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org APRIL-JUNE 2016

AACN

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

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 AACN
A d v a n c e d
Cr i t i c a l Ca r e
Co n t e n t s
F E AT U R E S

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

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

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

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

SYMPOSIUM
PAT I E N T A N D FA M I LY P O S T – I N T E N S I V E C A R E S Y N D R O M E
Judy E. Davidson, RN, DNP, and Maurene A. Harvey, MPH,
Symposium Editors

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

Judy E. Davidson and Maurene A. Harvey

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

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

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

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

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

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

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

Mark E. Mikkelsen, James C. Jackson, Ramona O. Hopkins, Carol Thompson,
Adair Andrews, Giora Netzer, Dina M. Bates, Aaron E. Bunnell, LeeAnn M. Christie,
Steven B. Greenberg, Daniela J. Lamas, Carla M. Sevin, Gerald Weinhouse, and
Theodore J. Iwashyna
 VOLUME 27 • NUMBER 2
APRIL-JUNE 2016

D E PA RT M E N T S

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

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

1 4 5 Issues in Advanced Practice

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

1 5 2 Creating a Healthy Workplace

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

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

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

2 3 6 Ethics in Critical Care

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

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

Earnest Alexander, PharmD Cynda Hylton Rushton, RN, PhD

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

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

Medication Management to Ameliorate

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

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

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

In the ICU
Glucose Dysregulation
Both hyperglycemia and hypoglycemia are associated with cognitive dys-
function in critically ill patients. Hyperglycemia decreases cerebral blood flow,
Joanna L. Stollings is Clinical Pharmacy Specialist in the Medical Intensive Care Unit (MICU) and Pharma-
cist in the ICU Recovery Center, Department of Pharmaceutical Services, Vanderbilt University Medical
Center, 1211 Medical Center Drive, BUH-131, Nashville, TN 37232 (joanna.stollings@vanderbilt.edu).
Sarah L. Bloom is Acute Care Nurse Practitioner in the MICU and the ICU Recovery Center, Department
of Medicine, Vanderbilt University Medical Center.
Elizabeth L. Huggins is Acute Care Nurse Practitioner, Department of Medicine, Vanderbilt University
Medical Center.
Scottie L. Grayson was a patient in the ICU Recovery Center at Vanderbilt University Medical Center.
James C. Jackson is Neuropsychologist and Assistant Director of the ICU Recovery Center, Center for
Health Services Research, Department of Medicine, Department of Psychiatry, Vanderbilt University
Medical Center, and Geriatric Research, Education and Clinical Center (GRECC) Service, Department
of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee.
Carla M. Sevin is Assistant Professor of Medicine and Director of the ICU Recovery Center, Vanderbilt
University Medical Center.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016931

