WORKFORCE STANDARDS FOR INTENSIVE CARE 2016 Suggested Citation Australian College of Critical Care Nurses (2016). Workforce Standards for Intensive Care Nursing. , ACCCN Ltd ISBN 9 780646 960739 Available at: www.acccn.com.au/aboutus/position-statements-standards ACKNOWLEDGEMENTS

Standards Development Group Standards Document Reviewers Dianne Callahana RN,MN ACCCN Paediatric Advisory Panel Diane Chamberlaina RN, PhD ACCCN Quality Advisory Panel Naomi Fayers RN, MN ACCCN Workforce Advisory Panel Bernadette Grealy RN,MN Key stakeholders Lyn Hopper RN, BSc (ICU Cert) Geraldine Kucharski RN, BN Standards Appraisal Claudia Matthews RN, MN Intensive Care Services Network, Agency for Clinical Innovation, Veronica McCartan RN, M lnt Care Nurs New South Wales Wendy Pollocka RN, PhD (Chair) Jackie Roberts-Thompsona RN, MN Systematic Review Librarian Tracey Swiney RN, MLN Raechel Damarell BA, Grad Dip lnfo Stud

Standards Evidence Reviewers Research Assistant Diane Chamberlaina RN, PhD Naomi Knoblach BSc (Hons) Raechel Damarell BA, GDinfoStud Naomi Knoblach RN, BSci Wendy Pollocka RN, PhD

Standards Writing Group Diane Chamberlaina RN, PhD Paul Fulbrooka RN, PhD Wendy Pollocka RN, PhD

a Director, ACCCN Board 1 CONTENTS

Foreword...... 3 Executive Summary...... 4 Standards in Summary...... 5 ACCCN Workforce Standards for Intensive Care Nursing...... 6 Context...... 6 Patient Experience...... 6 Background...... 7 Funding...... 7 Conflicts of interest...... 7 Purpose...... 7 Scope...... 7 Target users...... 7 Methods...... 7 Results...... 8 Pragmatic Issues of evidence...... 8 Body of evidence...... 8 Derivation of the Standards...... 8 Review and minor revision of the Standards...... 8 Appraisal...... 9 Ratification...... 9 Dissemination...... 9 Implementation of the Standards...... 9 Review...... 10 Audit...... 10 Standard One...... 11 Standard Two...... 12 Standard Three...... 13 Standard Four...... 14 Standard Five...... 15 Standard Six...... 16 Standard Seven...... 17 Standard Eight...... 18 Standard Nine...... 19 Standard Ten...... 20 References...... 21 Appendix A: Definitions...... 30 Appendix B: Evidence Tables...... 32 Appendix C. Body of Evidence...... 34

2 FOREWARD

On behalf of the Australian College of Critical Care Nurses is imperative to ensure patient safety, enhance staff recruitment (ACCCN) Board of Directors, it is my pleasure to present the and retention, and maintain an organisation's financial viability. ACCCN Workforce Standards for Intensive Care Nursing. The goal of the Standards is to ensure that quality care is The intensive and workforce plays an provided in an environment that is safe and has a positive impact essential role in the achievement of healthcare outcomes. A on patient and nursing outcomes. This document puts forth 10 growing body of evidence clearly demonstrates that inadequate essential standards for establishing and sustaining an intensive nurse staffing leads to an increase in negative outcomes care nursing workforce as part of a healthy work environment for patients, and ultimately a greater burden of cost to both that supports and fosters excellence in patient-centred care. the healthcare budget and society. Insufficient staffing and These landmark standards represent an important step in fulfilling inadequate skill mix are potentially compromising nurses' ability to ACCCN's commitment to its mission - to lead, represent, develop maintain the safety of those in their care, and to provide a level of and support critical care nurses in Australia. care that is likely to satisfy the nurses who provide the care and the patients who are the recipients of the care. Unhealthy work environments contribute to medical errors, Diane Chamberlain RN, PhD ineffective delivery of care, and conflict and stress amongst President, ACCCN health professionals. The creation of healthy work environments October 2016

3 EXECUTIVE SUMMARY

The Australian College of Critical Care Nurses (ACCCN) is the improve patient outcomes.1-5 Specifically, higher ratios of RNs peak professional nursing body representing critical care nurses providing direct patient care are associated with reduced length in Australia. of stay in ICUs, reduced incidence of nosocomial infection, fewer The ACCCN Workforce Standards for Intensive Care Nursing adverse events and lower ICU mortality. has been developed to safeguard the provision of an appropriate Although there are many factors that influence the safety and intensive and critical care nursing workforce, with the aim to outcomes of critically ill patients, it is indisputable that patient- ensure a safe and sustainable workforce that achieves the best centred care provided by an appropriately qualified nursing outcomes for critically ill patients. workforce makes a significant difference. Since the publication of the Institute of Medicine's report To Err Is In 2012, the Department of Health and Ageing commissioned a Human1, the relationship between characteristics such review of Australian government health workforce programs, with as intensive and critical care nurse staffing and the quality of care a focus on how to support the delivery of a high-quality, well- has become central to issues of healthcare delivery, research distributed, optimally utilised and responsive health workforce and policy. In the acute hospital setting, there is a long-standing, for Australia.6 The chair of the review stated, 'it is critical that consistent and robust evidence base that demonstrates the workforce innovation results in not only improved productivity, positive associations between the number of registered nurses improved retention and job satisfaction but also that the safety (RNs) employed to care for patients, the quality of their education, and quality of care is not affected ' (p. 72). These concepts sit at and improved patient outcomes. Furthermore, in intensive care the heart of the 2016 ACCCN Workforce Standards for Intensive units (ICUs), there is evidence that higher ratios of RN staff to Care Nursing. patients (specifically, 1:1 or 1:2) increase patient safety and

4 STANDARDS IN SUMMARY

Standard One Standard Seven Life support equipment for specialised diagnostic or therapeutic The ICU patient case mix and unit design must determine the procedures must be managed by a suitably skilled and qualified appropriate nursing service, knowledge and skills required for the RN. nursing workforce and support staffing of each unit. In addition to the minimum levels of staffing identified in Standards 2-10, each ICU must be evaluated objectively in Standard Eight terms of its unique patient case mix, design and environment to A liaison nurse service must be provided to optimise the use of determine whether additional staffing is required to safely meet the ICU within the hospital. the needs of its patients. Standard Nine Standard Two Intensive care nursing practice must be supported by a suitably A specified (formula/ratio based) number of nursing staff, with skilled and qualified RN researcher. suitable knowledge and skills, must be employed to provide direct patient- and family-centred care to critically ill patients. Standard Ten Standard Three Non-nursing staff, such as administrative, clerical, cleaning and equipment support staff that are based in the ICU, must be A specified (formula/ratio based) proportion of the nursing staff in provided to support service delivery and ensure that the nursing an ICU must hold a specialist critical care nursing qualification. staff is able to focus on the delivery of patient-centred care for critically ill patients. Standard Four The of the ICU must be provided by a specialist critical care RN who contributes to the planning of the The ACCCN Workforce Standards for intensive care service and collaborates actively with the hospital Intensive Care Nursing are presented executive regarding all ICU matters. and intended for application and interpretation as a full suite of Standard Five standards. A specified level of education and educational support must be provided within the ICU for all levels of its nursing staff. Nursing Individual application of any standard in isolation is not supported knowledge and skill must be maintained at an appropriate level in the evidence. to ensure high quality care for a complex case mix of critically ill patients.

Standard Six A predetermined (formula/ratio based) number of ACCESS nurses (see Appendix A) must be rostered to maximise ICU bed utility and optimise safety.

5 ACCCN WORKFORCE STANDARDS FOR INTENSIVE CARE NURSING

Context workforce is not complemented by specialised allied health practitioners such as respiratory therapists or dialysis nurses. Australia adopted intensive care nursing as a speciality in the One appropriately qualified RN operates, manages and problem 1970s.7 Since then the speciality has developed a reputable solves all of the technical equipment issues required to provide professional stance in the healthcare community. The peak life support to a critically ill patient. All elements of patient care, critical care nursing body, ACCCN, has had a long and mutually including those that may seem basic and non­ technical such as respectful association with intensive care medical colleagues washing and patient positioning, enable the ICU nurse to gather through the Australian and New Zealand Intensive Care Society vital information about the patient. For instance, skin condition (ANZICS). This respect and collaboration is evident from the and venous return to dependent body parts, haemodynamic collegial patient­ centred care at the bedside to the co-hosted stability when re-positioned, purposefulness of patient interaction national Annual Scientific Meeting on Intensive Care. This and movement when sedated are all evaluated during routine collaborative approach has helped to achieve excellent ICU patient care activities. patient outcomes in Australia, with reductions in mechanical The bedside nurse provides the constant surveillance and ventilation hours, length of ICU stay and mortality compared decision-making that is required to optimise outcomes and reduce to ICUs in equivalent developed nations. Importantly, these complications in the critically ill patient. This unique Australian improved outcomes relate to patients with a similar severity of critical care clinical practice model provides less variation and 7 illness in specific conditions and in ICUs overall. more stability in critically ill patients' condition.9 The clinical context of ICU nursing provision in Australia is An ICU nurse providing direct patient-centred care is the conduit quite different to most other nations in both the developed for information, effective communication and consultation from 8 and developing world. It is related to the high quality of ICU the many medical units and ICU specialists that have input into nursing clinical practice, education and research. Specialist ICU a patient's care.10 The ICU nurse is also a vital support person nursing postgraduate education is well established in Australia. for family members of critically ill patients, providing information, A postgraduate qualification provides advanced knowledge and guidance and support during the patients' stay in ICU. To skills for professional highly skilled, specialist work and further subdivide elements of care between different care providers is learning. not efficient. It would fragment care and reduce patient safety, The professional work and scope of practice of intensive and especially as the critically ill are so vulnerable. An ICU nurse critical care nurses in Australia is associated with improved providing direct patient and family-centred care to a critically ill patient outcomes that cannot be understated. Unlike many of patient is a key strength of Australian intensive care provision, their international counterparts, Australian ICU nurses routinely and this model of care should not be dismantled without good operate mechanical ventilators, independently adjust ventilator evidence that adverse outcomes will not occur as a result.8 settings to patient needs, suction and maintain an airway. They manage highly technical devices such as extracorporeal therapy and intra-aortic balloon pumps, measure cardiac output from Patient Experience highly technical hemodynamic devices and titrate vasoactive Everyone who is seeking or receiving care in the Australian drugs. They have not only technical skills but also knowledge, healthcare system has certain rights regarding the nature of and can apply these skills and knowledge to patient-centred care. that care. These are described in the Australian Charter of It is usual that each specialist critical care nurse cares for and Healthcare Rights.11 The rights included in the Charter relate to manages the multiple and complex needs of each critically ill access, safety, respect, communication, participation, privacy and ICU patient. Unlike some other countries, the intensive care comment. The critically ill patient is vulnerable and continually at

6 risk. Critical care nurses are central to providing care that meets Standards for Intensive Care Nursing (hereafter referred to as the the healthcare rights of each patient. Caring for ICU patients Standards) was produced. These Standards will help to ensure demands the nurse's constant and fully engaged presence the safety and quality of care for critically ill patients, which in turn and willingness to cooperate and interact with them in order will maintain and improve patient outcomes in Australian ICUs. to understand their dependence and vulnerability. 'A patient's endurance during mechanical ventilation seems to be facilitated by the presence of nurses that mediate hope and belief in Funding recovery, strengthening the patient's will to fight for recovery and The majority of the work involved in this review was undertaken survival'.12, p.6 ACCCN has published a position statement on on an in-kind basis. ACCCN provided funding for Workforce Partnering with Families in Critical Care (2015)b that underlines Standards Development Group meetings and publication of the these values. Standards.

