) patient-
friendly, so that it can be completed inde-
pendently, without the need for interpretation
or additional instructions; and (5) obligatory,
BACKGROUND: Patient’s presenting problem, meaning the documentation of the measure
admission diagnosis, medical and social history is a valuable data point in the patient care
should each be evaluated from the patient’s per- process and is therefore an expectation of
spective, using pertinent PROs specific to this
leadership and/or quality regulatory boards
admission (eg, pain scales or preexisting PROs in
the electronic health record)
such as The Joint Commission or the National
Quality Forum.

Technology and Incentives

ASSESSMENT: Objective and subjective PRO The third broad category of barriers to PRO
data are shared with oncoming nurse, including use in clinical practice includes technology-
relevant changes in PROs since previous shift based challenges. The goal for PRO data cap-
ture is to achieve fully integrated EHR
functionality, with interoperability across
settings of care and across devices, such as
RECOMMENDATION: Using the PRO scores, or electronic tablets, telephones, and other web-
changes in PROs, focus the care plan and tailor based devices. Although the horizon is short-
daily care goals (including patient education) to ening, and examples of PROs on electronic
align with patient-reported goals and priorities; platforms are becoming more common,15
base recommended plan of care and priorities for the state of “usual standard care” still does
postdischarge care planning on trends in PROs
not typically include ePROs. As shown in
Figure 3, electronic procurement of PROs
to support clinical inquiry would include
Inpatient stay: Discharge: Complete data sharing among providers across sites
continue with plan of care using PROs of care, graphic depiction of trends that are
care plan, update to drive outpatient goal easy to interpret and share with patients,
plan of care and setting; document and and online access to surveys for patients to
PRO report as print discharge instruc- complete at home or in the clinic waiting room
appropriate, and tions (after visit summary) after hospital discharge. Specific strategies
refer back to using PROs to educate for approaching technology-based barriers at
SBAR (situation, patients about home a given hospital or in a specific unit will vary
background, medications, follow-up
depending on the EHR system and the avail-
assessment, office visits, activity
and recommen- progression, and priori-
ability of information technology specialists;
dation) at each ties for lifestyle modifi- however, the pace of systematic changes across
shift change cation goals the country is rapidly moving forward in
support of electronic PRO systems.16,17
Figure 2: The SBAR (situation, background, assess-
ment, and recommendation) algorithm for using
The assessment of patients’ perspectives
patient-reported outcome (PRO) data in patient-
as key stakeholders in high-quality, high-value
centered handoff.
health care is quickly becoming an important
and recognized opportunity for nurses. To
given population of patients. The PRO most improve the ability to tailor and shape care
useful for clinical inquiry projects is one that plans to the needs and goals of individual
is (1) actionable, indicating that the results patients, we must improve our skills and the
have clinical meaning and drive or contrib- efficiency with which we select, interpret,
ute significantly to the care plan; (2) inter- and use PROs in clinical practice. Using
pretable, meaning that the scoring is clear strategies to address work-flow barriers,

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Clinical Inquiry

• Preventing unwanted site access: set up tablets on secure hosptial wi-fi instead of visitor wi-fi
• Integrate PRO scores into the EHR by working with information technology team at your
Technical local hospital
issues • Sending PRO scores home with patients for reference:
Print discharge summary with PRO score trends
Connect printers to tablets using wireless unit-based printers

• Use tablets to enable patient-driven completion of PROs (eliminating need for nurse
oversight during completion)
• Establish small groups of nurses to work together on PRO selection specific to unit’s
Motivation to
patient population
change work
• Mentor nurses to learn and understand scoring systems and trends in unit-selected PRO
• Institute monthly debrieings/communication about PRO improvements for the unit
• Create electronic scoreboard with incentives for data use (eg, “Most Patient-Centered Care

• Optimize patients’ exposure to PROs and opportunities to complete surveys

• Include a stylus with every tablet to prevent touchscreen errors
friendly use
• Create and use a patient-focused tutorial on how to use tablets for PRO assessment

Figure 3: Technology-based solutions for tablet integration into clinical work flow. Abbreviations: EHR, electronic
health record; PRO, patient-reported outcome; wi-fi, wireless Internet.

