The American Association of Critical-Care AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES NATIONAL SURVEY OF FACILITIES AND UNITS PROVIDING CRITICAL CARE

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BACKGROUND Little information is available nationally about critical care units and nurses. What is known about nurses in hospitals is generally not broken down among all the specialties.

OBJECTIVES To describe issues of workforce, compensation, and care specific to critical care units and nurses who work in them.

METHODS The American Association of Critical-Care Nurses conducted a survey of randomly selected facilities with critical care units in the United States. Facilities were solicited via e-mail to respond to a survey on the World Wide Web and provide information on operations, evaluations, nursing staff reim-bursement and incentives, staffing, and quality indicators. Responding facilities also provided contact information for units in the facilities. Those units were surveyed about operations, acuity systems, staffing, policies on visitation and end-of-life care, administrative structure, documentation, certification, professional advancement, vacancy/floating, staff satisfaction, orientation, association membership, wages, advanced practice nursing, and quality indicators.

RESULTS The initial response rate (120 of 658 eligible facilities) was 18.2%, and 300 of 576 solicited units nominated by the facilities responded, yielding a 52.1% response rate for the second phase.

CONCLUSIONS These survey data define the scope and intensity of services offered and provide more specific figures about staffing issues and unit practices than has been accessible before. Healthcare providers may use this information for benchmarking purposes, especially for instances in which the tables provide data for each particular type of critical care unit. (American Journal of Critical Care. 2006;15:13-28)

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To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

By Karin T. Kirchhoff, RN, PhD,and Nancy Dahl. From School of Nursing, University of Wisconsin-Madison, Madison, Wis (KTK),and Research Dimensions, Toronto, Ontario(ND).

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he American Association of Critical-Care

Nurses (AACN) developed its national critical care survey to collect vital information and to assess important US benchmarks against which hos-pitals can compare their institutions and critical care units. The information collected is expected not only to inform participating institutions and the AACN about the unmet needs in critical care units but also to provide critical care nurses and other involved parties with information they require to bring about the changes needed in the workplace, in clinical practice,

and in the regulations that affect these healthcare providers and the care of patients.

The types of data collected in this survey are not available elsewhere. Only recently have data from regional or national studies specific to critical care begun to be published. Halpern et al1provided infor-mation on the numbers of beds in intensive care units

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his AACN survey provides benchmarks against which hospitals and critical care units can compare care.

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(ICUs) in the United States and the costs of intensive care relative to national health expenses and the gross domestic product. Information is not available, how-ever, about the severity of the shortage of nurses in critical care units, statistics related to quality of care in critical care units, or other important factors that may vary from one type of unit to another. A search of the Cumulative Index to Nursing and Allied Health Literature with the terms “nurse,” “critical care,” and “statistics” and limited to the years 2000 to 2005 yielded only articles from other countries, about a sin-gle state, or articles about nurses and clinical issues. When the search was limited to US journals, only 72 references were found.

Although many groups gather and publish com-prehensive statistics on hospitals and nurses in the aggregate, few separate out the data for critical care units and critical care nurses. Reports of hospital statistics that include nursing issues and patient infor-mation tend to include only data combined across all units. Rarely are the data presented according to the specific characteristics of critical care units. It is there-fore diff icult to ascertain if the issues and events reported are similar in frequency in all types of units. For example, staffing statistics have not been analyzed by type of unit; no one has compared data from ICUs versus data from telemetry units versus data from postanesthesia care units (PACUs). Until now, these data have not been available on a national basis—only within individual hospitals.

Among the many variables included in the AACN national critical care survey were hospital characteris-tics, unit and staff demographics, certification, formal and continuing education, leadership, decision mak-ing, patients’ outcomes, and staffing.

In addition to traditional ICUs, the study included other areas within the hospital where acutely and criti-cally ill patients are cared for, such as progressive care, telemetry, and step-down units. Data on these types of units, their nurses, and their patients are even scarcer because these units are still relatively new developments. PACUs were also included in the sur-vey because they are an important part of the critical care continuum.

Planning for this survey began in the summer of 2003. Data were collected from facilities in the fall of 2003 and from units in the spring of 2004.

In this article, we present part of a more compre-hensive report available at www.aacn.org or by calling 800-899-2226. The goal of this initial article is to pre-sent the profile of the facilities and units surveyed. Specific areas of the findings will be covered in more depth in future articles.

Method

Sample

In addition to collecting data related to the char-acteristics of critical care units and the nurses and patients who fill the units, the survey team also sought to learn about the facilities in which the units are housed. Because many of the variables of interest were hospital-wide rather than specific to a unit, the survey was divided and administered in 2 phases: the facility phase and the unit phase. Contact information for collecting data in the unit-specific phase of the study was obtained during the facility phase.

Facility Phase. The survey team purchased a list of hospitals that met the survey criteria from a nation-ally recognized healthcare organization. Criteria for invitation to participate in the survey included the presence of one or more of the following types of units: ICUs (of any type), step-down units, progressive care units, telemetry units, PACUs, and other units where nursing care is provided for acutely and criti-cally ill patients.

Hospitals with fewer than 50 licensed beds were omitted from the sample. Although these facilities may be listed as having an ICU, many have only 1 or 2 beds designated for stabilization of critically ill patients, and those beds are not always available. Eligible hos-pitals were then divided up into strata by number of beds (50-100; 101-200; 201-300; 301-500, and ≥501) and were randomly sampled across the strata. Specifi-cally, quotas were placed on the number of hospitals contacted within various strata; that is, quotas were placed on hospitals with 50 to 100 operating beds, 101 to 200 operating beds, and so on. This process allowed the inclusion of more large hospitals and fewer smaller hospitals than would have been included if proportional sampling had been used; in proportional sampling, small hospitals would have predominated, preventing analyses of differences in hospitals with different numbers of beds.

A total of 749 facilities were included in the sample and invited to participate. During the course of the invi-tation and follow-up process, 91 facilities were deemed ineligible, resulting in a final eligible sample of 658 facilities. Of those eligible facilities, 120 (18.2%) par-ticipated. When the data were tabulated, they were

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profile of facilities and units surveyed is presented here. A more complete report is available at www.aacn.org.

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weighted to ensure that the range of facility sizes reflected the range of sizes of US hospitals in general. Both the unweighted and weighted profiles of the facilities are listed in Table 1.