Background Conflicts of Interest In 2001 a Senate inquiry into the critical care workforce No conflicts of interests were declared by any of the participants developed key statements that were later included in the ACCCN involved in the review and subsequent development of the ICU Staffing Position Statement (2003) on Intensive Care Nursing Standards. Although the ACCCN Board sponsored and provided Staffing.13 This position statement served the profession well some funding for this review, it did not seek to influence its until the cuts in healthcare spending that resulted from the recent outcome in any way. Some current and past members of the global financial crisis, which led to reductions in the critical care ACCCN Board of Directors were involved in the development of nursing workforce and affected the quality of patient-centred the Standards (see Acknowledgements above). care.14 Such decisions were based on simplistic assumptions about the numbers of nurses, rather than on evidence from research on critical care nurse staffing and workforce, such as Purpose their experience, qualifications, education and 'fit for purpose'.15 The purpose of the Standards is to define a safe and sustainable While the 2003 position statement provided important national intensive care nursing workforce in order to ensure the best guidance on intensive care nursing staff levels, its effectiveness outcomes for critically ill patients in Australia. was limited because it did not establish specific standards for practice. As nurses comprise the largest group of healthcare workers, Scope they represent an easy target for cost savings. The reduced staff The Standards apply to all adult, paediatric or mixed adult/ numbers and staff quality after the global financial crisis resulted paediatric ICUs in Australia. ICUs are defined as those units in an increased number of health-related adverse events, poorer providing level I-III treatment and care of critically ill patients (see productivity and poorer outcomes for patients.14-16 It also had an Appendix A), regardless of the title of the unit. impact on critical care workforce satisfaction and led to decreased retention of experienced senior critical care nurses. The clinical context of critical care nursing in Australia is different Target Users to most other nations in both the developed and developing These Standards are intended for reference and use by intensive world. The professional work and scope of practice of intensive and critical care nurses; ICU managers, allied health and medical and critical care nurses in Australia is associated with improved staff; hospital managers; health service district managers and patient outcomes that cannot be understated, and the outcomes executives; government health services administrators, managers 8 of critically ill patients are among the best in the world. The high and executives; hospital-based and university-based educators; quality of care is related to the high quality of nursing clinical and the public. practice, education and research. Specialist critical care nursing postgraduate education, which provides advanced knowledge and skills, is also well established in Australia. ACCCN has Methods published Practice Standards for Specialist Critical Care Nurses (2015)c that outline this quality. Several focus groups comprising members of the Workforce Standards Development Group were conducted. As a result, In the wake of the workforce issues described above, ACCCN several themes and keywords were identified that formed the received requests from the critical care nursing profession in basis of a systematic search and critical review of the literature. all states for a more robust evidence-based position on the The first tier of the literature review search commenced in 2012. ICU nursing workforce so that the quality and safety of patient­ This was a preliminary search of the Web of Science database. centred care of critically ill patients could be protected and Themes sourced from this search validated the use of the 2003 maintained. In response, in 2012, the ACCCN Board of Directors ACCCN position statement13 as the basis for the review. Ten established a working party that consisted of experts from each draft standards were derived, which guided the main literature state and members of the ACCCN Workforce Advisory Panel. It search and systematic review as detailed below. was charged with reviewing the 2003 position statement and its evidence base. As a result of this initiative, the ACCCN Workforce b Available at: www.acccn.com.au/documents/item/289 c Available at: www.acccn.com.au/documents/item/292 7 Search Strategy Pragmatic Issues of Evidence The second tier of the literature search was performed in 2014 The complex nature of the ICU, with variations in patient severity and repeated in 2015. This was to accrue literature related to of illness, comorbidities, support structures, management styles the standards in general, and then repeated specifically for and leadership makes the implementation of a randomised trial each standard. The search encompassed electronic databases, to test the implementation of an ICU workforce/staffing model reference lists from selected electronic articles, and Internet very difficult. We know that the quality of the relationship within search engines. For the main search, two librarians and the multidisciplinary team e.g. respect, positive communication, investigators searched the following electronic databases: autonomy, is important for nursing work and patient outcomes. Medline, CINAHL, Cochrane, Google Scholar, Embase, Scopus Thus, it is virtually impossible to obtain Level A evidence and Ovid. The search was limited to articles written in the English according to the NHMRC criteria (systematic review of RCTs, language that were published in the previous 10 years (January several RCTs). Notwithstanding this, there is a building body of 2005 to May 2015). strong observational evidence that support these Standards. This evidence fulfils the other four requirements of the NHMRC matrix Search Terms of evidence­: it is consistent, demonstrates substantial clinical The following terms and their combinations were used for the impact, is generalisable to the ICU patient population and is main search: 'nurses', 'nursing staff, hospital', 'intensive or critical applicable to the Australian healthcare context. care', 'nursing standards', 'nursing administration research', 'personnel staffing and scheduling ', 'nursing education research', Body of Evidence ' quality, access and evaluation', 'health services research', 'outcome assessment (health care)', 'personnel Assessment of Quality administration, 'hospital', 'patients', 'length of stay' and 'mortality'. The body of evidence in relation to each draft standard was Please refer to the Supplementary Online Appendicesd for assessed. Consideration was given to: MESH and keyword terms and combinations. • the quantity, level and quality of the evidence Inclusion and Exclusion Criteria • the consistency of the evidence across the included studies Articles were included in the review if they were: original research • the clinical impact (relevance) of the evidence (quantitative and qualitative) that measured or described nurse • the generalisability of the results to the population (for whom staffing and workforce in association with patient outcomes. the standard was intended) Descriptive reviews, systematic reviews, book chapters, editorials, dissertations and theses were also included. Grey • the applicability of the results to the Australian healthcare literature was sourced from Internet searches and communication setting. with other speciality organisations. The specific search criteria for These five components were then rated according to the NHMRC each Standard are available within the Supplementary Online body of evidence matrix17 (Appendix B, Table 2). The bodies of Appendicesd. evidence in relation to each standard are shown in Appendix C. Strengths and Limitations of the Evidence Results The bodies of evidence in relation to each draft standard were assessed using the NHMRC grades of evidence for the A total of 381 articles was retrieved from the initial search in 2012, development of guidelines17 (Appendix B, Table 3). Most of the and the search was repeated again in 2014 and 2015, resulting in draft standards were found to be supported by grade C evidence, a total of 553 articles. The full text of each article was assessed and the remainder by grade Band D evidence. independently by three researchers to determine its suitability for full review, resulting in the exclusion of 309 articles. The National Health and Medical Research Council (NHMRC) dimensions of Derivation of the Standards evidence criteria17 were used to assess the included studies: strength of evidence (level, quality, statistical precision); effect All ten draft standards were judged to be supported by bodies of size; and relevance of evidence (appropriateness of outcomes, evidence of grade c or above. The wording of each draft standard relevance of study question). was subsequently reviewed and revised as necessary to ensure consistency with the evidence base. The NHMRC levels of evidence (Appendix B, Table 1) were used to categorise and assess the quality of each article. These were then summarised in terms of the body of evidence Review and Minor Revision of the (Appendix B, Table 2). Only three qualitative studies were found. Standards These were assessed using the National Institute for Clinical Excellence qualitative appraisal checklist.18 The final draft of the Standards was invited for final review and comment by a validation panel of representatives of professional end-users as follows:

d The Supplementary Online Appendices are available at: www.acccn.com.au/aboutus/position-statements-standards 8 • ACCCN Advisory Panels (e.g. Paediatric, Quality, • Domain 1: Scope and purpose 112/144 = 78% Resuscitation) • Domain 2: Stakeholder involvement: 118/192 = 61% • ANZICS • Domain 3: Rigour of development: 255.5/336 = 76% • College of (CICM) • Domain 4: Clarity of presentation: 126/192 = 66% • Council of National Nursing Organisations (CoNNO) • Domain 5: Applicability 65/144 = 45% • Intensive care nurse unit managers • Domain 6: Editorial independence 62/96 = 65%. • Nurse educators (hospital-based) In terms of overall assessment, the Standards were scored 738.5 • University-based/clinical academics out of a possible total score of 1104 = 67%. This is equivalent Although the panel was selected to ensure that a broad range to an overall rating of 5 on the AGREE II rating scale (1-7). The of end-users was consulted, it was weighted towards intensive relatively low score achieved in the Applicability domain was care nurses and clinicians as they are the primary end-users. felt to be related to the design of the AGREE II tool, which was Using a consensus survey, each representative was asked to rate designed to assess clinical practice guidelines.However, in the their strength of agreement with each standard using a 9-point absence of a specific tool to appraise practice standards, the rating scale ranging from 1 (strongly disagree) to 9 (strongly AGREE II tool was the best available. The results of the AGREE agree). The level of consensus was set at a median of 7. A total II appraisal were reviewed by ACCCN National Board and no of 33 responses was received. A large majority agreed with further amendments to the Standards were deemed necessary. all standards. All sub-sections, with the exception of only two Detailed results of the appraisal are presented within the (6.3.1 and 8.3) achieved a median cut-off score of 7 required Supplementary Online Appendicesd. for approval. A large number of constructive comments was also received. In addition, consumer representatives were invited to comment Ratification on the Standards and indicate support for their use (yes, yes with The final version of the Standards was approved by the ACCCN modification, no) via an electronic survey. The following consumer Board of Directors in October 2016. groups participated in the review: • Health Care Consumers Association (ACT) Dissemination • Health Consumers Alliance (SA) The 2016 ACCCN Workforce Standards for Intensive Care • Health Consumers Council (WA) Nursing is available in printed and electronic format. • Health Consumers Queensland (Qld) To ensure widespread distribution and access to the Standards, • Health Consumers Network (NSW) the electronic version (pdf file) has been made available for • Health Issues Centre (Vic). download free-of-charge for members via the ACCCN website. It will also be e-mailed to all ACCCN members and associate In total, 14 consumers provided feedback about their overall members. agreement with each standard. All standards were supported by a large majority, with written suggestions for modifications. A complimentary print version of the Standards will be provided As a result of the surveys and the comments received during to: this phase, minor revisions were made to the standards. • relevant consumer groups Summary results from the review phase are presented in the • all Australian ICUs Supplementary Online Appendicesd. • the senior nursing executive in all Australian • relevant professional organisations (e.g. Royal College Appraisal of Nursing of Australia, Nursing and Midwifery Board of As a final assessment of rigour, the Standards were subjected Australia, ANZICS, CICM, CoNNO) to appraisal, using the AGREE II instrument, by an independent • all state and national chief nursing officers group of assessors that was not involved in the development • the Australian Minister and Shadow Minister for Health of the Standards. Appraisers from the Intensive Care Services • all state health ministers and state shadow health ministers. Network, Agency for Clinical Innovation NSW participated in this phasee. Eight reviewers (1 nurse manager, 2 nurse unit The print version will also be made available for purchase, at a managers, 3 clinical nurse consultants, 2 clinical nurse educators) nominal cost, to any interested party. participated in the appraisal. The Standards were appraised within six domains, comprised of between two to eight questions, scored on a scale of 1 (strongly disagree) to 7 (strongly agree). Implementation of the Standards The maximum minus the minimum possible scores was divided Not all ICUs will be able to conform to the Standards immediately. by the sum of the reviewers' scores minus the minimum possible Current models of care as well as funding models will require scores for each domain to give a scaled domain percentage review and revision. It is a reasonable expectation that ICUs score for each domain. The results were as follows: implement the Standards within one year of their release. d The Supplementary Online Appendices are available at: www.acccn.com.au/aboutus/position-statements-standards e This does not imply endorsement of the Standards by the Agency for Clinival Innovation NSW 9 There may be mitigating circumstances that prohibit some ICUs • workload from meeting the Standards within a one­ year time-frame. These • case mix variation. circumstances should be documented thoroughly, and a strategic At any time, on recommendation from the Advisory Panels, plan should be implemented in relation to each standard, to the ACCCN Board may initiate a full review of the Standards. ensure their implementation within a maximum two­ year period Minimally, the Standards will be subjected to full review every five from their release. years.

Review Audit The Standards will be reviewed biennially by the ACCCN Advisory Two years following the release of the Standards, ACCCN Panels. The purpose of this review is to ensure the Standards are will undertake a national audit of ICUs to assess the level of up to date and consistent with: compliance with the Standards. Aggregate results for each state • the current evidence base will be reported and made publicly available. • contemporary practice

10 STANDARD ONE

1. The ICU patient case mix and unit design must Grade of Evidence Level B determine the appropriate nursing service, knowledge and skills required for the nursing • Inadequate specialist paediatric nursing staff increases the workforce and support staffing of each unit. likelihood of adverse outcomes in a paediatric intensive care unit (PICU). [Level C] In addition to the minimum levels of staffing • PICU nursing has a distinct knowledge base and skill set. identified in Standards 1-9, each ICU must be [Level C] evaluated objectively in terms of its unique patient case mix, design and environment • Higher levels of experience and education in the paediatric critical care nursing workforce are associated with fewer to determine whether additional staffing is patient deaths. [Level B] required to safely meet the needs of its patients. • Single rooms provide increasing flexibility to accommodate 1.1 Paediatric Services: In ICUs that provide services for a range of patients, such as the provision of paediatric paediatric patients only, the critical care postgraduate intensive care beds in an adult ICU rather than a stand-alone qualification noted in each section of these standards refers pod should bed requirements be low. [Level D] to a paediatric specific speciality. • Single rooms will assist staff in managing patient care and 1.2 Mixed Adult/Paediatric: In ICUs that have a mixed adult/ reducing the risk of cross infection between patients. [Level paediatric population, there should be a designated C] paediatric critical care nurse leader who holds a paediatric- specific critical care qualification. • Single rooms are superior to multi-bed rooms in terms of patient safety. [Level B] 1.3 Special Needs: For critically ill patients with special needs e.g. maternity, oncology or morbidly obese patients, • Single rooms require dedicated surveillance and staffing due consideration must be given to the requirement for ratios to maintain safety. [Level D] additional, appropriate staff support to ensure that the • When ICU patients are cared for in single rooms, the ability patient's needs are met. of staff to supervise and support less-experienced staff is 1.4 Design and Layout: The design and layout of the ICU must reduced. When the staff is isolated, direct observation may be considered when determining nurse staffing and skill mix. be impaired, checking medication is more onerous, obtaining In ICUs where there is a large number of single rooms, the equipment can be time consuming, and emergency access nursing skill mix must be reviewed in order to ensure the to the patient may be compromised. [Level D] safety and needs of the critically ill patient. [See also 6.3.]