maximize reporting opportunities, and resolve perspective: the care transitions measure. Med Care.
technology barriers will improve the clarity 8. Rumsfeld JS. Health status and clinical practice: when
of the patient’s voice in clinical inquiry projects. will they meet? Circulation. 2002;106:5-7.
9. Snyder CF, Blackford AL, Aaronson NK, et al. Can
patient-reported outcome measures identify cancer
REFERENCES patients’ most bothersome issues? J Clin Oncol. 2011;
1. US Department of Health and Human Services FDA 29:1216-1220.
Center for Drug Evaluation and Research. Guidance for 10. Burston S, Chaboyer W, Gillespie B. Nurse-sensitive
industry: patient-reported outcome measures—use in indicators suitable to reflect nursing care quality: a
medical product development to support labeling claims, review and discussion of issues. J Clin Nurs. 2014;23:
draft guidance. Health Qual Life Outcomes. 2006;4:79. 1785-1795.
2. Doos L, Bradley E, Rushton CA, Satchithananda D, 11. Brown DS, Donaldson N, Burnes Bolton L, Aydin CE.
Davies SJ, Kadam UT. Heart failure and chronic Nursing-sensitive benchmarks for hospitals to gauge
obstructive pulmonary disease multimorbidity at high-reliability performance. J Healthc Qual. 2010;32:9-17.
hospital discharge transition: a study of patient and 12. Wolosin R, Ayala L, Fulton BR. Nursing care, inpatient
carer experience. Health Expect. 2015;18(6):2401-2412. satisfaction, and value-based purchasing: vital connections.
3. Reeve BB, Wyrwich KW, Wu AW, et al. ISOQOL J Nurs Adm. 2012;42:321-325.
recommends minimum standards for patient-reported 13. Weiner BJ. A theory of organizational readiness for
outcome measures used in patient-centered outcomes and change. Implement Sci. 2009;4:67.
comparative effectiveness research. Qual Life Res. 2013; 14. Compton J, Copeland K, Flanders S, et al. Implementing
22:1889-1905. SBAR across a large multihospital health system. Jt
4. Eapen ZJ, Tang F, Jones PG, et al. Variation in perfor- Comm J Qual Patient Saf. 2012;38:261-268.
mance measure criteria significantly affects cardiology 15. Sawyer T, Nelson M, McKee V, et al. Implementing
practice rankings: insights from the National Cardiovas- electronic tablet-based education of acute care patients.
cular Data Registry’s Practice Innovation and Clinical Crit Care Nurse. 2016;36(1):60-70.
Excellence Registry. Am Heart J. 2015;169:847-853. 16. Wu AW, Kharrazi H, Boulware LE, Snyder CF. Measure
5. Spertus J. Barriers to the use of patient-reported outcomes once, cut twice: adding patient-reported outcome mea-
in clinical care. Circ Cardiovasc Qual Outcomes. 2014;7:2-4. sures to the electronic health record for comparative
6. Wolf MS, King J, Wilson EA, et al. Usability of effectiveness research. J Clin Epidemiol. 2013;66(8
FDA-approved medication guides. J Gen Intern Med. suppl):S12-S20.
2012;27:1714-1720. 17. Jensen RE, Snyder CF. PRO-cision medicine: personaliz-
7. Coleman EA, Mahoney E, Parry C. Assessing the quality ing patient care using patient-reported outcomes. J Clin
of preparation for posthospital care from the patient’s Oncol. 2016;34(6):527-529.

AACN Advanced Critical Care
Volume 27, Number 2, pp. 236-240
© 2016 AACN

Et h i c s Cynda Hylton Rushton, RN, PhD

in Critical Care Karen Stutzer, RN, PhD
Department Editors

The Ethics of Post–Intensive Care Syndrome

Judy E. Davidson, RN, DNP
Karen Stutzer, RN, PhD, APN-C

P ost–intensive care syndrome (PICS) is the constellation of consequences

of critical illness that begins in the intensive care unit (ICU) and may
persist long after hospitalization. Patients’ families may also experience sequelae
from their experiences with a loved one in the ICU (PICS-F). A host of per-
sistent physical, cognitive, and mental health problems may adversely affect
quality of life, family integrity, and social outcomes.1,2 It is reported that at
least one-third of ICU patients and their families experience PICS and PICS-F.2
Why some patients and families are affected and others are not is unknown.2

Case Study
Jane walked into my office for her first day as a nursing leadership student
in her last semester of a registered nurse to bachelor of science in nursing
(RN to BSN) program. Traditionally these students wear business clothes to
their clinical rotation. Her initial words to me were an apology. She felt badly
that she had to wear orthopedic shoes because of the physical problems lin-
gering from a traumatic accident. She lifted her pant leg slightly to expose a
brace. I knew at that moment that this was not going to be a routine student
experience and asked her to tell me more. She sat across from me and her
story unfolded.
She had been struck on the way home from work one night by a drunk
driver and spent more than a year in the hospital recovering: many months in
the ICU and then several more in rehabilitation. Once her cognitive function
had recovered to the point where she could study, she went back to school to
obtain a bachelor’s degree in nursing. She hoped to obtain a nursing position
that did not require 12-hour shifts because she could no longer spend that
much time on her feet. That’s how she found me, randomly assigned to be her
preceptor. What I wasn’t prepared for was to hear her experience of PICS and
her mother’s experience of PICS-F. I had just returned from a trip to Chicago
for the Society of Critical Care Medicine, where I had co-chaired a task force
to explore the long-term consequences of critical illness. It was there in 2010
that we developed the terms PICS and PICS-F to help raise awareness about
the subject and set forward a national research agenda.1 Her testimony vali-
dated the importance of our work.

Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California
San Diego Health System, Mail Code 8929, 200 W Arbor Drive, San Diego CA 92103 (jdavidson@
Karen Stutzer is Assistant Professor of Nursing, College of St Elizabeth, Morristown, New Jersey.
The authors declare no conflicts of interest.