Unit Phase. Responding facilities were asked to submit lists of their critical care units, including pro-gressive care units, telemetry units, step-down units, and PACUs, and to provide contact information for the unit managers. The 120 responding hospitals listed 576 critical care units, and the managers of those units were subsequently sent the unit phase of the survey. Of the 576 units invited to participate, 300 (52.1%) responded to the questionnaire. Unit data were left unweighted because the numbers of different types of units in US hospitals are unknown.

Instrument

Two instruments were used: one questionnaire for the facility data and another for the unit data. Respon-dents to both the facility and unit questionnaires were instructed to report data for a full 12-month period, preferably from their most recently completed fiscal year. Several steps were taken to improve the reliability and validity of the instruments. Experts in questionnaire design and in critical care nursing and critical care management designed and tested the instruments. After development of the questionnaires, experts in nursing management reviewed them for correct use of terms and generalizability across settings. Because the questionnaires were converted to pages on the World Wide Web, AACN staff and volunteers tested flow, handling of potential responses, and ease of use.

Facility Survey. The facility questionnaire was administered online, and representatives for the invited facilities were e-mailed an invitation with a link to the survey instrument. The questions were pre-sented in a Web format, preprogrammed to allow respondent-selected options, when appropriate, or free text, when necessary. Facility representatives who did not have e-mail or who preferred a paper form were provided with a questionnaire on paper. The survey included questions on the following topics: demo-graphics about operations (14 questions), evaluations (4 questions), nursing staff reimbursement and incen-tives (7 questions), staffing (9 questions), quality indi-cators (4 questions), and information on critical care units and contact information for critical care unit managers to solicit responses to the unit survey.

Unit Survey. Also administered online (with a paper option available upon request), the unit survey contained questions on a wide array of topics: opera-tions (10 quesopera-tions), acuity systems (3 quesopera-tions), staffing (8 questions), policies on visitation and

end-of-life care (3 questions), administrative structure (13 questions), documentation (3 questions), certification (6 questions), professional advancement (5 questions), vacancy/floating (11 questions), staff satisfaction (2 questions), orientation (8 questions), association membership (3 questions), wages or registered nurses (RNs; 1 question), advanced practice nursing (8 ques-tions), and quality indicators (5 questions).

Procedure

After the facilities were randomly selected, a con-tact person equivalent to the critical care director was determined for each facility, and contact information was collected. E-mail invitations were sent to these individuals to encourage them to go to the Web site where the facility questionnaire was available. As facility questionnaires were completed and critical care units and managers were specified, invitations were sent to the unit contacts to ask them to complete the second phase, the unit questionnaire.

Follow-up was implemented by using a number of options. A full-time AACN employee was dedicated to follow up with nonrespondents in both phases of the survey. Special care was taken to follow up by e-mail and telephone to encourage participation or to

Table 1 Profile of facilities surveyed

Weighted 74 9 4 12 1 91 27 32 32 23 13 25 32 18 15 8 Percentage of 120 facilities Feature Organizational control Nongovernment,

not for profit

Investor-owned, for profit Government, nonfederal

hospital

Government, federal hospital No answer

Facility type

General medical and surgical hospital Academic medical center Setting

Urban Rural Suburban No answer

Facility size*(No. of operating beds)

50-100 101-200 201-300 301-500 >501 Unweighted 75 8 7 9 1 93 37 45 22 20 13 8 25 20 25 21

*Mean number of operating beds was 328 unweighted and 217 weighted. Percentages total less than 100 because of rounding.

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determine the reason for nonresponse. Nonresponse was a bigger factor in the facility phase of the survey than in the unit phase. Ultimately, the sample of facil-ity responders was compared with the group of nonre-sponders to ensure that the sample of renonre-sponders was representative of the randomized pool of hospitals. The research team validated that the responder facili-ties did not differ significantly from the nonresponder facilities in terms of available data such as number of beds or geographic distribution.

Output from the completed questionnaires was reviewed for consistency with expected responses, and clarification was sought for outliers. Extreme outliers in individual item responses that could not be verified were removed so as not to alter reported means.

Results

Participating Facilities

In total, 120 respondents participated in the facility survey. All participating facilities had 50 or more licensed beds; facilities with fewer beds had been excluded from the study. The actual (unweighted) and weighted profiles of facilities that participated in the study are shown in Table 1. US hospitals in general and the weighted data include fewer large hospitals than actu-ally participated in the study. Academic and urban hospi-tals tend to be larger than other facilities. Therefore, their proportions were reduced accordingly when the number of large hospitals in the weighted sample was reduced. The weighted profile of facilities is the profile that should be considered when the facility findings are examined, because the findings reflect this breakdown. According to this profile, the majority of facilities rep-resented in the data are general medical and surgical hospitals (91%), nongovernment, not-for-profit orga-nizations (74%), from a variety of settings, with a mean of 217 operating beds and 258 licensed beds. Where sample sizes allowed, differences between the various facility types and sizes are indicated.

Operations.Not all respondents provided informa-tion on inpatient admissions, excluding newborns but including neonatal and “swing” admissions and read-missions (swing beds are those that can be used to pro-vide either acute or long-term care depending on the needs of the community or patients). Participating insti-tutions had a mean of almost 13 000 admissions per year (Table 2). More than two thirds of respondents did not have data available on cost per patient day or were unable to answer the question. Of those responding, the mean cost per patient day was $1883 (Table 2). The mean cost per adjusted discharge was $7333.

Evaluations.Most hospitals surveyed (80%) were accredited by the Joint Commission on Accreditation

of Healthcare Organizations (JCAHO). Four percent were not accredited (16% did not provide that infor-mation). Facilities that were accredited had scored a mean of 93 on their most recent JCAHO survey.

At the time of the survey, only 5% of responding hospitals had been designated Magnet nursing ser-vices through the American Nurses Credentialing Center’s Magnet program. Seventy-nine percent of facilities did not have Magnet-designated services, but almost half of these (44%) said that they planned to apply for such status in the next 3 years. Mainly larger hospitals planned to apply (Table 3).

Incentives. Most hospitals offered tuition reim-bursement both to RNs for academic programs (83%) and to students in educational programs to become RNs (85%). Almost half of the facilities surveyed (44%) had implemented professional development and advancement programs for bedside nurses, pri-marily clinical ladder systems. A further 12% had pro-grams in development.