11 STANDARD TWO

2. A specified (formula/ratio-based) number of Grade of Evidence Level B nursing staff, with suitable knowledge and

skills, must be employed to provide direct • All critically ill patients require continuous observation patient- and family-centred care to critically ill and surveillance to halt the deleterious progression of deterioration related to critical illness and multi-organ failure. patients. [Level A] f 2.1 Critically ill patients , as determined clinically, require at a • Diluting the number of RN staff with non-RN staff in general minimum one RN to care for them in close proximity (less hospitals increases the likelihood of hospital mortality, than 3 metres) at all times. hospital-acquired infections and adverse events. [Level B] 2.2 The minimum professional qualification requirement is that of • Higher levels of RN staffing per patient in ICU are associated an RN; to ensure accountablity for direct patient and family- with lower rates of nosocomial pneumonia, nosocomial centred care for the needs of critically ill patients. sepsis and unplanned extubation. [Level B] 2.3 The RN-to-patient ratio must be at least: • The holistic patient and family-centred model of care in 2.3.1 One RN to one patient for ventilated patients and any Australia, with one RN for one ICU patient, provides the other patient in the ICU that the nurse-in-charge deems world-best outcomes for ICU patients, including lower to be clinically unstable or at risk; mortality, lower duration of mechanical ventilation and lower lengths of ICU stay. [Level B] 2.3.2 One RN to two patients for patients requiring a high complexity level of care, (e.g. stable non-ventilated • Allocation of an ICU patient to an EN to provide direct patients improving from their critically ill state). patient care, even with the support of an RN caring for an Deteriorating patients require a 1:1 ratio. ICU patient in an adjacent bed, results in increased adverse events and patient mortality. It is not a sustainable model of 2.4 On occasions when a patient has very complex needs, more care in tertiary-level ICUs and major non-metropolitan ICUs. than one RN to one patient may be required, as deemed [Level D] necessary by the nurse-in-charge or ICU specialist (e.g. a labouring obstetric patient or a patient with multiple extra- • There is professional support for the 1:1 RN-to-patient ratio corporal technology, major trauma or burns). for ICU patients in collegial ICU Standards (e.g. ANZICs, CICM, BACCN). [Level C] 2.5 Non-RN staff [e.g. enrolled nurses (EN) and patient care assistants] are additional to the above ratios and should not • There is no shortage of critical care qualified nursing staff in replace an RN. They may only assist in the care of patients ICUs that follow the Magnet Hospital framework. [Level D] under the direct supervision of an RN. • Use of non-RN staff in ICU is a contributing factor to the 1.6 The ratio applies to all adult, paediatric or mixed adult/ attrition of critical care qualified nurses. [Level D] paediatric ICUs in Australia.

f See definitions on pages 30-31 12 STANDARD THREE

3. A specified (formula/ratio-based) proportion Grade of Evidence Level B of the nursing staff in an ICU must hold a specialist critical care nursing qualification. • The proportion of critical care qualified staff is related to patient safety, with less falls and medication errors when a 3.1 A minimum of 50% of the RN staff that provide direct patient higher proportion of critical care specialist RNs are employed care in an ICU should hold a recognised postgraduate on staff. [Level B] intensive care (critical care) nursing qualification. • Inadequate knowledge, skills and competence of nursing 3.2 The qualification will meet at a minimum an Australian staff contribute to adverse events in ICU. [Level C] Qualifications Framework level 8 and the Australian clinical practice outcome Standards for critical care nurse • There is variation in what constitutes a critical care education.g qualification, both internationally and in Australia. [Level D] 3.3 The optimal proportion of critical care specialist qualified • A staff skill mix with a high proportion of RNs without critical RNs is 75%. The remaining 25% should be working towards care qualifications is a stressor to critical care qualified a post graduate qualification. The ratio applies to all adult, staff and a contributing factor to the attrition of critical care paediatric or mixed adult/paediatric ICUs in Australia. qualified nurses. [Level D] • There is a positive association between Australian critical care nursing qualifications and patient outcomes. [Level D] • A staff skill mix with a high proportion of RNs with critical care qualifications is needed for the education and mentoring for new staff including new graduate and students [Level D] • A critical care qualification will enable the RN to meet the ACCCN Practice Standards for Specialist Critical Care Nurses. [Level D]

g Gill F, Leslie G, Grech C, et al. (2015). Development of Australian clinical practice outcome standards for graduates of critical care . Journal of Clinical Nursing 24(3-4), 486-499. 13 STANDARD FOUR

4. The nursing management of the ICU must be Grade of Evidence Level C provided by a specialist critical care RN who • Nurse unit managers of large ICUs manage high numbers of contributes to the planning of the intensive staff (e.g. > 400 nurses) and large budgets (e.g. > $50 million care service and collaborates actively with the per annum) and require a management team/structure within hospital executive regarding all ICU matters. the ICU to support such a large enterprise. [Level B] 4.1 Every ICU must have a specialist critical care RN that is • The nurse unit manager of an ICU provides nursing dedicated exclusively to a nursing manager role. leadership within the ICU and within the hospital. [Level C] • Additional management /coordinating nursing staff are 4.1.1 The ICU nurse manager should possess a required to optimise the flow of patients in and out of the postgraduate qualification in management or similar, ICU. [Level C] and be prepared to Master's level in a recognised degree in either managment, critical care or similar. • It is beneficial for nurse unit managers to possess a critical care qualification and/or management qualification. [Level D] 4.2 The ICU nurse manager must be supernumerary to the allocation needs of clinical patient care. 4.3 In larger units (i.e. units with more than 10 beds), a broader array of management support nurses may be required (e.g. more than one nurse manager, assistant nurse managers); each must be supernumerary to the RN requirement for direct patient care stated in 2.3. 4.4 In addition to the ICU nurse manager, a clinical coordinator is required. This role is responsible for appropriate clinical allocation and bed management. The clinical coordinator may also provide an element of clinical support. 4.4.1 The clinical coordinator must be a critical care qualified RN. 4.4.2 There should be at least one clinical coordinator who is supernumerary per shift (i.e. in addition to staff providing direct patient care). 4.4.3 In larger units (i.e. units with more than 10 beds), there may be a need for more than one clinical coordinator per shift. For example, there may be a need for one clinical coordinator per 'pod' (e.g. 8-12 beds).

14 STANDARD FIVE

5. A specified level of education and educational Grade of Evidence Level C support must be provided within the ICU for all • Inadequate supervision or education of inexperienced staff levels of its nursing staff. Nursing knowledge contributes to an increase in adverse events. [Level A] and skills must be maintained at an appropriate • Continued experiential learning is essential for a safe and level to ensure high quality care for a complex competent workforce. [Level A] case mix of critically ill patients. • The ICU educator is a specialist role. [Level B] h 5.1 One full-time equivalent (FTE) ICU is • ICU nurse educators are part of the ICU staff team. [Level C] required per 50 ICU nursing staff head count (not FTE). • Specialist ICU nursing knowledge is unique, complex 5.2 The ICU nurse educator must be an ICU specialist RN with a and continuously changing under continuous quality critical care master's degree and an education qualification. improvement. [Level D] 5.3 To optimise their contribution to ICU nursing practice, ICU • ICU nurse educators are integral to the clinical area as nurse educators will be based in the ICU as part of its their knowledge of evidence based practice assists with the workforce, as opposed to a generic nurse education unit. provision of optimal patient care. [Level D] The nurse educator should work in collaboration with the ICU nurse manager. 5.4 All new nursing staff will undergo an ICU­ specific orientation and induction program. 5.5 Different levels of education support will be provided depending on the size of the ICU, the complexity of patient care, the staff skill mix and the proportion of intensive care qualified staff. 5.5.1 ICU nurse education specialistsi will provide ICU orientation, induction and mandatory ICU competency programs. 5.5.2 ICU nurse education specialists will provide transition programs for novice RNs (e.g. in the first year following graduation) and educational support to RNs who are new to the ICU environment. 5.5.3 ICU nurse education specialists will provide support to RNs who are postgraduate intensive care or critical care nursing students. This will be in partnership with the relevant university. This role may also be termed a clinical facilitator. 5.5.4 ICU nurse education specialists will provide continuing educational opportunities in collaboration with senior experienced intensive care nurses.

h Not to be interchanged with the term clinical facilitator; these are different roles. Refer to definitions on pages 30-31. i A nurse education specialist is a clinical nurse specialist that has been allocated a specific education role by the ICU nurse educator or similar. 15 STANDARD SIX

6. A pre-determined (formula-based) number of Grade of Evidence Level C ACCESS nurses must be rostered to maximise • A predetermined formula of ACCESS nurses is associated ICU bed utility and optimise safety. with patient safety. [Level C] j 6.1 A predetermined number of ACCESS nurses should be • The average number of beds in ICUs is increasing, with rostered to provide 'on-the-floor' support to nurses so that pods of beds becoming more common, requiring additional ICU bed utility is maximised and safety is optimised. non-clinical nursing staff for operational management and 6.2 ACCESS nurses are in addition to nurses providing direct supervision. [Level C] patient care as defined in 2.3, and other staff identified in • The ACCESS nurse facilitates the optimal use of ICU beds. Standards 3-5. [Level D] 6.3 The minimum requirement for ACCESS nurses is as follows: • The ACCESS nurse is an essential component of Medication Safety processes in the ICU. [Level D] 6.3.1 In ICUs with less than 50% qualified ICU nurses and/ or where 80% or more of the ICU beds are in single rooms, one ACCESS nurse is required per four patients per shift. 6.3.2 In ICUs with 50-75% qualified ICU nurses and less than 80% of the ICU beds are in single rooms, one ACCESS nurse is required per six patients per shift. 6.3.3 In ICUs with greater than 75% of qualified ICU nurses and less than 80% of the ICU beds are in single rooms, one ACCESS nurse is required per eight patients per shift. 6.4 Patients with very complex needs will require one ACCESS nurse to a smaller ratio of ICU beds compared to that which is stipulated in 6.3. HDU patients in an ICU bed will still require the minimum ACCESS nurse ratio as stipulated. 6.5 ACCESS nurse ratios will need re-evaluation in times that are contingent to unexpected late admissions, patient deterioration, or adjustments in ICU staffing.

j ACCESS = Assistance, Coordination, Contingency (for a late admission on the shift, or staff sick mid-shift), Education (of junior staff, relatives, and others), Supervision, and Support. ACCESS nurses hold a specialist critical care qualification. 16 STANDARD SEVEN

7. Life support equipment for specialised Grade of Evidence Level C diagnostic or therapeutic procedures is • Patient-centred care involves synergistic support from managed by a suitably skilled and qualified RN. technical equipment. Intensive care nurses possess the 7.1 The ICU equipment nurse should be a critical care qualified knowledge and skills to maintain this combined support. RN that is an ICU equipment and technology specialist. [Level C] 7.2 Larger units (i.e. greater than 10 beds) should have a • Critical care nurses make up the largest number of staff in dedicated equipment nurse to manage the complex array the technical support/equipment role in ICUs. [Level C] of equipment used in the intensive care environment (e.g. • Critical care nurses, in an equipment nurse role, should work ventilators, renal replacement therapy equipment) and collaboratively with biomedical engineering and technician oversee an appropriate quality control program in regards to support staff. [Level D] the equipment. • Intensive care nurses routinely possess the knowledge 7.3 Smaller units may have the equipment nurse role as part of a and skills to assemble technical equipment, conduct quality senior portfolio. checks on equipment, implement the use of life support equipment on patients and troubleshoot problems with 7.4 The ICU equipment nurse works collaboratively with equipment during application. [Level D] biomedical engineering expertise. 7.5 Equipment non-nurse technicians do not possess the expertise to provide patient centred care related to technical support and equipment (e.g. urgent bronchoscopy or problem solving patient mechanical ventilator interactions that are technically based).

17 STANDARD EIGHT

8. A liaison nurse service must be provided to Grade of Evidence Level B optimise the use of the ICU within the hospital. • The ICU liaison nurse role has a beneficial effect on ICU 8.1 A liaison nurse service will be managed by a suitably skilled mortality, hospital mortality, unplanned ICU admission, and qualified RN to coordinate and facilitate the intensive discharge delay and adverse events. [Level B] care liason team. ICU liason nurses must possess a critical • There is a significant burden on critical care services when care qualification, an expert knowledge base, and skills to no formal ICU liaison nurse role exists. [Level C] make complex decisions and must be clinically competent in expanded practice. • The ICU liaison nurse role improves formal and informal support and communication pathways between 8.2 ICU liaison nurses are part of the ICU staff and on the ICU geographically defined critical and ICUs and acute care ward roster, but are additional to the ICU staffing needs articulated staff. [Level D] in Standards 2-7. This position is supernumerary to direct • The best ICU liaison nurse service model to be implemented patient care and management roles. can vary according to the number of ICU liaison nurses, the 8.3 One ICU liaison nurse must be provided per 10 ICU beds. hours the service covers, and the combination of services provided. [Level D]. 8.4 The ICU liaison nurse role includes clinical services delivery and consultancy with and between hospital wards. The role • The ICU liason nurse functions as a member of the multi- is inclusive of quality improvement activities, education, disciplinary team, managing patients with complex care leadership and research in the liaison service. The role may needs across hospital departments, and facilitating the include Rapid Response Team and/or Code Blue response. smooth transition for patients admitted to and discharged from the ICU. [Level D]

18 STANDARD NINE

9. Intensive care nursing practice must be Grade of Evidence Level C supported by a suitably skilled and qualified RN • Critical care research evidence is needed to guide practice researcher. and reduce unsafe clinical practice variation. Variation that 9.1 In larger ICUs (i.e. greater than 10 beds), there will be a is not related to patient need or preference, raises questions nominated lead nurse researcher who is a critical care about quality and appropriateness of care, as well as quality, specialist RN. The minimum qualification for this role is efficiency and equity. [Level C] a research master's degree, but possession of a PhD • Increasing numbers of critical care qualified RNs possess is preferable. Partnerships will be linked with a tertiary doctoral research qualifications, resulting in an increase in institution (e.g. via a joint appointment). The nurse the critical examination of critical care nursing practices. researcher will initiate and coordinate nurse-oriented [Level D] research and is considered part of the ICU nursing • Embedding a research degree-qualified RN within a clinical workforce. This position is supernumerary to direct patient unit enhances the focus on evidence­ based practice and care needs. improves research translation. [Level D] 9.2 The RN researcher is a dedicated role to . It • The presence of a PhD-qualified nurse to conduct and is not a support role to medical or pharmaceutical research support nurse-initiated research increases nurse satisfaction, and clinical trials. research on nursing care/ practices and dissemination of 9.3 Smaller units should consider a fractional appointment to research findings. [Level D] support nursing research in the unit. • There is a cost benefit of having research-qualified nurses as 9.4 Smaller units should link with larger units to facilitate nursing part of the ICU team. [Level D] research.