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Ethics in Critical Care

As she recounted her postinjury experience, curtains. She found a urinal and kept it with
her strongest memory was of the fear caused her in case she needed to use it. It gave her
by loneliness and abandonment. Many of her comfort to be able to still see her daughter.
bones were broken, and in the beginning, she She continually feared that her daughter
could barely lift a finger to press the call but- would die alone.
ton. She was heavily sedated and receiving Jane shared that she and her mother both
mechanical ventilation. The physicians would received psychiatric care for many years to
come to round each day with her mother treat the mental illness caused by their ICU
present and declare, over her bed, that she experience; both were diagnosed with post-
would most likely not survive. She described traumatic stress disorder (PTSD). PTSD has
their rounding dialogue in detail, remember- been noted in both critical care patients and
ing every word as if it were yesterday. Jane family members of critically ill patients.3
assumed that the team thought she was either Jane and her mother openly admitted their
too critically ill or too sedated to remember, admiration for those who saved Jane’s life;
so their discussion was frank and open in but “the save” was not the end of the story.
regard to how seriously ill she was. It was the beginning of a long and arduous
She recalls that following a day of hearing journey of recovery. They remind us that how
about her poor prognosis, the night-shift staff the second chapter unfolds can be shaped by
encouraged her mother to go home to rest the first chapter—the ICU stay. In PICS and
because they rationalized that her mother PICS-F, anxiety, depression, or symptoms of
would need her strength to manage her daugh- PTSD related to the ICU stay may develop in
ter’s rehabilitation or death. But her mother the patient or the patient’s family. For instance,
did not want to leave her daughter’s bedside. our best intentions at helping patients’ family
She had rented a motor home to be as close members get rest or respite can be counter-
to her daughter as she could be. She was productive to their strong desire for presence
plagued by the thought that her daughter and safeguarding their loved one’s life.
might die alone without her family present.
When the nurses had encouraged her mother Ethics Analysis
to leave her beside, they told Jane that if she The ethical issues that attend the preven-
pushed the call bell, they would call her mother tion or mitigation of PICS/PICS-F include
and she could come in to be with her. Jane individual clinician and systems/organiza-
did push the call bell. The nurse came in and tional interventions. Nurses are moral agents;
said she would call her mother for a visit. The institutions are moral communities. A straight-
clock was visible from the head of the bed. forward ethical analysis of Jane and her moth-
Jane remembers watching the second hand er’s case might invoke the ethical principles
go around and around for hours. She prayed of nonmaleficence, beneficence, and respect
for her mother’s return, but it did not happen. for persons. We should, at a minimum, not
The nurses, she assumed, felt she was too harm our patients (or their families), and,
sedated or ill to remember. given informed consent, we are obligated to
Jane describes other instances of asking provide them with empirically sound benefi-
for her mother to be present at her bedside. cial treatment. We are also obligated, at a
She recalled that when the nurse left to get minimum, to respect the dignity of patients
her mother, she overheard the nurses at the and their family members as persons.
nursing station laughing, jeering at the thought Jane and her mother are grateful for Jane’s
that a grown young woman needed her mother lifesaving treatment—perceived benefits are
so badly. She could not fathom why the nurses not at issue. Further exploration is needed to
did not understand her need to have family understand the harms that resulted from the
with her. Jane perceived those nurses as cold behaviors, inattention, or disregard for what
and indifferent to her needs. Jane or her mother understood to be benefi-
Jane’s mother, on the other hand couldn’t cial to them and their well-being. Both women
cope with the imposed separation any longer. report being emotionally traumatized by their
To avoid being asked to leave, on some eve- forced separation, and by the apparent indif-
nings she hid under the bed. She would reach ference, infidelity, and uncaring attitudes
her hand up through the rails to touch Jane’s demonstrated by nurses and other critical
fingers. One night she even hid behind the care professionals.

Ethics in Critical Care W W W .AACN ACCON LIN E .ORG

Critical care nurses’ conception of profes- including lack of identification of patients’

sional duty is not limited to ethical analysis needs and lack of enthusiasm for patient
and ethical principles. Rather it is informed care.7 Compassion fatigue can also coexist
by a notion of moral agency that is conso- with other factors such as moral distress that
nant with the work of feminist philosopher can further erode nurse’s abilities to engage
Margaret Urban Walker.4 Walker sees moral- with empathy and compassion.
ity not as a theory or a set of rules or princi- In order for nurses to fulfill their ethical
ples, but as a set of practices in our everyday obligations, the code of ethics for nurses
lives. Patients, in Walker’s words, are nurses’ rightly calls nurses to care for themselves
business. She would see nursing practice as so that they can care for others. It states that
morally situated in 3 things: role, responsibil- the nurse owes the same duties
ity, and accountability. The critical care nurse to self as to others, including the
is a professional: she (or he) has a body of responsibility to promote health
expert knowledge that she professes to use and safety, preserve wholeness of
for the good of others (her patients). In her character and integrity, maintain
role as a nurse, she is responsible for and competence, and continue personal
accountable to her patients. The competent and professional growth.5
critical care nurse (physician or other clini- It is vital that critical care nurses understand
cian) presumes that an unconscious patient that the tension of persistently monitoring
can hear, can understand, and thus is mindful critically ill patients in order to ensure early
to touch the patient, to reassure, to explain, detection of deteriorating condition and the
to give the unconscious or even dying patient witnessing of suffering and death take their
“the benefit of the doubt.” toll. Failure to self-acknowledge the impact
The experiences of Jane and her mother of this level of responsibility and subse-
and their subsequent struggle with PICS and quently engaging in self-care activities can
PICS-F remind us of a key expectation of the result in expending a level of energy that
nurses’ code of ethics: “The nurse practices exceeds the nurses’ ability to recover, and
with compassion and respect for the inherent compassion fatigue ensues.7
dignity, worth and unique attributes of every
person.”5 Treating vulnerable people with Call to Action
compassion and honoring their dignity is a Providing care that minimizes the devel-
rigorous, nonnegotiable standard for all nurses. opment of PICS and PICS-F and the harms
What might have interfered with the nurses’ associated with them is the ethical responsi-
ability to demonstrate empathy and under- bility of nurses. Understanding the factors
standing for this patient and her mother? that contribute to PICS and PICS-F, a com-
Although none of us were in this specific mitment to live the ethical values reflected in
situation, we may have witnessed similar the code of ethics, awareness of the impact
instances where members of the health care of compassion fatigue on caring behaviors,
team have demonstrated a lack of empathy understanding patients’ experience, and
or caring. One possible explanation for the contributing to an environment that supports
behaviors described is compassion fatigue. humanistic care are elements of a multi-
Compassion fatigue is described as nurses pronged approach.
losing their ability to nurture in their rela-
tionships with patients and patients’ families.6 Understanding Patients’ Experience
An integral component of nursing is being Mitigating the impact of development of
present with patients and patients’ families, PICS and PICS-F begins with a robust under-
and as such, the nurse participates in both standing of the experience of patients in the
the joy and suffering that transpire in those ICU. The Society of Critical Care Medicine
interactions. Compassion fatigue is progres- has produced a number of videos available
sive and occurs in nurses as a result of the on YouTube (
stress of prolonged, intense relationships with ?v=mahm5WHxB7Q). Patients discuss their
patients in which the nurses’ compassionate experiences in their own words and identify
energy is expended and not restored.6,7 When interventions that they believe would be sup-
compassion fatigue is present, changes in portive of critically ill patients and their fami-
ethical and clinical values may occur, lies. In one video (