Staffing.About half of the responding institutions (52%) provided information on numbers of budgeted RN full-time equivalent (FTE) positions. Among those,

Table 2 Descriptive statistics of facilities (N = 120) with critical care units

Facility information

Inpatient admissions, excluding newborns, including neonatal and swing admissions (n = 87) Inpatient readmissions,

within 30 days (n = 45) Inpatient days, excluding

newborns, including neonatal and swing admissions (n = 87) Discharges (n = 77)

Costs, US$*

Per patient day (n = 38) Per adjusted discharge (n = 33)

Mean 12 761 902 58 620 11 495 1883 7333 Median 8776 350 43 151 8767 1742 6952

*More than two thirds of respondents did not answer this question.

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ive percent of responding hospitals had Magnet-designated nursing services, although almost half planned to apply.

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lmost half had nursing development programs such as a clinical ladder.

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the numbers of total budgeted RN FTEs ranged up to 1000 or more; most facilities (64%) had fewer than 300 positions. The median number of budgeted RN FTE positions was 214, and the mean was 332. The total number of unfilled budgeted RN FTE positions was up to 100 or more; most hospitals (64%) had fewer than 30 unfilled positions. The median and mean num-bers of unfilled positions were 21 and 36, respectively. The means for total and unfilled budgeted positions were slightly higher than the medians because some hospitals had many positions. The mean vacancy rate, calculated by dividing the mean number of unfilled positions (36) by the mean number of budgeted RN positions (332), was 10.8%.

Among the 51 facilities that provided informa-tion, the total number of RN staff who had terminated employment during a 12-month period (including vol-untary and involvol-untary termination) was up to 150 or more. The median number of terminations was 31, and the mean number was 53 (the mean is higher because a few hospitals had high termination levels). Respondent hospitals reported a mean turnover rate of 11.8%. The mean turnover rate was calculated by

dividing the mean number of terminations (53) by the mean number of RNs on the payroll (449).

Almost two thirds of respondents did not have data available on the number of days needed to fill a

vacant RN position or were unable to answer the ques-tion. Answers varied among those who responded, but it took a mean of 59 days (median 54 days) to fill a vacancy (Figure 1).

Most facilities surveyed (64%) did not have a col-lective bargaining unit representing their nursing staff.

Table 3 Facilities’ plans for Magnet-designated nursing services

Facility has Magnet-designated service Facility plans to apply for

Magnet designation

Facility size, No. of beds <300 (n = 65) 3 39 >301 (n = 55) 10 63 Academic (n = 44) 10 44 General medical/surgical hospital (n = 111) 4 43 Urban (n = 54) 9 58 Suburban/ rural (n = 50) 4 45

Facility type Setting

Status of facility

Percentage of responding facilities

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ospitals reported a nursing vacancy rate of 10.8% and a turnover rate of 11.8%.

Figure 1 Number of days required to fill a vacant position for a registered nurse.

*Questionnaire included a “data not available” response option that was combined with “no answer” responses in the data.

Percentage of 120 facilities

0 20 40 60 80 100

Data not available/no answer*

Among those answering (n = 45)

< 30 days 30-44 days 45-59 days 60-89 days 90-119 days >120 days

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ost hospitals (64%) did not have a collective bargaining unit representing their nursing staff.

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Twenty-two percent of hospitals did have collective bargaining units, half with mandatory (closed-shop) membership.

Participating Units

Critical care units were defined as any unit in which acute and critically ill patients received care. In this survey, the 3 prevalent types of critical care units, ICUs, PACUs, and progressive care units, were stud-ied (Table 4). From the 120 responding facilities, 300 critical care units participated in the survey. A little more than half of the units in this study were tradi-tional ICUs. The unit results were not weighted to reflect hospitals nationwide, because the proportions of critical care units across US hospitals in general are not well known. Therefore, we caution that the total results for each question are skewed to the activities of the more dominant units in the sample. (For example, the total results are somewhat more representative of the activities of recovery room/PACUs, medical-surgi-cal ICUs, and combined intensive/coronary care units and less representative of the activities of trauma units and burn ICUs). Differences between ICUs (total) and progressive care units (total) and PACUs specifically are discussed throughout this section, because their sample sizes were large enough for categorical analy-sis. The sample sizes for the other individual units were too small for such analysis.

The unit findings also often varied, depending on the size of the unit or the size or location of the tal the unit was in (eg, urban, suburban, or rural

hospi-tals). Significant differences are noted. Table 5 shows relationships between the types of units in a hospital and the unit’s size. Of note, in this table, smaller units (12-29 operating beds) are predominantly ICUs.

The larger units with 30 beds or more were mainly progressive care units. For this reason, smaller units and ICUs often had common patterns throughout the find-ings. The same was true of larger units and progressive care units.

Operations.Almost half (46%) of the critical care units in the study had fewer than 15 operating beds; the largest concentration of units (30% of units) had 10 to 14 beds. Overall, the mean unit size was 19 operating beds (median 16 beds; Figure 2).

Almost two thirds of the units provided informa-tion on their admissions. Overall, the number of criti-cal care admissions varied widely from less than 250 to 5000 or more. Critical care units had a mean of about 2000 admissions during a 12-month period, but, half of the units had fewer than 1000 admissions annually.

More than three quarters of units did not provide information on readmissions, an important indicator of quality of care. Perhaps the respondent did not have access to the information or that information was not collected in the unit. Of the units for which informa-tion was provided, 38% had had no readmissions within 48 hours during the preceding 12-month period. Among the few remaining respondents, the number of readmissions within 48 hours varied widely from 1 to 50 or more during a 12-month period. The median number of readmissions was 4, and the mean was 16

Table 4 Critical care units represented in this report

Type of critical care unit

Intensive care units Medical-surgical

Combined intensive/coronary care Cardiovascular/surgical Coronary care Neonatal Pediatric Medical Surgical Neuro-neurosurgical Trauma Burn

Postanesthesia care units/recovery rooms Progressive care units

Telemetry Step-down Intermediate care Progressive care

Other types of critical care units No answer Percentage of total sample (N = 300 units) 53 8 8 7 5 5 4 4 4 3 2 2 10 30 12 7 6 5 4 3

Table 5 Percentages of each unit type among small, medium, and large units*

Type of unit

Intensive care units Medical-surgical Combined intensive/

coronary care Neonatal

Progressive care units Telemetry Step-down Small <12 (n = 84) 82 7 11 1 13 5 2 Medium 12-29 (n = 150) 70 11 9 5 25 7 6 Large >30 (n = 57) 26 4 2 12 70 35 18 Unit size, No. of beds

*Numbers in table are percentages of each type of unit in each unit size range. For example, 82% of small (<12 bed) units are intensive care units. Percentages do not total 100. All other units represented in this study and listed in Table 4 are equally prevalent among smaller and larger units. A bold number within a category (eg, within Unit size) is significantly higher than nonbold numbers within the same category. An italic number is significantly higher than nonitalic numbers, but significantly lower than bold numbers.