19 STANDARD TEN

10. Non-nursing staff, such as administrative, Grade of Evidence Level C clerical, cleaning and equipment support staff • Interruption of nursing practices, such as answering the that are based in the ICU, must be provided to telephone etc., increases the likelihood of adverse events support service delivery and ensure that the (e.g. medication errors). [Level C] nursing staff is able to focus on the delivery of • Intensive care nurses performing support services have a patient-centred care for critically ill patients. reduced capacity to provide direct patient care. [Level D] 10.1 A dedicated ward clerk (or equivalent), whose role • The ideal number and composition of support staff are includes managing telephone enquiries, clerical duties and calculated according to unit needs. [Level D] responding to visitors' requests to enter the ICU, will be • The provision of support staff impact on nurse retention and rostered seven days per week between 08.00 to 20.00 hours patient outcomes. [Level D] or equivalent. Extra ward clerk support must be provided In ICUs where there are separate pods. 10.2 Dedicated non-nursing staff must be on hand to ensure that ICU cleanliness is maintained, bed areas are available for use for new patients, consumables are re-stocked, and samples etc. are collected and delivered as required in a timely manner. 10.3 The value and cost of using RNs for administrative or cleaning purposes is not justifiable unless the work requires specialised and professional knowledge or skills.

20 REFERENCES

1. Kohn LT, Corrigan JM, Donaldson MS (2002). To err is 11. Australian Commission on Safety and Quality in Health Care human: building a safer health system. National Academy of (2015). Australian Charter of Healthcare Rights. Sydney, Science, Institute of Medicine. ACSQHC. Available at: http://www.safetyandquality. gov.au/national-priorities/charter-of-healthcare-rights/ 2. Penoyer DA (2010). Nurse staffing and patient outcomes in [Accessed June 2015]. critical care: a concise review. Critical Care Medicine 38(7): 1521–1528. 12. Karlsson V, Bergbom I, Forsberg A (2012). The lived experiences of adult intensive care patients who 3. Frith KH, Anderson EF, Caspers B, et al. (2010). Effects of were conscious during mechanical ventilation: a nurse staffing on hospital-acquired conditions and length of phenomenological-hermeneutic study. Intensive and Critical stay in community hospitals. Quality Management in Health Care Nursing 28(1): 6–15. Care 19(2): 147–155. 13. Australian College of Critical Care Nurses (2003). ACCCN 4. Bray K, Wren I, Baldwin A, et al. (2010). Standards for ICU staffing position statement (2003) on intensive care nurse staffing in critical care units determined by: The nursing staffing. Melbourne, ACCCN. Available at: https:// British Association of Critical Care Nurses, The Critical Care www.acccn.com.au/about-us/position-statements Networks National Nurse Leads, Royal College of Nursing [Accessed June 2015]. Critical Care and In-flight Forum. Nursing in Critical Care 15(3): 109–111. 14. Buchan J, O’May F, Dussault G (2013). Nursing workforce policy and the economic crisis: a global overview. Journal of 5. Cho SH, Yun SC (2009). Bed-to-nurse ratios, provision of Nursing Scholarship 45(3): 298–307. basic nursing care, and in-hospital and 30-day mortality among acute stroke patients admitted to an intensive care 15. Wray J (2013). The impact of the financial crisis on nurses unit: cross-sectional analysis of survey and administrative and nursing. Journal of Advanced Nursing 69(3): 497–499. data. International Journal of Nursing Studies 46(8): 1092- 16. Braithwaite J, Matsuyama Y, Mannion R, et al. (Eds) 1101. (2015). Healthcare reform, quality and safety: perspectives, 6. Mason J (2013). Review of Australian Government Health participants, partnerships and prospects in 30 countries. Workforce programs. Canberra, ACT, Department of Farnham, UK, Ashgate Publishing. Health. Available at: http://www.health.gov.au/internet/ 17. National Health and Medical Research Council (2014). publications/publishing.nsf/Content/work-review- Levels of evidence and grades for recommendations for australian-government-health-workforce-programs-toc developers of guidelines. Available at: [Accessed June 2015]. http://www.nhmrc. gov.au/guidelines-publications/information-guideline- 7. College of Intensive Care Medicine of Australia and New developers/resources-guideline-developers [Accessed Zealand (2011). Minimum standards for intensive care May 2015]. units. Available at: http://www.cicm.org.au/CICM_Media/ 18. Methods for the development of NICE public health guidance CICMSite/CICM-Website/Resources/Professional%20 (3rd ed.), Appendix H, p. 221. Qualitative appraisal checklist. Documents/IC-1-Minimum-Standards-for-Intensive-Care- Available at: http://www.nice.org.uk/article/pmg4/chapter/ Units.pdf [Accessed May 2015]. appendix-h-quality-appraisal-checklist-qualitative- 8. Bellomo R, Stow PJ, Hart GK (2007). Why is there such a studies [Accessed January 2015]. difference in outcome between Australian intensive care 19. Aiken LH, Sloane DM, Bruyneel L, et al. (2014).Nurse units and others? Current Opinion in Anaesthesiology 20(2): staffing and education and hospital mortality in nine 100–105. European countries: a retrospective observational study. The 9. The Australian and New Zealand Intensive Care Society Lancet 383(9931): 1824–1830. (2015). Available at: http://www.anzics.com.au [Accessed 20. Kalfon P, Le Manach Y, Ichai C, et al. (2015). Severe May 2015]. and multiple hypoglycemic episodes are associated with 10. Wiles V, Daffurn K (2002). There’s a bird in my hand and increased risk of death in ICU patients. Critical Care 19(1): a bear by the bed – I must be in ICU: The pivotal years 153. of Australian critical care nursing. Carlton, Vic, Australian College of Critical Care Nurses.

21 21. Abbenbroek B, Duffield CM, Elliott D (2014). The intensive 36. Australian and New Zealand Intensive Care Society (2014). care unit volume-mortality relationship, is bigger better? Centre for Outcome and Resource Evaluation annual report An integrative literature review. Australian Critical Care 2012–-2013. Melbourne, Vic, ANZICS. 27(4):157–64. 37. Aragon Penoyer D (2010). Nurse staffing and patient 22. Abbey M, Chaboyer W, Mitchell M (2012). Understanding outcomes in critical care: a concise review. Critical Care the work of intensive care nurses: a time and motion study. Medicine 38(7): 1521–1528. Australian Critical Care 25(1): 13–22. 38. Arsenault S (2007). Staffing is a concern in telemetry. Critical 23. Australian Commission on Safety and Quality in Health Care Care Nurse 20(5): 14–16. (2011). Patient centred care: improving quality and safety 39. Assadian O, Toma CD, Rowley SD (2007). Implications through partnerships with patients and consumers. Sydney, of staffing ratios and workload limitations on healthcare- ACSQHC. associated infections and the quality of patient care. Critical 24. Agency for Health Care Research and Quality (2007). Care Medicine 35(1): 296–298. Guide to patient safety indicators. Available at: http://www. 40. Ausserhofer D, Gehri B, De Geest S, et al. (2015). Quality qualityindicators.ahrq.gov [Accessed May 2015]. improvement and practice development through study 25. American Association of Critical-Care Nurses (2005). findings in Swiss acute care hospitals: follow up survey of Standards for establishing and sustaining healthy work chief nursing officers from the RN4CAST hospitals. Pflege environments: a journey to excellence. American Journal of 28(1): 49–56. Critical Care 14(3): 187–197. 41. Australian College of Critical Care Nurses (2001). Senate 26. Ahluwalia S, Clarke R, Brennan M (2005). Transforming community affairs references committee inquiry into nursing. learning: the challenge of interprofessional education. Available at: http://www.google.com.au/url?url=http:// Hospital Medicine 66(4): 236–8. www.aph.gov.au/~/media/wopapub/senate/committee/ clac_ctte/completed_inquiries/2002_04/nursing/ 27. Aiken LH, Clarke SP, Sloane DM, et al. (2001). Nurses' submissions/sub814_doc.ashx&rct=j&frm=1&q=&esrc=s reports on hospital care in five countries. Health Affairs 20(3): &sa=U&ei=k0uCVciZINHe8AWMsIUo&ved=0CBQQFjAA& 43–53. sig2=t50NDX3_O7xPBhQ9rzFpwQ&usg=AFQjCNG5kmp 28. Aiken LH (2001). More nurses, better patient outcomes: why g2_6pmdZWwiClAoBfbCjIIg [Accessed June 2015]. isn't it obvious? Effective Clinical Practice 4(5): 223–225. 42. Bae SH, Brewer CS, Kelly M, et al. (2015). Use of temporary 29. Aitken LM, Burmeister E, Clayton S, et al. (2011). The impact nursing staff and nosocomial infections in intensive care of nursing rounds on the practice environment and nurse units. Journal of Clinical Nursing 24(7–8): 980–990. satisfaction in intensive care: pre-test post-test comparative 43. Balas MC, Burke WJ, Gannon D, et al. (2013). Implementing study. International Journal of Nursing Studies 48(8): the awakening and breathing coordination, delirium 918–925. monitoring/management, and early exercise/mobility bundle 30. Aitken LM, Chaboyer W, Vaux A, et al. (2014). Effect of into everyday care: opportunities, challenges, and lessons a 2-tier rapid response system on patient outcome and learned for implementing the ICU Pain, Agitation, and staff satisfaction. Australian Critical Care. doi: 10.1016/j. Delirium Guidelines. Critical Care Medicine 41(9, s1): S116– aucc.2014.10.044. [Epub ahead of print]. S127. 31. Aitken LM, Marshall AP (2015). Monitoring and optimising 44. Bahl V, Thompson MA, Kau TY, et al. (2008). Do the AHRQ outcomes of survivors of critical illness. Intensive and Critical patient safety indicators flag conditions that are present Care Nursing 31(1): 1–9. at the time of hospital admission? Medical Care 46(5): 516–522. 32. Alonso-Echanove J, Edwards JR, Richards MJ, et al. (2003). Effect of nurse staffing and antimicrobial-impregnated central 45. Ball C, Walker G, Harper P, et al. (2004). Moving on from venous catheters on the risk for bloodstream infections ‘patient dependency’ and ‘nursing workload’ to managing risk in intensive care units. Infection Control and Hospital in critical care. Intensive and Critical Care Nursing 20(2): 62- Epidemiology 24(12): 916–925. 68. 33. Alspach G (2003). Nurse staffing and patient outcomes. This 46. Barnhorst AB, Martinez M, Gershengorn HB (2015). Quality is news? Critical Care Nurse 23(1): 14–15. improvement strategies for critical care nursing. American Journal of Critical Care 24(1): 87–92. 34. Amaravadi RK, Dimick JB, Pronovost PJ, et al. (2000). ICU nurse-to-patient ratio is associated with complications and 47. Becker DJ (2007). Do hospitals provide lower quality care on resource use after esophagectomy. Intensive Care Medicine weekends? Health Services Research 42(4): 1589–1612. 26(12): 1857–1862. 48. Bennett S (2015). Design, organization and staffing of the 35. Anderson P, Weber DK (2012). Neonatal intensive care unit intensive care unit. Surgery (Oxford) 33(4): 148–152. rapid design process. Journal of Obstetric Gynecologic and 41(S1): S188–S.