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Ethics in Critical Care

/watch?v=TFHP7WbICro), the patient poi- fatigue, including chronic absenteeism, high

gnantly shares the most meaningful care she turnover, and interpersonal conflict among
received. She highlights that what might be the staff.7 Providing the staff with support
considered mundane, like talking about the and education on compassion fatigue is a
weather or some uplifting news, helped her to start. Creating an environment that fosters
feel human and connected. Readers should nurses supporting each other is vital.7 Pro-
consider viewing these videos with other grams aimed at enhancing nurses’ resiliency
members of the health care team in order to are showing promising results in regard to
facilitate insight into the patient’s perspective decreasing compassion fatigue and increasing
of the ICU stay. As a team, consider incorpo- compassion satisfaction.13 The effects of these
rating recommendations into practice on your programs have been sustained over time.13
unit. Be cognizant of the right of patients and Likewise, administrative supports that pro-
their families to participate in their own care mote a healthy work environment for all cli-
by use of open visiting hours, participation in nicians such as appreciative practice initiatives;
rounds, and answering questions honestly. It compassionate care programs for caregivers,
is also important to be aware of the words we patients, and families; and institutional resources
say and how we say them, so that caring is to address clinical ethical issues and moral
evident with all interactions. distress are promising practices.
A variety of factors in the ICU have been
noted to exacerbate the high rates of anxiety, Conclusion
depression, and PTSD noted in patients and The lifesaving critical care environment
their families after an ICU stay.3,8 One prom- is fraught with hazards for patients, their
ising approach to diminishing the emotional families, and the health care team. Under-
aftermath of a stay in the ICU is the use of standing the nature of PICS and PICS-F as
diaries.8,9 The diary is maintained by the ICU well as interventions to potentially mitigate
staff members and describes the patient’s the impact of an ICU stay is a key responsi-
daily activities, visitors, and the patient’s bility of the health care team. Being alert to
responses to those activities. Some diaries the development of compassion fatigue and
include photographs of the patient’s jour- acting preemptively to diminish its develop-
ney.3,8 Patients have responded positively to ment are key responsibilities of both leaders
receiving the diaries. The diaries assured them and members of the health care team. Having
that there were people who cared about them knowledge about our patients and caring for
as they went through their illness.3 It has self allow us to be optimal agents of care.
been reported that the patients and families
who received diaries had lower levels of REFERENCES
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diary.10-12 long-term outcomes after discharge from intensive
care unit: report from a stakeholders’ conference. Crit
Care Med. 2012;40(2):502-509.
Environments That Support 2. Davidson JE, Harvey MA, Schuller J, Black G. Post-
intensive care syndrome: what to do and how to pre-
Humanistic Care vent it. Am Nurse Today. 2013;8:32-38.
Jenkins and Warren7 share the wisdom of 3. Jones C. Recovery post ICU. Intensive Crit Care Nurs.
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4. Walker MU. Morality in practice: a response to Claudia
heal someone, you give a piece of yourself Card and Lorraine Code. Hypatia. 2002;17(1):174-182.
away.” How can critical care nurses ensure 5. American Nurses Association. Code of Ethics for
that they are able to give and restore in order Nurses With Interpretive Statements. Silver Spring,
MD: American Nurses Association; 2015.
to be ready to give again? Certainly taking 6. Coetzee SN, Klopper HC. Compassion fatigue within
care of themselves, learning stress manage- nursing practice: a concept analysis. Nurs Health Sci.
ment strategies, developing self-awareness, 7. Jenkins B, Warren NA. Concept analysis: compassion
and being mindful of balance in one’s life is fatigue and effects upon critical care nurses. Crit Care
a start.7 Beyond that, leaders in the environ- Nurs Q. 2012;35(4):388-395.
8. Akerman E, Ersson A, Fridlund B, Samuelson K. Pre-
ment where nurses practice need to be mind- ferred content and usefulness of a photodiary as
ful of the potential for compassion fatigue to described by ICU patients: a mixed method analysis.
develop in their staff. Aust Crit Care. 2013;26:29-35.
9. Ewens B, Chapman R, Tulloch A, Hendricks JM. ICU
Nursing leaders and colleagues need to survivors’ utilisation of diaries post discharge: a quali-
monitor one another for signs of compassion tative descriptive study. Aust Crit Care. 2014;27:28-35.