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(the mean was skewed high because a few critical care units had high numbers of readmissions).

Among the 59% of respondents who provided information, numbers of inpatient days for their units were as high as 10 000 or more in a 12-month period. The median number of inpatient days was 3708, and the mean was 4808 (the mean was skewed slightly higher than the median because some units had very large numbers of inpatient days).

Seventy percent of respondents provided informa-tion on the mean length of stay in their units. In most critical care units (74%), the length of stay was between 2 and 5 days. The longest stays were in larger critical care units (20% of patients in the largest units stayed for ≥11 days versus 2% in the smaller units) and in urban hospitals (which are more likely to have the larger critical care units; Table 6). Table 6 also shows how numbers of operating beds, admissions, and inpa-tient days varied depending on unit size and hospital setting. Naturally, larger units had more operating beds, admissions, and inpatient days; mean values among smaller and larger units are shown in the table.

Hospital size had little relation to the number of beds in a unit, except in the smallest hospitals. Small hospitals (101-200 operating beds) had a mean of 15 beds per critical care unit. Larger hospitals had a mean of 20 or 21 beds per critical care unit, regardless of whether the facility had 201 to 300 beds, 301 to 500 beds, or more than 500 beds.

Acuity Systems. Forty-two percent of critical care units in the study used a formal acuity system. Formal acuity systems were more prevalent in the largest hos-pitals (>500 beds) and urban hoshos-pitals (which tended to be the larger ones). A wide variety of systems were

in place. In about 7 in 10 critical care units surveyed, respondents had seen an increase in patients’ acuity in the preceding year or had perceived that acuity at the time of patients’ transfer or discharge was higher than it had been 1 year earlier.

Respondents from the larger units (12 or more oper-ating beds) and urban/suburban hospitals were most likely to have noticed these changes in acuity (although urban facilities were less likely than suburban facili-ties to have experienced higher-acuity transfers/dis-charges). Increases in patients’ acuity were reported equally in ICUs, progressive care units, and PACUs. But, progressive care units (and ICUs, directionally) were more likely than PACUs to see patients being transferred or discharged with higher acuity (Table 7).

The same trend was evident in terms of “chronic critical care” patients. Almost half of units (45%) had seen an increase in the percentage of longer-term chronic critical care patients who could not be placed elsewhere (eg, patients receiving long-term mechanical ventilation, patients with complex wound management, and patients in stable condition who were receiving intravenous vasoactive medications). Again, this increase had occurred more in urban and suburban hospitals than in rural facilities. Respondents from units in smaller hospitals (up to 300 operating beds) and the largest hospitals (>500 beds) were more likely to have noticed an increase than were respondents from mid-sized facilities (301-500 beds; Figure 3).

Staffing.In most of the critical care units surveyed (73%), the nurse manager or assistant nurse manager coordinated staffing. A few facilities coordinated staffing either through a staff-run scheduling committee or a staff nurse coordinator; these methods of coordinating

Percentage of 300 units 0

Percentage of units* Adult Recovery/ intensive Progressive postanesthesia

care care care No. of beds (n = 118) (n = 90) (n = 31) <12 38 12 39 12-29 58 42 52 >30 4 44 10 Mean 15 26 16 20 40 60 80 100 <10 beds 10-14 beds 15-19 beds 20-29 beds 30-39 beds >40 beds No answer

Figure 2 Total number of operating beds in the unit.

* A bold number within a category (eg, within intensive care) is significantly higher than nonbold numbers in other units (eg, progressive care). Numbers of units do not total 300 because of “no answer” responses, units unspecified, and exclusion of atypical units (eg, neonatal and pedi-atric intensive care units).

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were more prevalent among smaller or rural hospitals or government nonfederal hospitals (as opposed to nongovernment, not-for-profit centers).

Respondents were asked which factors they consid-ered in determining the number of nurses needed for their basic staffing plans. Of the 4 factors listed in the survey, the most commonly considered factor (by 88%

of respondents) was the expected patient census. The need for specialized skills (eg, balloon pumps, dialysis) and the skill mix of the staff ranked next in importance. A formal acuity system had the lowest priority.

The few PACUs were less inclined than ICUs and progressive care units to select any of the 4 factors. Smaller units (up to 29 operating beds) were more

Table 6 Unit statistics by type of facility and unit*

Unit size, No. of beds <12 (n = 84) 8 (n = 45) 1140 (n = 56) 2039 (n = 57) 58 40 2 4 Unit statistic

No. of operating beds <10

7-11 12-29 >30 Mean

No. of admissions, mean

No. of inpatient days, mean Length of stay, days

<4 4-10 >11 Mean 18 (n = 97) 2229 (n = 94) 4429 (n = 108) 53 37 10 6.5 >30 (n = 57) 39 (n = 28) 2996 (n = 35) 9276 (n = 39) 49 31 20 7 Urban (n = 198) 6 20 48 25 20 (n = 114) 2120 (n = 114) 4856 (n = 137) 46 42 12 6 Suburban (n = 46) 2 26 65 7 17 (n = 30) 1696 (n = 26) 4877 (n = 34) 68 26 6 5 Rural (n = 47) 15 28 45 11 16 (n = 36) 1969 (n = 33) 4073 (n = 34) 65 26 9 5 Setting

* This table includes results from 4 questions. The total numbers of respondents for each question are shown in parentheses. Most numbers in the body of the table are percentages of respondents reporting that statistic. The 4 rows of mean values are actual numbers of that statistic rather than percentages of respondents. A bold number within a category (eg, within Unit size, Setting) is significantly higher than nonbold numbers within the same category. An italic number is significantly higher than nonitalic numbers, but significantly lower than bold numbers.

12-29 (n = 150)

Table 7 Perceived changes in patients’ acuity in the preceding year by type of facility

Percentage of all units or facilities responding* Unit type Recovery/ postanesthesia care (n = 31) 68 26 0 6 58 36 6 Progressive care (n = 90) 77 18 2 3 78 17 6 Adult intensive care (n = 118) 69 25 4 2 70 28 2 Patients’ acuity had

Increased Stayed the same Decreased No answer Were patients being

transferred or discharged with higher acuity?