22 49. Berkow S, Vonderhaar K, Stewart J, et al. (2014). Analyzing 62. Breckenridge-Sproat S, Johantgen M, Patrician P (2012). staffing trade-offs on acute care hospital units. The Journal Influence of unit-level staffing on medication errors and falls of Nursing Administration 44(10): 507–516. in military hospitals. Western Journal of Nursing Research 34(4): 455–474. 50. Bérubé M, Valiquette MP, Laplante E, et al. (2012). Nursing residency program: a solution to introduce new grads into 63. Bridges EJ (2015). Research at the bedside: it makes a critical care more safely while improving accessibility to difference. American Journal of Critical Care 24(3): 195. services. Nursing Leadership 25(1): 50–67. 64. Brown KK, Gallant D (2006). Impacting patient outcomes 51. Blackwood B, Albarran JW, Latour JM (2011). Research through design: acuity adaptable care/universal room design. priorities of adult intensive care nurses in 20 European Critical Care Nursing Quarterly 29(4): 326–341. countries: a Delphi study. Journal of Advanced Nursing 65. Brown S, Bell S, Dente E, et al. (2014). Design of a 67(3): 550–562. communication portal in the intensive care unit: surveys of 52. Blay N, Duffield CM, Gallagher R, et al. (2014). potential stakeholders. Critical Care Medicine 42(12): A1507. Methodological integrative review of the work sampling 66. Buchan J, Twigg D, Dussault G, et al. (2015). Policies to technique used in nursing workload research. Journal of sustain the nursing workforce: an international perspective. Advanced Nursing 70(11): 2434–2449. International Nursing Review 62(2): 162–170. 53. Blegen MA, Goode CJ, Spetz J, et al. (2011). Nurse staffing 67. Bucknall TK, Manias E, Presneill JJ (2008). A randomized effects on patient outcomes safety-net and non-safety-net trial of protocol-directed sedation management for hospitals. Medical Care 49(4): 406–414. mechanical ventilation in an Australian intensive care unit. 54. Blegen MA, Vaughn T, Vojir CP (2008). Nurse staffing levels: Critical Care Medicine 36(5): 1444–1450. impact of organizational characteristics and 68. Carayon P, Gürses AP (2005). A human factors engineering supply. Health Services Research 43(1 Pt 1): 154–173. conceptual framework of nursing workload and patient safety 55. Blot S, Afonso E, Labeau S (2014). Insights and advances in intensive care units. Intensive and Critical Care Nursing in multidisciplinary critical care: a review of recent research. 21(5): 284–301. American Journal of Critical Care 23(1): 70–80. 69. Carberry M (2006). Hospital emergency care teams: our 56. Bohmer RMJ, Imison C (2013). Analysis and commentary: solution to out of hours emergency care. Nursing in Critical lessons from England’s health care workforce redesign: no Care 11(4): 177–187. quick fixes. Health Affairs 32(11): 2025–2031. 70. Catangui EJ, Robertsis CJ. (2014). The lived experiences 57. Rashid M, Boyle DK, Crosser M (2013). Developing of nurses in one hyper-acute stroke unit. British Journal of intensive care unit (ICU) nurse and physician questionnaires Nursing 23(3): 143–8. to assess the design of ICUs as work environments. In: A 71. Cheung A, van Velden FHP, Lagerburg V, et al. (2015). The Joseph, U Nanda (Eds), Development of tools for healthcare organizational and clinical impact of integrating bedside environments research and practice (pp. 53–55). Available equipment to an information system: a systematic literature at: http://www.edra.org/sites/default/files/publications/ review of patient data management systems (PDMS). EDRA_HealthcareTools_2013.pdf [Accessed June 2015]. International Journal of Medical Informatics 84(3): 155–165. 58. Boyle DK, Kochinda C (2004). Enhancing collaborative 72. Chittawatanarat K, Sataworn D, Thongchai C, et al. (2014). communication of nurse and physician leadership in two Effects of ICU characters, human resources and workload intensive care units. Journal of Nursing Administration 34(2): to outcome indicators in Thai ICUs: the results of ICU- 60–70. RESOURCE i study. Journal of the Medical Association of 59. Brack S, Sandford M (2011). Partnerships in intensive care Thailand 97(1, S1): S22–S30. unit (ICU): a new model of nursing care delivery. Australian 73. Cho SH, Jeong HH, Kim J (2008). Nurse staffing and patient Critical Care 24(2): 101–109. mortality in intensive care units. Nursing Research 57(5): 60. Braun BI, Kritchevsky SB, Wong ES, et al. (2003). 322–330. Preventing -associated primary 74. Cho SH, June KJ, Kim YM, et al. (2009). Nurse staffing, bloodstream infections: characteristics of practices among quality of nursing care and nurse job outcomes in intensive hospitals participating in the evaluation of processes and care units. Journal of Clinical Nursing 18(12): 1729–1737. indicators in infection control (EPIC) study. Infection Control and Hospital Epidemiology 24(12): 926–935. 75. Cimiotti JP, Haas J, Saiman L, et al. (2006). Impact of staffing on bloodstream infections in the neonatal intensive 61. Bray K, Wren I, Baldwin A, et al. (2010). Standards for care unit. Archives of Pediatrics and Adolescent Medicine nurse staffing in critical care units determined by: The 160(8): 832–836. British Association of Critical Care Nurses, The Critical Care Networks National Nurse Leads, Royal College of Nursing 76. Cimiotti JP (2007). Staffing level: a determinant of late-onset Critical Care and In-flight Forum. Nursing in Critical Care ventilator-associated pneumonia. Critical Care (London) 15(3): 109–111. 11(4): 154.

23 77. Clark K, Normile LR (2002). Delays in implementing 90. Dodek PM, Keenan SP, Norena M, et al. (2010). Review of admission orders for critical care patients associated with a large clinical series: structure, process, and outcome of all length of stay in emergency departments in six mid-Atlantic intensive care units within the province of British Columbia, States. Journal of 28(6): 489–495. Canada. Journal of Intensive Care Medicine 25(3): 149–155. 78. Cochrane J (2011). Learning and maintaining professional 91. Driscoll A, Currey J, George M, et al. (2013). Changes in expertise within a multi-professional critical care team. In: health service delivery for cardiac patients: implications for J Adams, M Cochrane, L Dunne (Eds). Applying theory to workforce planning and patient outcomes. Australian Critical educational research: an introductory approach with case Care 26(2): 55–57. studies (pp. 15–29). Oxford, Wiley-Blackwell 92. DuBose JJ, Nomoto S, Higa L, et al. (2009). Nursing 79. Constantin JM, Leone M, Jaber S, et al. (2010). Activity involvement improves compliance with tight blood glucose and the available human resources working in 66 French control in the trauma ICU: a prospective observational study. Southern intensive care units. Annales Francaises Intensive and Critical Care Nursing 25(2): 101–107. d’Anesthesie et de Reanimation 29(7–8): 512–517. 93. Dwyer T, Jamieson L, Moxham L, et al. (2007). Evaluation of 80. Coombs M, Lattimer V (2007). Safety, effectiveness and the 12-hour shift trial in a regional intensive care unit. Journal costs of different models of organising care for critically ill of Nursing Management 15(7): 711–720. patients: literature review. International Journal of Nursing 94. Edkins RE, Cairns BA, Hultman CS (2014). A systematic Studies 44(1): 115–129. review of advance practice providers in acute care: options 81. Cooper S, Porter J, Peach L (2013). Measuring situation for a new model in a burn intensive care unit. Annals of awareness in emergency settings: a systematic review of Plastic Surgery 72(3): 285–288. tools and outcomes. Open Access Emergency Medicine 6: 95. Eliott S, Chaboyer W, Ernest D, et al. (2012). A national 1–7. survey of Australian Intensive Care Unit (ICU) Liaison Nurse 82. Cowin LS, Eagar SC (2013). Collegial relationship (LN) services. Australian Critical Care 25(4): 253–262. breakdown: a qualitative exploration of nurses in acute care 96. Elliott M, Page K, Worrall-Carter L (2014). Factors settings. Collegian 20(2): 115–121. associated with post-intensive care unit adverse events: 83. Danckers M, Grosu H, Jean R, et al. (2013). Nurse-driven, a clinical validation study. Nursing in Critical Care 19(5): protocol-directed weaning from mechanical ventilation 228–235. improves clinical outcomes and is well accepted by intensive 97. Elliott M, Worrall-Carter L, Page K (2014). Intensive care care unit physicians. Journal of Critical Care 28(4): 433–441. readmission: a contemporary review of the literature. 84. Dang D, Johantgen ME, Pronovost PJ, et al. (2002). Intensive and Critical Care Nursing 30(3): 121–137. Postoperative complications: does intensive care unit staff 98. Emaminia A, Corcoran PC, Siegenthaler MP, et al. (2012). nursing make a difference? Heart and Lung: Journal of Acute The universal bed model for patient care improves outcome and Critical Care 31(3): 219–228. and lowers cost in cardiac surgery. Journal of Thoracic and 85. Darcy AE, Hancock LE, Ware EJ (2008). A descriptive Cardiovascular Surgery 143(2): 475–481. study of noise in the neonatal intensive care unit: ambient 99. Eschiti V, Hamilton P (2011). Off-peak nurse staffing: critical- levels and perceptions of contributing factors. Advances in care nurses speak. Dimensions of Critical Care Nursing Neonatal Care 8(3): 165–175. 30(1): 62–69. 86. Department of Health, Victoria (2010). Exploring the 100. Fagerstrom L (2009). Evidence-based human resource workforce experience of intensive care nurses. Available management: a study of nurse leaders’ resource allocation. at: http://www.health.vic.gov.au/__data/assets/pdf_ Journal of Nursing Management 17(4): 415–425. file/0006/587157/Exploring-the-Workforce-Experience-of- Intensive-Care-Nurses-Final-Report.pdf [Accessed May 101. Ferrer J, Boelle PY, Salomon J, et al. (2014). Management of 2015]. nurse shortage and its impact on pathogen dissemination in the intensive care unit. Epidemics 9: 62–9. 87. Deutschman CS, Ahrens T, Cairns CB, et al. (2012). Multisociety task force for critical care research: key issues 102. Ferri M, Zygun DA, Harrison A, et al. (2015). Evidence-based and recommendations. Chest 141(1): 201–209. design in an intensive care unit: end-user perceptions. BMC Anesthesiology 15(1): 57. 88. Dimick JB, Swoboda SM, Pronovost PJ, et al. (2001). Effect of nurse-to-patient ratio in the intensive care unit 103. Frey B, Argent A (2004). Safe paediatric intensive care. Part on pulmonary complications and resource use after 2: workplace organisation, critical incident monitoring and hepatectomy. American Journal of Critical Care 10(6): guidelines. Intensive Care Medicine 30(7): 1292–1297. 376–382. 104. Fries M, Schüpfer G (2003). Is there an influence of nurse 89. Dimick JB (2005). Organizational characteristics and the staffing on patient safety? A critical review. Swiss Surgery quality of surgical care. Current Opinion in Critical Care 9(s2): 18–20. 11(4): 345–348.

24 105. Frith KH, Anderson EF, Caspers B, et al. (2010). Effects of 120. Guilhermino MC, Inder KJ, Sundin D, et al. (2014). Nurses’ nurse staffing on hospital-acquired conditions and length of perceptions of education on invasive mechanical ventilation. stay in community hospitals. Quality Management in Health Journal of Continuing Education in Nursing 45(5): 225–232. Care 19(2): 147–155. 121. Health Workforce Australia (2013). Australia’s health 106. Fry M (2011). Literature review of the impact of nurse workforce series: nurses in focus. Adelaide, SA, Health practitioners in critical care services. Nursing in Critical Care Workforce Australia. 16(2): 58–66. 122. Health Workforce Australia (2014). Australia’s future health 107. Furillo J (2001). Ensuring safe nurse-to-patient ratios. workforce: nurses detailed. Adelaide, SA, Health Workforce Western Journal of Medicine 174(4): 233–234. Australia. 108. Gaies MG, Clarke NS, Donohue JE, et al. (2012). Personnel 123. Halm M, Peterson M, Kandels M, et al. (2005). Hospital and unit factors impacting outcome after cardiac arrest in nurse staffing and patient mortality, emotional exhaustion, a dedicated pediatric cardiac intensive care unit. Pediatric and job dissatisfaction. Clinical Nurse Specialist 19(5): Critical Care Medicine 13(5): 583–588. 241–251. 109. Gallesio AO (2009). Optimization of limited resources and 124. Hamilton KES, Redshaw ME, Tarnow-Mordi W (2007). Nurse patient safety. In: A Gullo et al. (Eds), Intensive and critical staffing in relation to risk-adjusted mortality in neonatal care. care medicine world federation of societies of intensive and Archives of Disease in Childhood 92(2): F99–F103. critical care (Chapter 7). Italy, Springer-Verlag. 125. Hamilton P, Eschiti VS, Hernandez K, et al. (2007). 110. Garland A, Gershengorn HB (2013). Staffing in ICUs: Differences between weekend and weekday nurse work physicians and alternative staffing models. Chest 143(1): environments and patient outcomes: a focus group approach 214–221. to model testing. Journal of Perinatal and Neonatal Nursing 21(4): 331–341. 111. Gautam N, Reay H, Bion J (2008). Education and training in critical care. In: Critical care medicine: principles of diagnosis 126. Haniffa R, De Silva AP, Iddagoda S, et al. (2014). A cross- and management in the adult (pp. 1567–1574). sectional survey of critical care services in Sri Lanka: a lower middle-income country. Journal of Critical Care 29(5): 112. Giakoumidakis K, Baltopoulos GI, Brokalaki-Pananoudaki H 764–768. (2010). The association between the nursing workload and patient mortality. Nosileftiki 9(3): 225–235. 127. Happ MB (2015). A research lens on care and communication in critical and complex illness (G02 special 113. Gill FJ, Leslie GD, Grech C, et al. (2015). Development of session). International, 26th International Australian clinical practice outcome standards for graduates Nursing Research Congress. San Juan, Puerto Rico, 23–27 of critical care nurse education. Journal of Clinical Nursing July 2015. 24(3-4): 486–499. 128. Harding T, Wright M (2014). Unequal staffing: a snapshot 114. Gill FJ, Leslie GD, Grech C, et al. (2012). A review of critical of nurse staffing in critical care units in New South Wales, care nursing staffing, education and practice standards. Australia. Contemporary Nurse 47(1–2): 7. Australian Critical Care 25(4): 224–237. 129. Harless DW, Mark BA (2010). Nurse staffing and quality of 115. Gill FJ, Leslie GD, Grech C, et al. (2015). An analysis of care with direct measurement of inpatient staffing. Medical Australian graduate critical care nurse education. Collegian Care 48(7): 659–663. 22(1): 71–81. 130. Hart P, Davis N (2011). Effects of nursing care and staff skill 116. Gój K, Knapik P, Kucewicz-Czech E, et al. (2009). The mix on patient outcomes within acute care nursing units. Therapeutic Intervention Scoring System (TISS-28) for Journal of Nursing Care Quality 26(2): 161–168. assessment of cardiac surgical postoperative intensive care. Anestezjologia Intensywna Terapia 41(1): 34–37. 131. Haugh R (2003). Pressures converge in the ICU. Hospitals and Health Networks 77(12): 56–60. 117. Goryakin Y, Griffiths P, Maben J (2011). Economic evaluation of nurse staffing and nurse substitution in health care: a 132. He J, Almenoff PL, Keighley J, et al. (2013). Impact of scoping review. International Journal of Nursing Studies patient-level risk adjustment on the findings about nurse 48(4): 501–512. staffing and 30-day mortality in veterans affairs acute care hospitals. Nursing Research 62(4): 226–232. 118. Gray JE, Davis DA, Pursley DM, et al. (2010). Network analysis of team structure in the neonatal intensive care unit. 133. Herdman TH, Burgess LPA, Ebright PR, et al. (2009). Impact Pediatrics 125(6): e1460–e1467. of continuous vigilance monitoring on nursing workflow. Journal of Nursing Administration 39(3): 123–129. 119. Grundmann RT (2009). Intensive care medicine from a surgical point of view. efficiency, economic aspects, 134. Hick JL, Christian MD, Sprung CL (2010). Chapter 2. Surge guidelines, borderline situations. Chirurgische Praxis 70(3): capacity and infrastructure considerations for mass critical 403–412. care. Intensive Care Medicine 36(s1): S11–S20.