Ethics in Critical Care W W W .AACN ACCON LIN E .ORG

10. Garrouste-Orgeas M, Coquet I, Perier A, et al. Impact 12. Jones C, Backman C, Griffiths RD. Intensive care dia-
of an intensive care unit diary on psychological dis- ries and relatives’ symptoms of posttraumatic stress
tress in patients and relatives. Crit Care Med. 2012; disorder after critical illness: a pilot study. Am J Crit
40(7):2033-2040. Care. 2012;21(3):172-176.
11. Jones C, Backman C, Capuzzo M, et al. Intensive care 13. Potter P, Deshields T, Berger JA, Clark, M, Olsen S,
diaries reduce new onset post traumatic stress disorder Chen L. Evaluation of a compassion fatigue resiliency
following critical illness: a randomised, controlled trial. program for oncology nurses. Oncol Nurs Forum. 2013;
Crit Care. 2010;14(5):R168. 40(2):180-187.

AACN Advanced Critical Care
Volume 27, Number 2, pp. 241-247
© 2016 AACN

ECG Gerard B. Hannibal,

Challenges Department Editor

2015 Advanced Cardiac Life Support Updates

and Strategies for Improving Survival After
Cardiac Arrest
Gerard B. Hannibal, RN, MSN, CCRN

T he ECG Challenge for this issue takes a diversion from the electrocardiogram
to examine 2 important documents published simultaneously in October
2015. The first is the eagerly awaited 2015 American Heart Association Guide-
lines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascu-
lar Care.1 The second is a brand new book-sized report from the Institute of
Medicine (IOM) titled Strategies to Improve Cardiac Arrest Survival: A Time
to Act.2 Both of these documents recommend that we take a bold new approach
to the treatment of cardiac arrest in the United States.
According to the IOM report, sudden cardiac arrest is the third leading cause
of death in the United States. The annual incidence (number of new cases in
the United States per year) of cardiac arrest outside the hospital (OHCA) is
395 000 with 5.5% surviving to hospital discharge, and the incidence of cardiac
arrest in hospitalized patients (IHCA) is 200 000 with 24% surviving to hospi-
tal discharge. Resuscitation outcomes in the United States have not improved
in the past 30 years—overall survival rates are stable at 7.6%. Despite these
dismal statistics, only 3% of the population of the United States receives
instruction in cardiopulmonary resuscitation (CPR) each year.2 We know that
resuscitation outcomes can be improved with prompt bystander CPR and early
use of automated defibrillators.
The IOM report suggests the need for a comprehensive systems-based frame-
work to identify short- and long-term strategies that focus on 5 factors for
improving patients’ outcomes after cardiac arrest: the public, emergency
medical services systems, hospitals and health care systems, researchers, and
professional education and advocacy organizations.2 The American Heart
Association (AHA) guidelines update announces the elimination of the 5-year
guideline revisions timetable in favor of a continuously updated website with
the aim of rapid translation of research to the bedside. The single “chain of
survival” diagram is replaced with separate diagrams for OHCA and IHCA.
The AHA report also reiterates 2 major impact goals for the period from
2010 to 2020: to double the rate of bystander CPR and to double cardiac
arrest survival rates.1

Gerard B. Hannibal is Staff Nurse, Progressive Care Unit, The Louis Stokes Cleveland Department of
Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106 (
The author declares no conflicts of interest.