Yes No No answer

Unit size, No. of beds <12 (n = 84) 57 33 4 6 58 36 6 Setting 12-29 (n = 150) 75 21 3 1 73 26 1 >30 (n = 57) 77 19 2 2 74 25 2 Urban (n = 198) 71 23 3 3 65 33 2 Suburban (n = 46) 78 22 0 0 85 13 2 Rural (n = 47) 55 32 6 6 66 28 6

* A bold number within a category (eg, within Unit type, Unit size, Setting) is significantly higher than nonbold numbers within the same category.

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likely than large units to take into account the need for specialized skills. Formal acuity systems were more of a priority to urban hospitals, where these systems were more established, than to suburban/rural facilities. Still, acuity systems had the lowest priority even among urban hospitals (Table 8).

The majority of respondents thought that the staffing had not been optimal up to 25% of the time in terms of the match between patients’ acuity and the nurses’ skill level or mix.

Nine percent of critical care units participating in the study had recently been required to close beds for more than 30 days because of insufficient numbers of RNs. This finding was consistent among all types and sizes of units.

Overall, most critical care units (71%) had a pol-icy that patients being transported out of the unit must be accompanied by a unit nurse. The number of trans-ports of patients out of the unit for tests or procedures varied considerably and depended on the unit.

Respondents were asked what they used when they needed to adjust staffing to manage sudden or emergency admissions or sudden increases in patients’ acuity. Of the 7 options given in the survey, the most commonly used strategies (used by 70% of units or more) were calling in regular staff RNs on their days

off, calling in regular staff RNs early, and juggling current RN staff to make do. Borrowing (“floating”) RNs from other critical care areas was the next-most-used alternative (by just more than half of the units). Floating RNs from other noncritical areas was the least favored option.

The predominant way that units in the study man-aged floating among their staff was via cluster unit floating; staff were required to float, but in a desig-nated unit only (55% of units). Among the remaining units, 2 practices were equally prevalent: in open units (23%), staff were required to float to any unit within the facility; in closed units (19%), staff were not required to float outside of their unit. The strategies used to manage sudden or emergency situations or to manage floating varied considerably by type of unit and hospital. Progressive care units were less likely than ICUs and PACUs to use on-call systems and were more likely to float RNs from non–critical care areas.

ICUs and progressive care units were more likely than PACUs to use several different approaches for managing sudden admissions or increases in patients’ acuity. They were more likely than PACUs to call in regular staff RNs on their days off, to float RNs from other critical care areas, or to use agency nurses. The reasons were not addressed in the survey. This finding may be linked to the fact that the few PACU nurses in the study used other strategies that were not listed among the options for that item. Or, perhaps PACUs did not adjust staffing for sudden situations to the same degree that ICUs and progressive care units did.

Similarly, rural hospitals were less likely than urban or suburban hospitals to use many of the strate-gies listed. Again, the reasons for this finding were not addressed in the survey. Perhaps fewer rural hospitals

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ost respondents thought that the

staffing had not been optimal up to 25% of the time in terms of the match between patients’ acuity and the nurses’ skill level or mix.

Figure 3 Percentage of 300 respondents who had perceived changes in the number of long-term “chronic critical care” patients in the preceding year.

* Bold numbers within a category (eg, facility size, setting) are significantly higher than nonbold numbers in the same category.

Decreased

Stayed the same

Increased

No answer

Feature of Percentage of facility respondents* Size, No. of beds

101-200 52 201-300 50 301-500 31 >500 54 Setting Urban 48 Suburban 50 Rural 26

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than urban/suburban hospitals had increases in the acuity of patients or in the number of patients requir-ing long-term chronic critical care. Or, perhaps rural hospitals used other approaches that were not listed in the questionnaire. Or, perhaps they did not need to make staffing adjustments to the same degree as urban and suburban hospitals did.

Visitation Policies. In the survey, respondents were asked what their unit’s family visitation policy was and were given 3 alternatives to select from, with an option to write in another response (these other responses were quite diverse). The 3 family visitation policies given were as follows: open on a scheduled basis only, open except for rounds and/or changes in shift reports, and open at all times.

Family visitation policies varied considerably by unit type and size. Units that were open on a sched-uled basis only (eg, hourly, every 2 hours for a speci-fied time, or some other schedule) were almost always ICUs or progressive care units; very few respondents from PACUs reported having this policy (Figure 4).

Policies varied even within unit type. Most ICUs were open on a scheduled basis only (44%). But, ICUs also commonly had a policy of being open except for rounds and/or changes in shift reports (31%). The per-centage of progressive care units that were open at all times (36%) did not differ significantly from the per-centage that were open on a scheduled basis only (34%). Not surprisingly, most (84%) of the few PACUs in this

study used some other family visitation policy than the 3 just listed (Figure 4). Smaller units (<30 operat-ing beds) were more likely than large units to have a policy of being open except for rounds and/or changes in shift reports. Larger units (≥30 beds) were more likely than other units to be open at all times.

End-of-Life Care. Respondents were also asked what policies they initiated for managing patients when the goals of care changed from aggressive care to comfort care. Again, they were given 3 alternatives to select from, with an option to write in another response (these other responses varied widely). The 3 comfort care policies that they were given were pallia-tive care standards, end-of-life care standards, and hospice services in the unit.

Comfort care policies varied considerably by type of unit. Progressive care units (86%) and ICUs (75%) were most likely to have comfort care policies. Among both progressive care units and ICUs that did have policies, palliative care standards and end-of-life care standards were equally prevalent. Progressive care units were more likely than ICUs to also imple-ment hospice services in the units (Figure 5). Most PACUs (71%) did not have comfort care standards or those policies were not applicable to their units. Those that did have policies tended to use policies that dif-fered from the policies listed in the questionnaire.

In terms of facility types, smaller hospitals (101-300 operating beds) were more likely to use hospice services in the unit than were larger hospitals. Urban and rural facilities were most likely to initiate palliative care standards, whereas suburban hospitals imple-mented a variety of approaches. Nongovernment, not-for-profit institutions were less likely than government, nonfederal facilities to have any comfort care policies. Overall, about 1 in 4 critical care units reported using some type of end-of-life protocol, and this

find-M

ost intensive care units were open

for family visitation on a scheduled basis only; larger units were more likely to be open all the time.