25 135. Hickey P, Gauvreau K, Connor J, et al. (2010). The 149. Kantamineni P, Emani V, Saini A, et al. (2014). relationship of nurse staffing, skill mix, and magnet® Cardiopulmonary resuscitation in the hospitalized patient: recognition to institutional volume and mortality for impact of system-based variables on outcomes in cardiac congenital heart surgery. Journal of Nursing Administration arrest. American Journal of the Medical Sciences 348(5): 40(5): 226–232. 377–381. 136. Hickey P, Gauvreau K, Curley MA, et al. (2014). The effect 150. Kelly DM, Kutney-Lee A, McHugh MD, et al. (2014). Impact of critical care nursing and organizational characteristics on of critical care nursing on 30-day mortality of mechanically pediatric cardiac surgery mortality in the United States. The ventilated older adults. Critical Care Medicine 42(5): 1089– Journal of Nursing Administration 44(10): S19–S26. 1095. 137. Higgins TL (2002). Current issues affecting critical care 151. Kim JH, Hong SK, Kim KC, et al. (2012). Influence of practice. Seminars in Cardiothoracic and Vascular full-time intensivist and the nurse-to-patient ratio on the 6(3): 279–284. implementation of severe sepsis bundles in Korean intensive care units. Journal of Critical Care 27(4): 414.e11–e21. 138. Hughes RG, Bobay KL, Jolly NA, et al. (2015). Comparison of nurse staffing based on changes in unit-level workload 152. King A, Long L, Lisy K (2014). Effectiveness of team nursing associated with patient churn. Journal of Nursing compared with total patient care on staff wellbeing when Management 23(3): 390–400. organizing nursing work in acute care ward settings: a systematic review protocol. JBI Database of Systematic 139. Hugonnet S, Chevrolet JC, Pittet D (2007). The effect of Reviews and Implementation Reports 12(1): 59–73. workload on infection risk in critically ill patients. Critical Care Medicine 35(1): 76–81. 153. Kleinpell RM (2014). ICU workforce: revisiting nurse staffing. Critical Care Medicine 42(5): 1291–1292. 140. Hugonnet S, Uçkay I, Pittet D (2007). Staffing level: a determinant of late-onset ventilator-associated pneumonia. 154. Kleinpell R, Aitken L, Schorr CA (2013). Implications of Critical Care 11(4): R80. the new international sepsis guidelines for nursing care. American Journal of Critical Care 22(3): 212–222. 141. Husain T, Gatward JJ, Hambidge ORH, et al. (2012). Strategies to prevent airway complications: a survey of adult 155. Kluge GH, Brinkman S, van Berkel G, et al. (2015). The intensive care units in Australia and New Zealand. British association between ICU level of care and mortality in the Journal of Anaesthesia 108(5): 800–806. Netherlands. Intensive Care Medicine 41(2): 304–311. 142. Jacobs P, Rapoport J, Edbrooke D (2004). Economies of 156. Kontou P, Topalidou G, Karagiannaki K, et al. (2009). scale in British intensive care units and combined intensive Evaluation of critical care nurses’ work environment and job care/high dependency units. Intensive Care Medicine 30(4): satisfaction in Greece. Intensive Care Medicine 35: S183. 660–664. 157. Lazar I, Abukaf H, Sofer S, et al. (2015). Impact of 143. Jacques T, Harrison GA, McLaws ML (2008). Attitudes conversion from an open ward design paediatric intensive towards and evaluation of medical emergency teams: a care unit environment to all isolated rooms environment on survey of trainees in intensive care medicine. Anaesthesia incidence of bloodstream infections and antibiotic resistance and Intensive Care 36(1): 90–95. in Southern Israel (2000 to 2008). Anaesthesia and Intensive Care 43(1): 34–41. 144. Jenkins SD, Lindsey PL (2010). Clinical nurse specialists as leaders in rapid response. Clinical Nurse Specialist 24(1): 158. Levenson D (2001). Having more ICU nurses saves money, 24-30. study finds. Report on Medical Guidelines and Outcomes Research 12(23): 5–7. 145. Jepsen S (2015). Using a scorecard to demonstrate clinical nurse specialists' contributions. AACN Advanced Critical 159. Lewis PS, Latney C (2002). Achieve best practice with Care 26(1): 43–49. an evidence-based approach. Create a collaborative environment that improves patient care through consistent 146. Johnston MJ, Arora S, King D, et al. (2015). A systematic outcomes measurement. Nursing Management 33(12): review to identify the factors that affect failure to rescue and 24–30. escalation of care in surgery. Surgery 157(4): 752–763. 160. Lewis R (2012). Interprofessional learning in acute care: 147. Kalisch BJ, Friese CR, Choi SH, et al. (2011). Hospital nurse developing a theoretical framework. Nurse Education Today staffing: choice of measure matters. Medical Care 49(8): 32(3): 241–245. 775–779. 161. Li YF, Wong ES, Sales AE, et al. (2011). Nurse staffing and 148. Kane RL, Shamliyan TA, Mueller C, et al. (2007). The patient care costs in acute inpatient nursing units. Medical association of registered nurse staffing levels and patient Care 49(8): 708–715. outcomes: Systematic review and meta-analysis. Medical Care 45(12): 1195–1204.

26 162. Lundgrén-Laine H, Kontio E, Perttilä J, et al. (2011). 177. Moerer O, Plock E, Mgbor U, et al. (2007). A German Managing daily intensive care activities: an observational national prevalence study on the cost of intensive care: an study concerning ad hoc decision making of charge nurses evaluation from 51 intensive care units. Critical Care 11(3): and intensivists. Critical care (London) 15(4). R69. 163. Marinelli AM (2005). Can regulation improve safety in critical 178. Mumma BE, McCue JY, Li CS, et al. (2014). Effects of care? Critical Care Clinics 21(1): 149–162. emergency department expansion on emergency department patient flow. Academic Emergency Medicine 21(5): 504–509. 164. Mark BA, Harless DW, McCue M, et al. (2004). A longitudinal examination of hospital registered nurse staffing and quality 179. Munoz DA, Bastian ND, Ventura M (Eds) (2014). A workflow of care. Health Services Research 39(2): 279–300. assessment for a pediatric intensive care unit: a mixed- methods approach. IIE Annual Conference and Expo 2014. 165. Martin JM, Hart GK, Hicks P (2010). A unique snapshot of intensive care resources in Australia and New Zealand. 180. Nashed SW (2012). Innovation in the intensive care unit Anaesthesia and Intensive Care 38(1): 149–158. design and policy. (Doctoral dissertation, Ain Shams University). 166. Mathur M, Rampersad A, Howard K, et al. (2005). Physician assistants as physician extenders in the pediatric intensive 181. Needleman J, Buerhaus P, Pankratz VS, et al. (2011). Nurse care unit setting: a 5-year experience. Pediatric Critical Care staffing and inpatient hospital mortality. New England Journal Medicine 6(1): 14–19. of Medicine 364(11): 1037–1045. 167. Matlakala MC, Bezuidenhout MC, Botha ADH (2014). 182. Needleman J (2015). Nurse staffing: the knowns and Strategies to address management challenges in larger unknowns. Nursing Economics 33(1): 6. intensive care units. Journal of Nursing Management doi: 183. Niven DJ, Bastos JF, Stelfox HT (2014). Critical care 10.1111/jonm.12240 [Epub ahead of print]. transition programs and the risk of readmission or death 168. McAdam J, Puntillo K (2015). The intensive care unit. In: after discharge from an ICU: a systematic review and meta- BR Ferrel (Ed), Structure and processes of care (chapter 4). analysis. Critical Care Medicine 42(1): 179–187. Oxford, Oxford University Press. 184. Norridge M, While AE (2015). The impact PICU nursing 169. McDonald K, Rubarth LB, Miers LJ (2012). Job satisfaction expertise has on a child’s unplanned extubation. Nursing in of neonatal intensive care nurses. Advances in Neonatal Critical Care doi: 10.1111/nicc.12160. [Epub ahead of print]. Care 12(4): E1–E8. 185. Editorial (2013). Nurse staffing ratios. AORN Journal 97(5): 170. McGahan M, Kucharski G, Coyer F (2012). Nurse staffing 604. levels and the incidence of mortality and morbidity in the 186. Odetola FO, Clark SJ, Freed GL, et al. (2005). A national adult intensive care unit: a literature review. Australian survey of pediatric critical care resources in the United Critical Care 25(2): 64–77. States. Pediatrics 115(4): e382–e386. 171. McIntyre T, Taylor C, Eastwood GM, et al. (2012). A survey of 187. O’Hara S (2014). Planning intensive care unit design using ward nurses attitudes to the intensive care nurse consultant computer simulation modeling: optimizing integration of service in a teaching hospital. Australian Critical Care 25(2): clinical, operational, and architectural requirements. Critical 100–109. Care Nursing Quarterly 37(1): 67–82. 172. McNeil A, Koppel C (2015). Managing quality and 188. O’Keeffe VJ, Tuckey MR, Naweed A (2015). Whose safety? compliance. Critical Care Nursing Quarterly 38(1): 89–96. Flexible risk assessment boundaries balance nurse safety 173. Mefford LC, Alligood MR (2011). Evaluating nurse staffing with patient care. Safety Science 76: 111–20. patterns and neonatal intensive care unit outcomes using 189. Omer S, Preventza O, Cornwell LD (2014). Out of sight, out Levine's conservation model of nursing. Journal of Nursing of mind. Commentary on ‘intensive care unit design and Management 19(8): 998–1011. mortality in trauma patients’. Journal of Surgical Research 174. Meltzer LS, Huckabay LM (2004). Critical care nurses’ 190(2): 413–414. perceptions of futile care and its effect on burnout. American 190. Park SH, Blegen MA, Spetz J, et al. (2012). Patient turnover Journal of Critical Care 13(3): 202–208. and the relationship between nurse staffing and patient 175. Miller CL, LaFramboise L (2009). Student learning outcomes. Research in Nursing and Health 35(3): 277–288. outcomes after integration of quality and safety education 191. Park SH, Blegen MA, Spetz J, et al. (2015). Comparison of competencies into a senior-level critical care course. Journal nurse staffing measurements in staffing-outcomes research. of Nursing Education 48(12): 678–685. Medical Care 53(1): e1–e8. 176. Minnick AF, Mion LC, Johnson ME, et al. (2007). How unit level nursing responsibilities are structured in US hospitals. Journal of Nursing Administration 37(10): 452–458.