Emergency Cardiac Care Table 1: Numbers and Percentages of

Guidelines Update 2015 Emergency Cardiac Care Updates in
The authors of the emergency cardiac care 2015 Classified by Level of Evidencea
guidelines make it clear that the 2015 docu-
ment published in Circulation is an update— Level of No. of % of
not a revision. A revision is a change that Evidence Description Updates Total
corrects or improves, whereas an update A Systematic reviews 3 1
reviews the most recent information about a
topic. For example, when the International B-R Randomized studies 50 15
Liaison Committee on Resuscitation (ILCOR) B-NR Nonrandomized studies 46 15
changed the emphasis of emergency care from
C-LD Limited data 145 46
breathing and airway as the primary survey
to circulation as the primary focus (ABC C-EO Consensus of expert 73 23
survey to CAB survey), that was a revision. opinion
In the current document, an upper limit is, a
Note the low number of updates based on high-level evidence.
for the first time, added to the rate of chest
compressions. This change is an update based
on research that indicates that overly rapid based on limited data or expert consensus as
chest compressions do not allow adequate opposed to the low number of updates based
depth of compression. on high-level evidence illustrates the paucity
The guidelines have been revised periodically of high-quality, pertinent research in the field
in the past 50 years. CPR came into use in of resuscitation.
the early 1960s, and the National Academy
of Sciences published the first US guidelines Basic Life Support Updates
in 1966. The American Heart Association The basic life support (BLS) updates (Table 2)
published 7 guideline revisions in the next are focused on 2 areas: improving the quality
50 years, starting in 1974 and resulting in and performance of CPR and instituting “just
the current guidelines. This new iteration of in time” bystander CPR by emergency medi-
emergency cardiac care guidelines takes advan- cal response dispatchers.5 CPR quality issues
tage of current Internet technology and the include adding an upper limit of 120 compres-
need to quickly translate science into action. sions per minute to promote adequate depth
The complete searchable updates and current of compressions and complete chest recoil,
guidelines are now available for immediate reducing pauses before and after a shock,
review at and adding the use of intramuscular or intra-
.php/circulation/cpr-ecc-guidelines-2/.3 nasal naloxone by BLS health care providers
The method used for both gathering and when opioid-related stupor is likely. The update
evaluating evidence for the current guidelines includes the addition of a new limit to com-
and the update was also revised for 2015. pression depth of 2.4 inches for adult victims,
The committee used the PICO method (popu- along with a goal of increasing the chest
lation, intervention, comparator, and outcome) compression fraction to at least 60%. Chest
to formulate questions based on clinical sig- compression fraction is a measure of the per-
nificance and new evidence. One hundred centage of time that chest compressions are
sixty-five PICO questions were reviewed, result- actually in progress. Additionally, CPR pro-
ing in 315 updates for emergency cardiac viders are urged not to lean on the chest so
care. Levels of evidence and classifications that full recoil can be attained.5
of recommendations were also revised; the The BLS section of the update also places
guidelines and updates are divided into 5 a heavy emphasis on improving the rate of
classes of recommendation, with 5 levels of bystander CPR. EMS dispatchers are urged
evidence. Note that class III recommendations to learn to identify cardiac arrest on the basis
are newly divided into 2 subcategories: no of descriptions of bystanders. Dispatchers
benefit to a procedure or treatment, and dan- should assume that the victim is in cardiac
gerous treatments or procedures that should arrest if the bystander describes gasping
not be performed.4 Table 1 summarizes the (agonal breathing) or the absence of breath-
total number of updates with their levels of ing. Dispatchers should then either provide
evidence. The high percentage of updates support to a bystander who is trained in

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 ECG Challenges

Table 2: Selected Updates for 2015 questions related to oxygen use, advanced
Guidelines for Cardiopulmonary airways, ventilation rate, carbon dioxide
Resuscitation Quality and Classification detection, physiological monitoring, prog-
of Recommendation nostication, defibrillation, drugs, and extra-
corporeal CPR (Table 3).6 Providers should
Emergency Cardiac Care Practice COR continue to use the maximum feasible amount
Compression rate 100-120 (new upper limit) IIa of oxygen during CPR. When feasible, the
update recommends physiological monitoring
Compression depth 2-2.4 inches (5-6 cm) I
such as quantitative waveform capnography
(new lower limit)
and arterial pressure monitoring during CPR.
Reduce pauses before and after shock I Use of a bag mask valve device and use of
Increase chest compression fraction IIb an advanced airway for oxygenation and
(goal at least 60%)a ventilation are considered equivalent from
an evidence standpoint in the update, and
Naloxone for opioid stupor (health care IIa
either can be used depending on the skills of
the provider. When an endotracheal tube is
OHCA, shockable rhythm—3 cycles 200 IIb used, a combination of continuous waveform
compressions with passive oxygen insufflation capnography and clinical assessment is the
(EMS only)
most reliable method of confirming and mon-
No routine passive ventilation for conventional IIb itoring tube placement.6
CPR The rate of assisted breathing for all breath-
Routine passive ventilation okay for EMS IIb less patients with an advanced airway is sim-
bundled services plified to 10 breaths per minute (one breath
every 6 seconds) to prevent excessive ventila-
EMS dispatchers—assess for consciousness I
and abnormal breathing
tion. Biphasic defibrillation is preferred over
monophasic defibrillation, and the single-shock
Dispatcher to assume victim is in cardiac I approach continues to be preferred over the
arrest if no normal breathing stacked-shock method. Vasopressin was
Educate dispatchers to identify cardiac I removed from the general-use pulseless vic-
arrest through a range of clinical signs tim algorithms because its effect is equivalent
and symptoms to that of epinephrine6; however, there remains
Dispatchers provide “chest compression I a use for vasopressin in a bundled approach
only” instructions for OHCA to IHCA with intravenous steroids.7 Epi-
nephrine use in nonshockable rhythms was
10 breaths per minute during CPR with IIb
advanced airway
upgraded; epinephrine should be used as soon
as feasible in cardiac arrest victims with
Artifact-filtering algorithms not recommended IIb nonshockable rhythms (asystole or pulseless
except for research electrical activity). Extracorporeal CPR (extra-
Audiovisual feedback devices may be used IIb corporeal membrane oxygenation) is now
Lay rescuers not to use head-immobilization III
included in the ACLS algorithm for use in
devices special circumstances.6
The complete emergency cardiac care guide-
Abbreviations: COR, class of recommendation; CPR, cardiopulmonary lines are available free from the website https://
resuscitation; EMS, emergency medical services; OHCA, cardiac
arrests occurring outside of the hospital.
Chest compression fraction measures the percentage of time that
chest compressions are actually in progress.
/cpr-ecc-guidelines-2/, including a full-color PDF
version of the highlights of the 2015 guide-
lines update.3 Updates are clearly compared
CPR or teach the untrained bystander to do with the 2010 guidelines, and the rationale
“compressions-only CPR” until EMS providers for each change is included for all categories
reach the scene.5 in the highlights of the PDF document. The
journal Circulation is also allowing free access
Advanced Cardiac Life Support to the 2015 update via its website. For those
Updates who have the Circulation iPad application,
The advanced cardiac life support (ACLS) both the ILCOR and AHA versions of the
updates were developed by addressing 37 PICO update are available as free downloads.