Table 8 Factors considered in determining the number of nurses needed for basic staffing plan by type of facility and unit

Percentage of units or facilities responding* Unit type Recovery/ postanesthesia care (n = 31) 84 32 26 10 23 Progressive care (n = 90) 90 49 60 28 20 Adult intensive care (n = 118) 90 85 64 25 14 Factor considered

Expected patient census Specialized skills needed Skill mix of nurses Formal acuity system Other

Unit size, No. of beds <12 (n = 84) 86 71 60 29 13 Setting 12-29 (n = 150) 89 73 59 25 17 >30 (n = 57) 91 40 65 32 28 Urban (n = 198) 87 69 62 33 16 Suburban (n = 46) 94 65 50 17 20 Rural (n = 47) 85 57 64 17 28

* A bold number within a category (eg, within Unit type, Unit size, Setting) is significantly higher than nonbold numbers within the same category.

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ing was consistent across most types of units and facilities studied. The one exception was among urban hospitals, where an end-of-life protocol was somewhat more prevalent than it was in suburban facilities.

Administrative Structure. Slightly more than half of the units (55%) surveyed had formalized shared

governance through written bylaws and staff-directed committees, mostly at a facility-wide level. Units with a formalized structure were more likely to be PACUs (particularly when compared with progressive care units), rural hospitals, and smaller units with fewer than 30 operating beds.

Figure 4 Family visitation policy.

* A bold number within a category (eg, within Unit type, Unit size) is significantly higher than nonbold numbers within the same category. Num-bers of units do not total 300 because of “no answer” responses, units unspecified, and exclusion of atypical units (eg, neonatal and pediatric intensive care units).

Percentage of 300 units

0 20 40 60 80 100

Open on scheduled basis only Open except for rounds/shift changes Open at all times

Other No answer Adult intensive care (n = 118) 44 31 14 9 2 Unit type

Unit size, No. of beds Progressive care (n = 90) 34 8 36 19 3 Recovery/ postanesthesia care (n = 31) 3 0 7 84 6 12-29 (n = 150) 35 26 20 19 0 >30 (n = 57) 32 9 35 23 2 <12 (n = 84) 31 25 18 20 6 Percentage of responding units*

Figure 5 Services initiated when goals changed to comfort care.

Totals exceed 100% because of multiple mentions.

* A bold number within a unit (eg, within intensive care) is significantly higher than nonbold numbers in other units. An italic number is signifi-cantly higher than nonitalic numbers, but signifisignifi-cantly lower than bold numbers. Numbers of units do not total 300 because of “no answer” responses, units unspecified, and exclusion of atypical units (eg, neonatal and pediatric intensive care units).

Percentage of 300 units

0 20 40 60 80 100

Palliative care standards End-of-life care standards Hospice services in the unit

Physician writes orders Transfer to appropriate unit Other None Not applicable No answer Adult intensive care (n = 118) 53 46 14 4 5 11 23 0 2

Percentage of units that initiated each service* Progressive care (n = 90) 56 42 27 2 1 14 11 0 3 Recovery/ postanesthesia care (n = 31) 3 3 0 0 7 39 45 26 10

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Documentation. Overall, 42% of the critical care units surveyed used an electronic documentation sys-tem. These units were more likely to be ICUs and pro-gressive care units, smaller hospitals (up to 300 operating beds), suburban hospitals, and nongovern-ment, not-for-profit hospitals. The majority of critical care nurses (83%) could access the Internet in their units as a resource for their nursing practice. Nurses in large hospitals (>500 operating beds), mid-sized hospi-tals (201-300 beds), and mid-sized units (12-29 beds) had even greater Internet access than did other nurses.

Recognition. Nursing recognition awards were presented in 84% of the units in the study. The awards were often presented on multiple levels, usually including the facility level (62% of respondents), but nurses were also commonly awarded at the nursing department (41%) and unit levels (39%).

Nursing recognition awards had a variety of forms, depending on what nurses were being recog-nized for. Public acknowledgment was an often-used reward across different activities. Many facilities rewarded a particular achievement in several ways. As indicated in Table 9,

• Almost all facilities rewarded nurses for years of service at the facility, usually via public acknowledg-ment or a gift (about two thirds of facilities) or often with a letter (30%).

• About three quarters of facilities recognized nurses for certification, mostly through public acknowl-edgment (42% of facilities) or bonuses (25%).

• About half to two thirds of facilities rewarded nurses for volunteer and research/scholarly activities, respectively, again usually through public acknowl-edgment.

• About 7 in 10 facilities did not recognize associ-ation membership at all. (Smaller units and suburban/ rural hospitals were less likely to reward membership than were larger units with ≥30 beds and urban

hospi-tals.) Similarly, about 8 in 10 facilities surveyed offered no financial support for association membership, and this finding was consistent across all types and sizes of facilities.

Professional Advancement. Most of the hospitals in the study (84%) offered financial support to nurses for continuing education. This support most often was in the form of paid registration or paid time off for local or regional/national meetings (in about two thirds of units).

Progressive care nurses were less likely than ICU or PACU nurses to receive support for continuing edu-cation. The same was true for nurses in government nonfederal hospitals, compared with nurses in non-government not-for-profit facilities. Small to mid-sized units (≤29 operating beds) were more likely than large units to offer paid time off for meetings.

Filling Vacancies. The total number of budgeted RN FTE positions in the critical care units in the recent months before the survey was up to 50 or more (mean 34 positions). The total number of open/unfilled budgeted RN FTE positions (excluding contract) was up to 10 or more. But 40% of units had minimal num-bers of unfilled positions. Specifically, 19% had no unfilled positions and 21% had 1 or 2 open positions. On average, units had 4 open/unfilled positions.

The mean vacancy rate was 11.8%. This rate was slightly higher than the 10.8% vacancy rate reported facility-wide. The vacancy rate was calculated by dividing the mean number of unfilled positions (4) by the mean total number of budgeted RN positions (34).

The actual total number of RNs (individuals) in the units was up to 70 or more; about half of the units had between 20 and 49 RNs. The mean number of individuals working in the units was 38. Total num-bers of RN FTEs working in the units seemed lower than the total number of RNs working there; this find-ing was not surprisfind-ing because of the number of

part-Table 9 Percentages of 300 units responding in which nurses were recognized for activities*

Recognition Public acknowledgment Bonus Plaque Letter Gift None Other No answer Certification 42 25 13 12 2 23 11 4 Association membership 13 2 1 3 <1† 65 11 8 Research/ scholarly activities 47 3 2 9 1 31 16 5 Volunteer activities 31 3 1 10 1 42 17 5 Years of service at facility 61 10 11 30 63 4 14 3

*Totals exceed 100% because of multiple mentions.