27 192. Pastores SM, O'Connor MF, Kleinpell RM, et al. (2011). 207. Rogowski JA, Staiger D, Patrick T, et al. (2013). Nurse The Accreditation Council for Graduate Medical Education staffing and NICU infection rates. JAMA Pediatrics 167(5): resident duty hour new standards: history, changes, and 444–450. impact on staffing of intensive care units. Critical Care 208. Rolls K, Kowal D, Elliott D, et al. (2008). Building a Medicine 39(11): 2540–2549. statewide knowledge network for clinicians in intensive 193. Pattison N (2012). Critical care outreach: capturing nurses’ care units: knowledge brokering and the NSW Intensive contributions. Nursing in Critical Care 17(5): 227–230. Care Coordination and Monitoring Unit (ICCMU). Australian Critical Care 21(1): 29–37. 194. Pattison N, O’Gara G, Wigmore T (2015). Negotiating transitions: involvement of critical care outreach teams in 209. Rose L, Blackwood B, Burns SM, et al. (2011). International end-of-life decision making. American Journal of Critical perspectives on the influence of structure and process of Care 24(3): 232-240. weaning from mechanical ventilation. American Journal of Critical Care 20(1): e10–e18. 195. Pettit NR, Wood T, Lieber M, et al. (2014). Intensive care unit design and mortality in trauma patients. Journal of Surgical 210. Rose L, Blackwood B, Egerod I, et al. (2011). Decisional Research 190(2): 640–646. responsibility for mechanical ventilation and weaning: an international survey. Critical Care 15(6): R295. 196. Profit J, Petersen LA, McCormick MC, et al. (2010). Patient- to-nurse ratios and outcomes of moderately preterm infants. 211. Rose L, Nelson S, Johnston L, et al. (2008). Workforce Pediatrics 125(2): 320–326. profile, organisation structure and role responsibility for ventilation and weaning practices in Australia and New 197. Rainess M, Archer W, Hofmann L, et al. (2015). Empowering Zealand intensive care units. Journal of Clinical Nursing float nurses. Nursing Management 46(2): 15–19. 17(8): 1035–1043. 198. Ramsay P, Huby G, Thompson A, et al. (2014). Intensive 212. Sakr Y, Moreira CL, Rhodes A, et al. (2015). The impact care survivors’ experiences of ward-based care: Meleis’ of hospital and ICU organizational factors on outcome in theory of nursing transitions and role development among critically ill patients: results from the Extended Prevalence critical care outreach services. Journal of Clinical Nursing of Infection in Intensive Care Study. Critical Care Medicine 23(5–6): 605–615. 43(3): 519–526. 199. Rashid M (2011). Technology and the future of intensive care 213. Sales AE, Lapham GG, Squires J, et al. (2011). unit design. Critical Care Nursing Quarterly 34(4): 332–360. Organizational factors associated with decreased mortality 200. Rashid M (2014). Two decades (1993–2012) of adult among veterans affairs patients with an ICU stay. CIN – intensive care unit design: a comparative study of the Computers Informatics Nursing 29(9): 496–501. physical design features of the best practice examples. 214. Samuels O, Webb A, Culler S, et al. (2011). Impact of a Critical Care Nursing Quarterly 37(1): 3–32. dedicated neurocritical care team in treating patients with 201. Ringdal M, Rose L (2012). Recovery after critical illness: the aneurysmal subarachnoid hemorrhage. Neurocritical Care role of follow-up services to improve psychological well- 14(3): 334–340. being. Canadian Journal of Nursing Research 44(1): 7–17. 215. Santamaria JD, Duke GJ, Pilcher DV, et al. (2015). Timing 202. Ringerman ES, Ventura S (2000). An outcomes approach to of discharge from the intensive care unit and subsequent skill mix change in critical care. Nursing Management 31(10): mortality. a prospective, multicenter study. American Journal 42–46. of Respiratory and Critical Care Medicine 191(9): 1033– 1039. 203. Rischbieth A (2006). Matching nurse skill with patient acuity in the intensive care units: a risk management mandate. 216. Schmalenberg C, Kramer M, King CR, et al. (2005). Journal of Nursing Management 14(5): 397–404. Excellence through evidence: securing collegial/collaborative nurse-physician relationships, part 1. Journal of Nursing 204. Robertson LC, Hawkins M, Ellis K, et al. (2011). Intensive Administration 35(10): 450–458. care use and organ failure interventions reduced following changes to the organisation and delivery of high dependency 217. Schmid A, Hoffman L, Happ MB, et al. (2007). Failure to care. Journal of the Intensive Care Society 12(4): 281–288. rescue: a literature review. Journal of Nursing Administration 37(4): 188–198. 205. Robnett MK (2006). Critical care nursing: workforce issues and potential solutions. Critical Care Medicine 34(3): S25– 218. Schubert M, Clarke SP, Aiken LH, et al. (2012). Associations S31. between rationing of nursing care and inpatient mortality in Swiss hospitals. International Journal for Quality in Health 206. Rochefort CM, Clarke SP (2010). Nurses' work Care 24(3): 230–238. environments, care rationing, job outcomes, and quality of care on neonatal units. Journal of Advanced Nursing 66(10): 2213–2224.

28 219. Scott LD, Arslanian-Engoren C, Engoren MC (2014). 233. van Sluisveld N, Hesselink G, van der Hoeven JG, et al. Association of sleep and fatigue with decision regret among (2015). Improving clinical handover between intensive care critical care nurses. American Journal of Critical Care 23(1): unit and general ward professionals at intensive care unit 13–23. discharge. Intensive Care Medicine 41(4): 589–604. 220. Sharit J, McCane L, Thevenin DM, et al. (2008). Examining 234. Wagenaar WA, Souverijn AM, Hudson PTW (2013). Safety links between sign-out reporting during shift changeovers management in intensive care wards. In: B Wilpert, T Qvale and patient management risks. Risk Analysis 28(4): 969– (Eds), Reliability and safety in hazardous work systems: 981. approaches to analysis and design (chapter 9). Psychology Press. 221. Shehabi Y, Bellomo R, Reade MC, et al. (2012). Early intensive care sedation predicts long-term mortality 235. Ward NS, Afessa B, Kleinpell R, et al. (2013). Intensivist/ in ventilated critically ill patients. American Journal of patient ratios in closed ICUs: a statement from the Society Respiratory and Critical Care Medicine 186(8): 724–731. of Critical Care Medicine Taskforce on ICU Staffing. Critical Care Medicine 41(2): 638–645. 222. Shekelle PG (2013). Nurse-patient ratios as a patient safety strategy: a systematic review. Annals of Internal Medicine 236. Williams GF (2009). Nursing workforce management in 158(5 Part 2): 404–409. intensive care. In: A Gullo et al. (Eds), Intensive and critical care medicine World Federation of Societies of Intensive and 223. Sherenian M, Profit J, Schmidt B, et al. (2013). Nurse-to- Critical Care (pp. 107-118). Milan, Italy, Springer-Verlag. patient ratios and neonatal outcomes: a brief systematic review. Neonatology 104(3): 179–183. 237. Williams GF, Fulbrook PR, Alexandrov AW, et al. (2009). Intensive and critical care nursing perspectives. In: A Gullo 224. Shirey MR (2006). Authentic leaders creating healthy work et al. (Eds), Intensive and critical care medicine World environments for nursing practice. American Journal of Federation of Societies of Intensive and Critical Care Critical Care 15(3): 256–268. (pp.119-132). Milan, Italy, Springer-Verlag. 225. Sink DW, Hope SAE, Hagadorn JI (2011). Nurse: patient 238. Weil MH, Tang W (2011). From intensive care to critical ratio and achievement of oxygen saturation goals in care medicine: a historical perspective. American Journal of premature infants. Archives of Disease in Childhood 96(2): Respiratory and Critical Care Medicine 183(11): 1451–1453. F93–F98. 239. West E, Barron DN, Harrison D, et al. (2014). Nurse 226. Skinner E, Warrillow S, Denehy L (2015). Organisation and staffing, medical staffing and mortality in Intensive Care: an resource management in the intensive care unit: a critical observational study. International Journal of Nursing Studies review. International Journal of Therapy and Rehabilitation 51(5): 781–794. 22(4): 187–196. 240. Williams G, Bost N, Chaboyer W, et al. (2012). Critical care 227. Squiers J, King J, Wagner C, et al. (2013). ACNP intensivist: nursing organizations and activities: a third worldwide review. a new ICU care delivery model and its supporting International Nursing Review 59(1): 73–80. educational programs. Journal of the American Academy of Nurse Practitioners 25(3): 119–125. 241. Williams G, Crilly J, Souter J, et al. (2013). A state wide validation and utilisation study of the Queensland emergency 228. Srivastava N, Tucker JS, Draper ES, et al. (2008).A literature nursing workforce tool. Journal of Nursing Management review of principles, policies and practice in extended 22(8): 1076–1088. nursing roles relating to UK intensive care settings. Journal of Clinical Nursing 17(20): 2671–2680. 242. Wielenga JM, Tume LN, Latour JM, et al. (2015). European neonatal intensive care nursing research priorities: an 229. Stalpers D, de Brouwer BJM, Kaljouw MJ, et al. (2015). e-Delphi study. Archives of Disease in Childhood 100(1): Associations between characteristics of the nurse work F66–F71. environment and five nurse-sensitive patient outcomes in hospitals: a systematic review of literature. International 243. Wise S, Fry M, Duffield C, et al. (2015). Ratios and nurse Journal of Nursing Studies 52(4): 817–835. staffing: the vexed case of emergency departments. Australasian Emergency Nursing Journal 18(1): 49–55. 230. Stone PW, Larson EL, Mooney-Kane C, et al. (2009). Organizational climate and intensive care unit nurses' 244. Wunsch H, Harrison DA, Jones A, et al. (2015). The impact intention to leave. Journal of Nursing Administration 39(7–8): of the organization of high-dependency care on acute S37–S42. hospital mortality and patient flow for critically ill patients. American Journal of Respiratory and Critical Care Medicine 231. Tabanejad Z, Pazokian M, Ebadi A. (2015). Examining the 191(2): 186–193. impact of liaison nurse role on patients’ clinical outcomes after intensive care unit discharge: a clinical trial. Journal of 245. Zolnierek CD, Steckel CM (2010). Negotiating safety when Critical Care Nursing 8(1): 253–258 staffing falls short. Critical Care Nursing Clinics of North America 22(2): 261-269. 232. Tourangeau AE (2011). Mortality rate as a nurse-sensitive outcome. In: DM Doran (Ed), Nursing outcomes: the state of the science. Sudbury, MA, Jones & Bartlett.

29 APPENDIX A DEFINITIONS

ACCESS Nurse Code Blue Team The ACCESS Nurse is an RN who provides 'on-the­ floor' The Code Blue Team is responsible for responding to an Assistance, Coordination, Contingency (for a late admission on individual requiring cardiopulmonary resuscitation. the shift, or staff sick mid-shift), Education (of less-experienced staff, relatives and others), Supervision and Support (for RNs Critically Ill Patient providing direct patient care). A clinical nurse specialist with a Critically ill refers to a unstable clinical state of a patient who critical care speciality post graduate qualification. requires an intensive level of care (monitoring and treatment for organ support). Examples include: intubated, mechanically Associate Nurse Unit Manager (ANUM) ventilated patients; patients receiving continuous infusions of The ANUM/Clinical Nurse is a senior critical care qualified inotropes and/or sedation, renal replacement therapy; patients nurse who is an integral member of the unit management with unstable conditions who are at risk of deterioration. team, assisting the Nurse Unit Manager in the coordination of clinical practice within the unit. The ANUM is responsible for the Direct Patient Care Nurse coordination of the unit in the absence of the Nurse Unit Manager. The Direct Patient Care Nurse is an RN whose role is to provide direct bedside care and treatment of an intensive care patient and Clinical Facilitator provide patient-centred care. A Clinical Facilitator is a critical care qualified RN who provides teaching and learning guidance and supervision to nurses, High Dependency Unit (HDU) predominantly postgraduate and undergraduate nurses in An HDU is a specially staffed and equipped section of an addition to nurses in the ICU, under the direction of an ICU intensive care complex that provides a level of care that is educator or a University academic. intermediate between intensive care and general ward care.

Clinical Nurse Consultant (CNC) Hospital: Levels The role of CNC differs between states; it ranges from unit The level of complexity of clinical activities undertaken by a management to provision of a global critical care resource. The hospital ranges from Level 1 (least complex) to Level 6 (most role may provide education and leadership to specific units, complex). Intensive care services are primarily delivered in hospital- and area-wide services and the tertiary education sector. hospitals with a Level 4-6 role delineation.

Clincial Nurse Specialist in the ICU Level4 A clinical nurse speciaist in the ICU is a critical care qualified RN A Level 4 hospital is capable of providing mechanical ventilation who applies and demonstrates a high level of clinical nursing and simple invasive cardiovascular monitoring for several knowledge, experience and skills in providing complex nursing hours. It has a separate and self-contained facility capable of with minimum direct supervision. providing basic, multi-system life support usually for less than 24 hours, and a medical director (1) with training and experience in intensive care. In addition to attending specialist(s), the unit must Clinical Support Nurse; Clinical Nurse have at least one RMO (1) on site or available to the unit at all Educator; Clinical Facilitator times. Equivalent to level I# of FICANZCA Guidelines. The Clinical Support Nurse is a critical care qualified nurse assigned to the ICU to support orientation of staff to the unit Level 5 and the development, assessment and maintenance of clinical As Level 4, plus mechanical ventilation, extra­ corporeal renal competence within the unit. The Clinical Support Nurse may also support services and invasive cardiovascular monitoring for a assist the Nurse Educator with the management of postgraduate period of several days. A Level 5 hospital has a separate and self­ education courses within the unit. contained facility (unit) capable of providing complex multi-system life support, and a medical director (1) accredited intensive care specialist or consultant physician in intensive care. It must have