Table 3: PICO (Population, Intervention, Comparator, Outcome) Topics With Selected

2015 Advanced Cardiac Life Support Updates

PICO Question Topic Recommendation COR

Oxygen use Continue to use maximum feasible inspired oxygen during CPR IIb
Physiological It may be reasonable to use physiological parameters to optimize CPR IIb
monitoring quality
Advanced airway use Either a bag-mask device or an advanced airway during CPR for OHCA IIb
and IHCA
Carbon dioxide Use continuous waveform capnography and clinical assessment for I
detection confirming and monitoring correct placement of ETT
Ventilation rate One breath every 6 seconds with advanced airway management IIb
Defibrillation Biphasic defibrillation preferred over monophasic defibrillation IIa
A single-shock strategy (as opposed to stacked shocks) is reasonable for IIa
Prognostication PETCO2 less than 10 mm Hg after 20 minutes CPR can be used as a factor IIb
when considering ceasing efforts
Antiarrhythmic drugs Routine use of magnesium in adults not recommended (no benefit) III
Vasopressors Vasopressin removed as sole pressor for pulseless individual IIb
Administer epinephrine as soon as feasible for pulseless nonshockable rhythm IIb
Steroids Steroid use in a bundled approach to IHCA IIb
ECMO Use in select patients where cause of cardiac arrest is potentially reversible IIb

Abbreviations: COR, class of recommendation; CPR, cardiopulmonary resuscitation; ECMO, extracorporeal membrane oxygenation; PETCO2,
end-expiration partial pressure of exhaled carbon dioxide; ETT, endotracheal tube; IHCA, in-hospital cardiac arrest; OHCA, cardiac arrest outside
of hospital.

IOM Report on Improving research; delayed translation of research to

Cardiac Arrest Survival the field; and leadership deficiencies. The report
Nurses are most familiar with the IOM for concludes with 8 major recommendations
landmark reports on hospital safety in 1999 for improvement and suggests organizational
and on the future of nursing in 2011. This cur- leadership for each area (Table 4).2
rent IOM study and report was requested by
the American College of Cardiology, the AHA, IOM Recommendations
the American Red Cross, the Centers for The first recommendation is to establish a
Disease Control and Prevention, the National national cardiac arrest registry through the
Institutes of Health, and the US Department of leadership of the Centers for Disease Control
Veterans Affairs to study resuscitation research and Prevention, with cooperation of state and
and resuscitation outcomes in the United States local health departments. Accurate data col-
as a public health problem. The committee lection for both OHCA and IHCA by using
was charged to look at all aspects of resusci- such a registry will encourage accountability
tation except for prevention of cardiac arrest.2 and promote improvement in outcomes. The
The report provides a broad overview of second recommendation is to promote public
issues related to both IHCA and OHCA. awareness and public readiness to participate
Extensive reviews of the research literature in resuscitation activities. Bystander CPR and
are presented at the end of each chapter. procurement of automatic external defibrilla-
Barriers to successful resuscitation outcomes, tors (AEDs) are critical factors in improving
reviewed in detail, include lack of a national outcomes for OHCA victims. The IOM sug-
reporting system for cardiac arrest; lack of gests that state and local departments of health
community engagement in resuscitation aims; and education, in partnership with training
disparities in treatment based on ethnicity, organizations, should support CPR and AED
location of arrest, economic status, age, and training. Legislation to make CPR training a
sex; a dearth of research and funding for requirement for graduation from high school

VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 ECG Challenges

Table 4: Institute of Medicine Recommendations to Improve Cardiac Arrest Survivala

Recommendation Responsible Agency

Establish a national cardiac arrest registry Centers for Disease Control and Prevention
Foster a culture of action through public awareness State and local departments of health and education,
training training organizations
Enhance the capabilities and performance of National Highway Traffic Safety Administration
emergency medical services
Set national accreditation standards related to The Joint Commission
cardiac arrest for hospitals and health care systems
Adopt continuous quality improvement programs Hospitals, health care systems, and emergency
related to cardiac resuscitation medical services systems
Accelerate research on pathophysiology, new National Institutes of Health, The American Heart
therapies, and translation of science for cardiac arrest Association, and The US Department of Veterans
Accelerate research on the evaluation and adoption National Institutes of Health, Agency for Healthcare
of cardiac arrest therapies Research and Quality, US Department of Veterans
Affairs, Patient-Centered Outcomes Research Institute
Create a national cardiac arrest collaborative American Heart Association and American Red Cross