Less than 1 2of 1%.

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time staff (fewer units had ≥50 RN FTEs). But these numbers should be viewed with some discretion because 20% of the units did not provide information on RN FTEs. Thirty-four percent of units used RN FTEs that were contract staff (including travelers and local external agencies).

Slightly more than half of the units surveyed (52%) reported that their numbers of budgeted RN positions had not changed since the previous 12-month period. Twenty-seven percent of units, however, had experienced an increase in the number of bud-geted positions; these were more likely in suburban facilities than in urban/rural ones. The number of bud-geted RN positions had decreased among 17% of units, particularly units in larger hospitals (the number of positions in smaller hospitals was more likely to have remained unchanged).

The turnover rates for ICUs, progressive care units, and PACUs were 11.2%, 13.3%, and 6.5%, respectively.

Turnover rates were determined by dividing the mean number of terminations by the mean number of RNs on the unit’s payroll.

More than half of the respondents did not have data available on the number of days required to fill a vacant RN position in their units or were unable to answer the question. Among those who provided information, it took a mean of 66 days to fill a vacant post, although some units required more than 120 days. Progressive care units (mean 90 days), followed by ICUs (mean 62 days), took the longest to f ill vacancies. PACUs were able to fill vacant RN posi-tions quickly in comparison (mean 33 days).

Orientation Programs.About 8 in 10 units in the study reported having clinical rotations of not-yet-licensed students in their units and hiring newly licensed RNs (Table 10).

Respondents from more than 80% of units reported having standardized orientation programs for all

Table 10 Orientation to critical care by unit type and facility size*

Unit type Recovery/ postanesthesia care (n = 31) 61 32 65 71 7 26 6 23 3 36 90 68 94 7 35 13 13 26 6 Progressive care (n = 90) 83 90 89 93 6 39 23 16 10 7 87 74 94 12 43 18 16 7 4 Adult intensive care (n = 118) 85 82 85 88 4 19 19 23 23 12 88 69 96 11 31 17 20 18 3 Not-yet-licensed students have a clinical

rotation on unit

Unit hires newly licensed registered nurses Newly licensed registered nurses

A standardized program is used for all orientees

Preceptors are assigned to each orientee Mean length of orientation, days

<30 30-59 60-89 90-119 >120 No answer

New-hire experienced registered nurses A standard program is used for all

orientees

Components are individualized for each nurse

Preceptors are assigned to each orientee Mean length of orientation, days

<15 15-30 31-45 46-60 >60 No answer Facility size, No. of beds Total (N = 300) 82 80 84 88 6 28 19 19 16 13 88 71 96 10 35 16 18 16 4 101-200 (n = 46) 59 63 72 78 4 35 15 13 11 22 83 57 94 17 41 15 2 17 7 >201 (n = 244) 87 85 87 91 6 27 19 20 18 10 89 74 97 9 34 16 21 16 4

* A bold number within a category (eg, within Unit type, Facility size) is significantly higher than nonbold numbers within the same category.

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newly licensed RNs and for all newly hired experi-enced RNs. Almost all units assigned preceptors to all orientees. In most units, components of the orientation were individualized for each newly hired experienced RN. But, individualization was not quite as commonly practiced as were implementing standardized pro-grams and assigning preceptors (Table 10). ICUs and progressive care units and larger hospitals (>200 beds) were more likely to have orientation programs in place for newly licensed RNs.

Almost all units, including recovery room/PACUs, had standardized orientation programs for newly hired experienced RNs. But larger hospitals were more likely to have individualized components for each experienced nurse.

The orientation programs for newly licensed RNs range varied considerably in length; some exceeded 120 days. The median length was 60 days, and the mean length was 80 days (the mean was skewed higher by a few facilities that had lengthy programs). The longest orientation programs were more likely to be run by ICUs; a higher proportion of progressive care units than ICUs had programs that lasted only 30 to 59 days. (Many of the few PACUs in this study did not provide information, making any comparisons difficult.)

Orientation programs for newly hired experienced RNs were shorter than such programs for newly licensed RNs. Some programs lasted more than 60 days; more than one third of programs lasted between 15 and 30 days. The mean duration of an orientation program was 45 days. Again, the longest programs were more likely to be conducted by ICUs and also PACUs; a higher proportion of progressive care units had pro-grams that lasted 30 days or less. Larger facilities (>200 operating beds) and urban and rural hospitals were also more likely than other hospitals to run longer programs for newly hired experienced RNs.

Wages.Survey respondents reported that the mean hourly wage of RNs employed in the unit at entry level was $21. The entry-level wage paid most often was $18 to $19 per hour (27% of units). With 10 years of experi-ence, the mean hourly wage of RNs increased to $27 (with most nurses earning between $22 and $29).

Wage rates were the same among nurses who worked in ICUs, progressive care units, and recovery rooms/PACUs. Government nonfederal hospitals paid higher wages than did nongovernment, not-for-profit institutions. Hospitals with 201 to 300 operating beds paid the lowest wages.

Entry-level wages were the same among small and large units and among urban, suburban, and rural hospitals. However, more of a wage discrepancy was apparent among experienced nurses. With 10 years of

experience, RNs in large units earned more than did those in the smallest units (<12 beds). Experienced RNs in urban and suburban facilities earned higher wages than did those in rural hospitals.

Advanced Practice Nursing. Forty-two percent of critical care units surveyed had hospital-employed clini-cal nurse specialists allocated to their units. In almost all cases, one clinical nurse specialist was assigned to the unit. Far fewer units (16%) had been allocated hos-pital-employed nurse practitioners, especially smaller units. It was more often the larger units (≥30 operating beds) that were assigned nurse practitioners. The num-ber of nurse practitioners assigned to a unit varied among the small number of units that had them.