30 at least one specialist accredited with appropriate experience support, which supports the hospital's delineated responsibilities. in intensive care, one RMO (1) who is on site, predominantly It should be capable of providing mechanical ventilation, renal present in the unit and exclusively rostered to the unit at all replacement therapy and invasive cardiovascular monitoring times, and an NUM (1) with post-registration qualifications in for an indefinite period, providing appropriate specialty support intensive care or the clinical specialty of the unit. The nurse in is available within the hospital. If appropriate specialty support charge of the shift is a permanent staff member and appropriately (e.g. neurosurgery, cardiothoracic surgery) is not available within qualified. All nursing staff of the unit responsible for direct patient the hospital, there should be an arrangement with a designated care are RNs. The majority of nursing staff has post-registration tertiary hospital so that patients referred can be accepted for qualifications in intensive care or the clinical specialty of the specialty management (including ICU management). Some unit. 1:1 care for ventilated or equivalently critically ill patients. training and experience in managing critically ill children, Capacity to provide greater than 1 :1 care if required. There preferably with APLS provider status or equivalent, is desirable must be at least two RNs (2) in the unit if there is a patient in the for medical and nursing staff in rural ICUs. All patients admitted unit. Active medical and nursing education programs. Access to the unit must be referred for management to the attending to CNE (1). 24-hour access to pharmacy, pathology, operating intensive care specialist. suite and imaging. Appropriate access to physiotherapist, social worker, dieticians, pastoral care and other allied health services. Level III Equivalent to level II# of FICANZCA Guidelines. A Level Ill ICU is a tertiary referral unit for intensive care patients and should be capable of providing comprehensive critical care Level 6 including complex multi-system life support for an indefinite As Level 5, plus mechanical ventilation, extra­ corporeal renal period. Level Ill units should have a demonstrated commitment support services and invasive cardiovascular monitoring for an to academic education and research. All patients admitted to the indefinite period. A Level 6 hospital has a separate and self- unit must be referred for management to the attending intensive contained facility (unit) capable of providing complex, multi­ care specialist. system life support for an indefinite period, and a referral centre for intensive care patients. It must have a medical director (1) Liaison Nurse accredited intensive care specialist or consultant physician in The intensive care liaison nurse is a member of the multi- intensive care, one RMO (1) who is in the hospital, predominantly disciplinary team. The purpose of the role is to assist in the present in the unit and exclusively rostered to the unit at all times, transition of patients from the ICU to the ward, respond to a an NUM (1) with post-registration qualifications in intensive care deteriorating patient in an appropriate and timely manner, and in or the clinical specialty of the unit. The nurse in charge of the some instances act as an integral member of medical emergency shift is a permanent staff member and appropriately qualified. teams (METs). The liaison nurse will be a senior critical care RNs providing direct patient care must be RNs. The majority of qualified nurse. the nursing staff have post-registration qualifications in intensive care or the clinical specialty of the Unit. 1:1 care for ventilated Medical Emergency Team (MET) or equivalent critically ill patients, greater than 1:1 for selected Also known as a Rapid Response Team (RRT), the MET is a patients. More than two RNs (2) must be present in the unit team of healthcare professionals who bring critical care expertise if there is a patient in the unit. CNE (1) and formal nursing to an individual. educational program. Physiotherapy services are accessible. Appropriate access to other allied health services. Active Nurse Educator research. Designated social worker. Biomedical engineering A Nurse Educator is a critical care qualified RN who is services on site. Equivalent to level Ill# of FICANZCA Guidelines. accountable at an advanced practice level for the design, implementation and assessment of intensive care nursing Intensive Care Unit (ICU) education programs, managing educational resources and ICUs are defined as those units providing Level 1-111 treatment providing nursing expertise relating to educational issues in and care of critically ill patients (see below), regardless of the title intensive care nursing practice. of the unit. Nurse Manager ICU Levels The Nurse Manager (or Nurse Unit Manager/Clinical Nurse Level l Consultant) is a critical care qualified RN who is accountable at A Level I ICU should be capable of providing immediate an advanced practice level for the coordination of clinical practice resuscitation and short-term cardio­ respiratory support for and the provision of human and material resources within the critically ill patients. It will also have a major role in the monitoring ICU. and prevention of complications in 'at-risk' medical and surgical patients. It must be capable of providing mechanical ventilation Patient-centred Care and simple invasive cardiovascular monitoring for at least several Patient-centred care refers to the recognition of the patient or hours. designee as the source of control and full partner in providing Level II compassionate and coordinated care based on respect for A Level II ICU should be capable of providing a high standard patient's preferences, values and needs. of general intensive care, including complex multi-system life

31 APPENDIX B EVIDENCE TABLES

Table 1. NHMRC levels of evidence

Level Intervention I A systematic review of level II studies II A randomised controlled trial III-1 A pseudorandomised controlled trial (i.e. alternate allocation or some other method) A comparative study with concurrent controls: non-randomised experimental trial; cohort study; case-control study; III-2 interrupted time series with a control group A comparative study without concurrent controls: historical control study; two or more single arm studies; interrupted time III-3 series without a parallel control group IV Case series with either post-test or pre-test/post-test outcomes

Table 2. NHMRC body of evidence matrix

A B C D Component Excellent Good Satisfactory Poor Several Level I or II One or two Level II studies Level Ill studies with low Level IV studies, or Level l studies with low risk of with low risk of bias or a risk of bias, or Level I or II to Ill studies with high risk Evidence base bias systematic review/ multiple studies with moderate risk of bias Level Ill studies with low of bias risk of bias All studies consistent Most studies consistent Some inconsistency Evidence is inconsistent and inconsistency may be reflecting genuine Consistency explained uncertainty around clinical question Clinical impact Very large Substantial Moderate Slight or restricted Population(s) studied in Populations(s) studied Populations(s) studied in Populations(s) studied in the body of evidence are in the body of evidence the body of evidence differ the body of evidence differ the same as the target are similar to the target to the target population to the target population for Generalisability population for the guideline population for the guideline for the guideline, but it is the guideline, and it is clinically sensible to apply hard to judge whether it is this evidence to the target sensible to generalise to population the target population Directly applicable to Applicable to Australian Probably applicable Not applicable to Applicability Australian healthcare healthcare context with to Australian healthcare Australian healthcare context few caveats context with some caveats context

32 Table 3. NHMRC grades of recommendations

Grade Description A Body of evidence can be trusted to guide practice B Body of evidence can be trusted to guide practice in most situations C Body of evidence provides some support for recommendation(s), but care should be taken in its application D Body of evidence is weak, and recommendation must be applied with caution A comparative study without concurrent controls: historical control study; two or more single arm studies; interrupted time E series without a parallel control group

33 APPENDIX C BODY OF EVIDENCE

Grade NHRMC Search Clinical Generalis- Applic- of Standard References Levels of Consistency Terms Impact ability ability Recommend- Evidence ation Standard 1 *Nursing 4, 7, 8, 35, 48, Good Good Good Good Excellent Grade B *Intensive care 56, 57, 64, 65, *Critical care 102,136,157, One or more Most studies Substantial Population(s) Directly Body of *Paediatric 166, 179, 180, Level II studies consistent and studied in body applicable to evidence can *Staffing 181,186,187, with a low inconsistency of evidence Australian be trusted to *Unit design 189, 195, 199, risk of bias or may be are similar healthcare guide practice *Pods 200, 234 several level II explained to the target context *Single room studies with a population for *Infection low risk of bias the standard *Patient outcome Reviews 3 *Patient safety Cohort studies 10 Expert opinion 2 Surveys 3 (45 records, 22 Clinical standards removed) 2 Book chapters 3 Standard 2 *Nursing 2-5, 7,12, 20, Good Good Good Excellent Excellent Grade B *Intensive care 21, 22-25, 27, *Staffing 28, 31-37, 40, One or more Most studies Substantial Population(s) Directly Body of *Ratio 45, 46, 50, Level II studies consistent and studied in body applicable to evidence *Management 52-55, 57, 60, with a low inconsistency of evidence Australian can be trusted *Patient 61, 67, 68, 70, risk of bias or may be are the same healthcare to guide outcome 73-76, 79-86, several Level Ill explained as the target context practice *Patient safety 88, 91-93, 96, studies with a population for 98- 101, 103- low risk of bias the standard (82 records, 9 105, 107, removed) 109, 110, 115, Reviews 12 118, 120, 123, Systematic 124, 127, 130, reviews 4 Cohort studies 37 132, 134, 137, Surveys 7 141,142, 145, Qualitative 149, 156, 164, studies 3 165, 172, 173, Expert opinion 2 222, 232, 236, Editorials 6 239, 243, 245 Clinical standards 5 Book chapters 2

34 Grade NHRMC Search Clinical Generalis- Applic- of Standard References Levels of Consistency Terms Impact ability ability Recommend- Evidence ation Standard 3 *Nursing 2-5,19, 27, 33, Good Good Good Excellent Excellent Grade B *Intensive care 36, 37, 44, 49, *Critical care 57, 63, 66, One or more Most studies Substantial Population(s) Directly Body of *Staffing 67, 83, 86, Level II studies consistent and studied in body applicable to evidence can *Skill 99,101- 103, with a low risk inconsistency of evidence Australian be trusted to *Mix 105, 114- 116, of bias or SR/ may be are the same healthcare guide practice *Education 123, 124, 129- several Level Ill explained as the target context *Qualification 131,133,135- studies with a population for *Patient 138,147, 150, low risk of bias the standard outcome 160,164,174, *Patient safety 177, 179,182, Reviews 10 191,195, 198, Cohort studies 27 (66 records, 18 200, 203, 206 Surveys 1 Qualitative removed) studies 1 Clinical standards 2 Standard 4 *Nursing 2, 4, 19, 33-36, Good Good Good Satisfactory Good Grade C *Intensive care 44, 45, 50, 51, *Critical care 54, 55, 57, 63, One or more Most studies Substantial Evidence not Evidence Body of *Staffing 67, 72, 74, 75, Level II studies consistent and directly applicable to evidence can *Management 79, 81, 83, 90, with a low inconsistency generalisable Australian be trusted to *Leadership 93, 94, 99, risk of bias or may be to the target healthcare guide practice *Education 114-117, 121, SR/several explained population but context with in most *Qualification 138, 145, 148, Level Ill could be few caveats situations *Patient 148, 157, 169, studies with a sensibly outcome 184, 185, 188, low risk of bias applied *Patient safety 205, 208, 211, 224, 228, 239 Reviews 10 (53 records, 8 Cohort studies 27 removed) Surveys 1 Qualitative studies 1 Clinical standards 2 Standard 5 *Nursing 4, 7, 19, 25, Good Good Good Excellent Good Grade C *Intensive care 35, 38, 43, *Critical care 46-48, 55, 59, One or more Most studies Substantial Population(s) Evidence Body of *Staffing 60, 63, 75, 90, Level II studies consistent and studied in body applicable to evidence can *Education 104, 106-108, with a low inconsistency of evidence Australian be trusted to *Educational 140, 150, 164, risk of bias or may be are the same healthcare guide practice support 177, 193, 194, several Level Ill explained as the target context with in most *Educator 197, 208, 209, studies with a population for few caveats situations *Induction 216, 218 low risk of bias the standard *Experiential learning Reviews 4 Cohort studies 14 (39 records, 8 Surveys 5 Qualitative removed) studies 2 Clinical standards 3 Book chapters 3

35 Grade NHRMC Search Clinical Generalis- Applic- of Standard References Levels of Consistency Terms Impact ability ability Recommend- Evidence ation Standard 6 *Nursing 4, 7, 19, 22, Good Good Good Good Good Grade C *Intensive care 35, 38, 43, *Critical care 46-48, 53, 59, One or more Most studies Substantial Population(s) Evidence Body of *Staffing 60, 63, 75, 90, Level II studies consistent and studied in body applicable evidence can *Nurse patient 104, 106-108, with a low risk inconsistency of evidence to Australian be trusted to ratio 140, 150, 164, of bias or SR/ may be are similar healthcare guide practice *Patient 177, 193, 194, several Level Ill explained to the target context with in most outcome 197, 203, 206, studies with a population for few caveats situations *Patient safety 211, 212, 218, low risk of bias the standard 226 (64 records, 31 Reviews 9 removed) Systematic reviews 3 Cohort studies 4 Surveys 4 Qualitative studies 3 Expert opinion 1 Editorials 4 Clinical standards 5 Standard 7 *Nursing 4, 9, 19, 28, Good Good Good Satisfactory Good Grade C *Intensive care 33, 35, 47, 51, *Critical care 53, 57, 64, 66, One or more Most studies Substantial Evidence not Evidence Body of *Staffing 76, 77, 79, 87, Level II studies consistent and directly applicable evidence can *Defibrillator 119, 124, 132, with a low risk inconsistency generalisable to Australian be trusted to *Advanced 140, 184, 197, of bias or SR/ may be to the target healthcare guide practice life support 213, 226, 228, several Level Ill explained population but context with in most *Technology 231, 234 studies with a could be few caveats situations *Technica l low risk of bias sensibly *Equipment applied *Tracheostomy Reviews 7 Systematic (38 records, 11 reviews 3 Cohort 11 removed) Survey 2 Qualitative studies 1 Book chapters 1 Clinical standards 2 Standard 8 *Nursing 4, 30, 31, 40, Good Good Good Excellent Excellent Grade B *Intensive care 44, 51, 53, *Critical care 59, 63, 66, One or more Most studies Substantial Population(s) Directly Body of *Staffing 75, 77, 91-93, Level II studies consistent and studied applicable to evidence can *Liaison 122,139,161, with a low inconsistency in body of Australian be trusted to *Outreach 163, 164, 175, risk of bias or may be evidence healthcare guide practice 185, 186, 190, several Level Ill explained are the same context (51 records, 18 193, 204, 207, studies with a as the target removed) 218, 220, 222, low risk of bias population for 228, 231, 233 the standard Reviews 7 Systematic reviews 3 Cohort studies 13 Surveys 4 Qualitative studies 2 Clinical standards 2 Book chapters 2

36 Grade NHRMC Search Clinical Generalis- Applic- of Standard References Levels of Consistency Terms Impact ability ability Recommend- Evidence ation Standard 9 *Nursing 4, 24, 30, 31, Good Good Good Good Good Grade C *Intensive care 40, 43, 46, 51, *Critical care 52, 55, 63, 78, One or more Most studies Substantial Population(s) Evidence Body of *Staffing 87, 106, 127, Level II studies consistent and studied in body applicable to evidence can *Research 145, 190, 220, with a low risk inconsistency of evidence Australian be trusted to *Priorities 227, 240, 242 of bias or SR/ may be are similar healthcare guide practice several Level Ill explained to the target context with in most (81 records, 60 studies with a population for few caveats situations removed) low risk of bias the standard

Reviews 4 Systematic reviews 1 Expert opinion 1 Cohort studies 8 Qualitative studies 3 Clinical standards 2 Book chapters 1 Standard 10 *Nursing 2, 4, 5, 22, 37, Good Good Good Good Excellent Grade C *Intensive care 48, 49, 54, 61, *Critical care 62, 99, 117, One or more Most studies Substantial Population(s) Directly Body of *Staffing 128, 130, 138, Level II studies consistent and studied in body applicable to evidence can *Non nursing 148, 170, 182, with a low inconsistency of evidence Australian be trusted to work 192, 226, 235, risk of bias or may be are similar healthcare guide practice *Non direct 239, 244 several Level II explained to the target context in most care studies with population for situations *Patient a low risk of the standard outcome bias *Patient safety Reviews 6 (30 records, 7 Systematic removed) reviews 1 Cohort studies 11 Surveys 1 Clinical standards 3 Book chapters 1

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