Based on information from Graham et al.2

(already in place in some states) is one of the quality indicators, but its use for emergency
tantalizing strategies suggested.2 resuscitation in hospitals is not optimal.
The third recommendation is to enhance the Recommendation 6 calls for the acceleration
capabilities and performance of emergency of research in pathophysiology, new therapies,
medical systems through the leadership of and translation of science through the leader-
the National Highway Traffic Safety Admin- ship of the National Institutes of Health (NIH),
istration. The IOM charges this administra- the AHA, and the US Department of Veter-
tion with coordination of the various ans Affairs. The IOM notes that traditional
federal, state, and local agencies involved in research methods using multiphase trials may
training first responders and paramedics. Goals not be appropriate for cardiac arrest research,
include standardized dispatcher-assisted CPR and adaptive trial designs are more likely to
protocols and development of a consistent lead to rapid translation of findings.2
training curriculum across the country. The Recommendation 7 calls for acceleration
fourth recommendation charges The Joint of research related to evaluation and adop-
Commission to collaborate with stakeholders tion of cardiac arrest therapies through the
to develop accreditation standards for health leadership of the NIH, the Agency for Health-
care facilities specific to care and treatment of care Research and Quality, US Department
patients with cardiac arrest. The IOM report of Veterans Affairs, and the Patient-Centered
notes that no accrediting agency requirements Outcomes Research Institute. New technolo-
for hospitals to report outcomes from cardiac gies and treatments should be applied in a
arrest are currently in place.2 timely manner and evaluated for their effec-
With the fifth recommendation, the IOM tiveness in improving resuscitation outcomes.
charges hospitals, health care systems, and The final recommendation, and perhaps the
EMS systems to adopt continuous quality most important one, is to create a national
improvement (CQI) programs. CQI activities collaborative for cardiac arrest led by the
should include data collection, setting of AHA and American Red Cross. The collab-
performance benchmarks, feedback, and orative will develop strategies, convene work-
fine-tuning of cardiac arrest protocols to ing groups for projects, meet on a regular
promote improvement of outcomes. Most basis, and encourage the development of
hospitals use the principles of CQI for many new technologies.2


Role of Nurses in Improving in-hospital cardiac arrests (82%)6 are associ-

Cardiac Arrest Survival ated with nonshockable cardiac rhythms,
The 2015 emergency cardiac care updates specifically pulseless electrical activity and
call for a renewed effort to provide timely asystole. IHCA numbers are high in part
and highly effective CPR both inside and out- because of the serious nature of the illness of
side the hospital. Nurses are the first respond- hospitalized patients, and one way to decrease
ers in hospitals and are in the ideal position the occurrence of IHCAs is to reduce futile
to take the lead in ensuring high-quality CPR care. Supporting critically ill individuals’
for IHCA. As CPR providers, nurses can use wishes for peaceful last days and appropri-
their skills to provide compressions at the ate, timely hospice care can have the second-
proper rate and depth to promote maximum ary effect of decreasing the numbers of
effectiveness. Nurses can use their leadership, in-hospital resuscitations.
communication, and team-building skills to Although nurses are ideally positioned in
ensure that other CPR providers use the their roles as bedside caregivers to improve
principles of high-quality CPR. IHCA outcomes, they need to be creative in
Even though most training centers rely on order to have an impact on improving OHCA
a retraining schedule of every 2 years, the survival. One potential area in which nurses
emergency cardiac care guidelines note that can influence OHCA is in teaching the basics
the optimal training interval needed to main- of CPR to family members of at-risk individ-
tain BLS and ACLS skills is unknown.8 BLS uals or providing CPR resources so that they
skills deteriorate rapidly after a training course, can learn on their own. The AHA has a con-
and it is reasonable to provide more frequent cise 1-minute video that teaches hands-only
training for individuals who are likely to treat CPR.9 Such a video is useful for patient and
victims of cardiac arrest. Nurses can have family education both inside and outside of
an impact on skill maintenance by training the hospital. Nurses can also become politi-
regularly with mock codes, providing the cally active and influence state legislators to
skill reinforcement and self-efficacy needed pass legislation promoting citizen education
to maintain optimal CPR skills and team in CPR and proper use of the AED. Nurses
process. Mini practice sessions on nursing can participate in research related to knowl-
care units using high-fidelity mannequins edge gaps identified in both the emergency
could provide opportunities for more frequent cardiac care updates and the 2015 IOM report.
practice and self-guided skill checks. Internet-
based simulation skill practice programs such Summary
as those developed by the AHA could also Acute and critical care nurses endeavor to
aid in skill maintenance. ensure optimal outcomes for patients in all
Nurses are also hospital leaders in continu- of their interactions with critically ill persons.
ous quality management and are in a good The current deficiencies in outcomes related
position to influence leadership through data to cardiac arrest and the lack of significant
collection, setting benchmarks, and feedback. progress in the past 30 years is a concern for
Nurses can provide support for CQI and out- all of us. Nurses can make their optimal
comes measurement related to cardiac arrest contribution in this area by fully supporting
care. Serving as busy direct care providers, AHA and IOM initiatives to improve cardiac
nurses may not feel that they have the time arrest outcomes.
to “stick around after a code” and review
what went well and what did not, but critical REFERENCES
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Strategies to Improve Cardiac Arrest Survival: A Time to
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