A greater proportion of ICUs and progressive care units than PACUs had clinical nurse specialists assigned to them. Units in larger hospitals (>300 oper-ating beds), urban hospitals, and academic medical centers (which tended to be larger), and government nonfederal facilities were more likely than units in other institutions to have a clinical nurse specialist. We found no significant relationship between the size of a unit and the presence of a clinical nurse specialist. Most clinical nurse specialists earned an hourly wage at entry level of between $24 and $34, for a mean wage of $29 per hour. With 10 years of experi-ence, the mean hourly wage for clinical nurse special-ists had increased to $34 (with wages mostly concentrated between $26 and $34 per hour). The number of respondents providing information about nurse practitioners’ wages was too small for analysis.

Conclusion

More details about facilities and units serving criti-cally ill patients are now available as a result of the AACN national critical care survey. We have more information about the scope and intensity of services offered and more specific figures about staffing issues and unit practices than has been accessible before. Healthcare providers can use this information for benchmarking purposes, especially in instances in which the tables provide the information for the same type of critical care unit. The methods for obtaining this information have now been tested, and adjustments can be made to increase response rates in future surveys.

A

lmost half of the units had a clinical nurse specialist allocated to their unit, whereas only 16% had been allocated nurse practitioners.

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This article offers a broad overview of the find-ings, and additional articles are planned that will focus more closely on specific areas of the findings, for example, the similarities and differences we vali-dated between ICUs and progressive care units.

The full report of f indings from the AACN national critical care survey is available through AACN at www.aacn.org or by calling 800-899-2226.

ACKNOWLEDGMENTS

Mi-Kyung Song and Rick Voland assisted with initial data analysis, and Elfa Gretars-dottir assisted with preparation of the tables and figures.

Commentary by Mary Jo Grap (see shaded boxes).

REFERENCE

1. Halpern NA, Pastores SM, Greenstein RJ. Critical care medicine in the United States 1985-2000: an analysis of bed numbers, use, and costs. Crit

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Study Synopsis: This study reports on the findings of AACN’s national critical care survey, which was developed to provide information focusing on critical care nursing, including issues related to workforce, compensation, and care issues specific to critical care units and nurses. Descrip-tive survey information was obtained from 300 critical care units of 120 hospitals nationwide. Participants completed facility and unit survey questionnaires that assessed informa-tion on operainforma-tions, staffing, quality indicators, acuity sys-tems, administrative structure, and other aspects of nursing practice. Responding facilities include academic and general medical and surgical hospitals in urban, suburban, and rural settings with from 50 to more than 500 beds. The results of the survey provide important information on acute and criti-cal care nursing practice including staffing, documentation systems, shared governance, wages, and nursing recognition awards; unit characteristics include orientation programs, family visitation policies, end-of-life protocols, and charac-teristics of patients such as length of stay and acuity levels. The results of the national survey provide data on facilities and units serving critically ill patients that were not previ-ously known. Additionally, the survey results offer important information on critical care practices that can be used for benchmarking purposes.

A. Description of the Study

• What were the objectives of the research?

• What specific information was collected on facility and unit practices?

B. Literature Evaluation

• What previous research has been conducted evaluating critical care practices?

• What contributions does the current study make to the research literature?

C. Sample

• How were specific units and hospitals identified for study participation?

D. Methods and Design

• What specific instruments were used in the study? • How were the instruments developed and tested? • What was the procedure used to contact sites and

obtain survey responses?

E. Results

• How did the respondents compare to national facilities with respect to size and geographic location?

• Why was a weighted profile developed? • What were important facility-based findings? • What were important unit-based findings?

F. Clinical Significance

• What are implications of the survey for critical care nursing?

Information From the Authors:Karin Kirchhoff, RN, PhD,lead author of this journal club article, provided addi-tional information about the study. She relates “AACN was the initiator of this research effort. We developed the topics to be covered and the questions to be used. This paper reports on the major findings of the study.”

Kirchhoff adds that the study results have important implications for critical care nursing. She states “The data can be useful for benchmarking. For example, the study provides information on what units are doing about traveling with patients for procedures—whether it is a common prac-tice, and if not, what could we do instead?”

Kirchhoff reports that additional information on the study is available. She relates “The full study report is avail-able from AACN. There are many data tavail-ables that provide additional study information.” She adds “Another use for the study data is to query the results as issues arise in the unit so that you can see what others might have thought of, for instance with respect to nursing staffing, or what units have in place for EOL [end-of-life] issues.”

Implications for Practice:This national survey provides helpful information on facilities and units providing care to critically ill patients. The study findings provide information to institutions as well as to the critical care community on aspects of critical care nursing, unit, and facility practices. Kirchhoff highlights the significance of the national AACN survey and adds “This is the first report of some of these variables by type of unit. Also the inclusion of other units such as PACUs [postanesthesia care units] gives us a better idea of how the patient transitions and what the issues are there.”

Journal Club feature commentary is provided by Ruth Kleinpell.

I

n a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club par-ticipants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice.

When critically appraising this issue’s AJCCjournal club article, “American Association of Critical-Care Nurses’ National Survey of Facilities and Units Providing Critical Care,”consider the questions and discussion points listed below.

Figure

Table 1 Profile of facilities surveyed

Table 1

Profile of facilities surveyed p.3
Table 2 Descriptive statistics of facilities (N = 120) with critical care units

Table 2

Descriptive statistics of facilities (N = 120) with critical care units p.4
Table 3 Facilities’ plans for Magnet-designated nursing services

Table 3

Facilities’ plans for Magnet-designated nursing services p.5
Table 5 Percentages of each unit type among small, medium, and large units*

Table 5

Percentages of each unit type among small, medium, and large units* p.6
Figure 2 Total number of operating beds in the unit.

Figure 2

Total number of operating beds in the unit. p.7
Table 7 Perceived changes in patients’ acuity in the preceding year by type of facility

Table 7

Perceived changes in patients’ acuity in the preceding year by type of facility p.8
Figure 3 Percentage of 300 respondents who had perceived changes in the number of long-term “chronic critical care” patients in the preceding year.

Figure 3

Percentage of 300 respondents who had perceived changes in the number of long-term “chronic critical care” patients in the preceding year. p.9
Table 8 Factors considered in determining the number of nurses needed for basic staffing plan by type of facility and unit Percentage of units or facilities responding*

Table 8

Factors considered in determining the number of nurses needed for basic staffing plan by type of facility and unit Percentage of units or facilities responding* p.10
Figure 4 Family visitation policy.

Figure 4

Family visitation policy. p.11
Figure 5 Services initiated when goals changed to comfort care.

Figure 5

Services initiated when goals changed to comfort care. p.11

References

Updating...