133
Drug Update
injures the vascular endothelium, increases
permeability of the blood-brain barrier, and
increases excitatory neurotransmitter release
and resultant neuronal death.8 A retrospective
study of 74 survivors of acute respiratory
distress syndrome (ARDS) demonstrated that
having a blood glucose value of 153.5 mg/dL
(to convert to millimoles per liter, multiply
by 0.0555) was associated with a 2.9 times
greater chance of cognitive impairment.3
Additionally, a retrospective, case-control
study of 37 surgical ICU patients who had
experienced at least 1 episode of hypoglyce-
mia during treatment showed that cognitive
dysfunction, specifically in visuospatial skills,
was higher in the hypoglycemia group than
in the control group (P < .01).4
Hyperglycemia is also a risk factor for
critical illness polyneuropathy (CIP) and
critical illness myopathy (CIM). Insulin has
anti-inflammatory effects, protects endothe-
lium, improves the metabolism of lipids, and
is an anabolic hormone.7 Intensive insulin
therapy (maintaining blood glucose levels
between 80 and 100 mg/dL) in surgical ICU
patients decreased neuropathy from 51.9%
to 28.7%. Also, intensive insulin therapy
decreased the prevalence of CIP and CIM
from 49% to 25% in surgical ICU patients
(P < .001) and from 51% to 39% in the
medical ICU (P = .02) in patients who had an
ICU stay of at least 1 week.9,10 Moreover, the
percentage of patients receiving mechanical
ventilation for at least 2 weeks was reduced
from 42% to 32% in the surgical ICU (P = .04)
and from 47% to 35% in the medical ICU
(P = .01).9,10 However, a subsequent study,
NICE-SUGAR,11 showed increased mortality
in the intensive insulin group (27.5%) com-
pared with conventional glucose control (< 180
mg/dL; 24.5%; P = .02). On the basis of that
study, SCCM guidelines for the use of an insu-
lin infusion in critically ill patients suggests
that patients with a blood glucose level of
150 mg/dL or greater receive an intervention
to maintain blood glucose level at less than
180 mg/dL while avoiding hypoglycemia.12
Pain, Agitation, and Delirium
The pain, agitation, and delirium (PAD)
guidelines13 were published by SCCM in 2013
and summarize the best evidence available for
providing physical and psychological comfort
through management of PAD. A program
called the ICU Liberation Collaborative has
134
W W W .AACN ACCON LIN E .ORG
been started by SCCM to aid in the imple-
mentation of the PAD guidelines in 77 hospi-
tals in the United States that are committed
to improving outcomes for patients and their
families.
Delirium. In 2013, a large, multicenter,
prospective observational cohort study5 of
821 adult medical and surgical ICU patients
with respiratory failure, cardiogenic shock,
or septic shock, called Bringing to Light the
Risk Factors and Incidence of Neuropsycho-
logical Dysfunction in ICU Survivors (BRAIN-
ICU), was reported. The researchers sought to
estimate the prevalence of long-term cogni-
tive impairment following critical illness.
The strongest independent predictor of cogni-
tive impairment was ICU delirium, which
was found in 50% of study patients. Three
months following hospital discharge, a Repeat-
able Battery for Neuropsychological Status
(RBANS) score similar to what has been seen
in individuals with mild Alzheimer’s disease
(2 standard deviations below the population
mean) was found in 26% of patients, and a
score similar to the scores seen in patients
with moderate traumatic brain injury (1.5
standard deviations below the population
mean) was found in 40% of patients.5
Pain. Inadequate pain management has
been associated with numerous complications,
including nosocomial infections, increased
duration of mechanical ventilation, and delir-
ium.14 The treatment of pain with opiates in
critically ill patients has been associated with
an increased risk of delirium in some studies15
and a decreased risk of delirium in others.16
Although other medications such as gabapen-
tin (Neurontin), nonsteroidal anti-inflammatory
drugs, and acetaminophen (Tylenol) are good
adjunctive therapies, opioids are the medication
class of choice for treating pain in critically
ill patients.13 The potential for the develop-
ment of delirium highlights one of the many
reasons why pain assessment in critically ill
patients is so imperative. The PAD guidelines13
recommend that all adult critically ill patients
be routinely assessed for pain. Self-reporting
of pain is considered the reference standard
for pain assessment. However, if a patient is
nonverbal, the PAD guidelines13 recommend
use of the Behavioral Pain Scale or the Criti-
cal Care Pain Observational Tool in ICU
patients who are unable to self-report pain.
Sedation. Benzodiazepines have been asso-
ciated with the development of delirium in
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table 1: Stop, THINK, and Medicate
Stop
Do any medications need to be
stopped or lowered?
Especially consider sedatives
Is patient receiving minimal
amount necessary?
Daily sedation cessation
Targeted sedation plan
Assess target daily
Do sedatives need to be changed?
Remember to assess for pain!
several studies.15,16 The PAD guidelines rec-
ommend using nonbenzodiazepine sedation
strategies (eg, dexmedetomidine [Precedex])
in delirious patients.13 Three studies17-19 have
demonstrated that patients are less likely to
remain delirious if dexmedetomidine is used.
In a double-blind, randomized, controlled
trial of 106 patients receiving mechanical
ventilation, The Maximizing Efficacy of Tar-
geted Sedation and Reducing Neurological
Dysfunction (MENDS) study,20 researchers
found that the median number of days alive
without delirium or coma was 7 in the dex-
medetomidine group versus 3 in the lorazepam
(Ativan) group (P = .01). The daily prevalence
of delirium was lower in the dexmedetomidine
group than in the lorazepam group (P = .004)
after the day of randomization.20
In a second double-blind, randomized,
controlled trial of 375 medical/surgical ICU
patients, the Safety and Efficacy of Dexme-
detomidine Compared with Midazolam
(SEDCOM) study,17 researchers found that
60.3% of dexmedetomidine patients and
59.3% of midazolam (Versed) patients were
delirious at baseline according to the Confusion
Assessment Method for the ICU. During the
study period, the prevalence of delirium was
54% in the dexmedetomidine group compared
with 76.6% in the midazolam group (P < .001).17
A pilot, phase 3, double-blind, randomized
study was conducted by Ruokonen et al18 in
2009 to compare dexmedetomidine with stan-
dard care (midazolam or propofol [Diprivan]).
Patients with a target score of 0 to -3 on the
Drug Update
THINK Medicate
Toxic situations No published studies report
that haloperidol (Haldol)
Congestive heart failure,
decreases the duration of
shock, dehydration
delirium
New organ failure (liver/kidney)
Atypical antipsychotics may
Hypoxemia decrease the duration of
delirium
Infection/sepsis (nosocomial),
immobilization Dexmedetomidine (Precedex)
may result in more days alive
Nonpharmacological interventions
without delirium and lower
Hearing aids, eyeglasses, daily prevalence of delirium
reorient, sleep protocols,
music, noise control,
ambulation
Electrolyte problems (eg,
potassium)
Richmond Agitation-Sedation Scale (RASS)
were more likely to be at the target RASS score
with dexmedetomidine (74%) than with
standard care (64%).
In a phase 3, multicenter, randomized, double-
blind trial,19 MIDEX, researchers found that
the composite outcome of agitation, anxiety,
and delirium occurred in 27% of patients who
received midazolam versus 29% of patients
who received dexmedetomidine (P = .69). In a
second phase 3, multicenter, randomized, double-
blind trial,20 PRODEX, researchers found that
the composite outcome of agitation, anxiety,
and delirium occurred in 29% of patients who
received propofol versus 18% of patients who
received dexmedetomidine (P = .008). Overall,
these studies suggest that the use of dexme-
detomidine results in increased days alive with-
out delirium and reduced daily prevalence of
delirium compared with benzodiazepines.
Management of Delirium
Nonpharmacological management of delir-
ium through risk factor reduction has been
studied in non-ICU patients, and the results
generalize to the ICU population. However,
these interventions need to be investigated
further in critically ill patients. An example
of risk-reducing strategies that can be simpli-
fied into a simple phrase “Stop, THINK, and
Medicate” is presented in Table 1.
Pharmacological interventions should be
considered only after nonpharmacological
strategies have been implemented and modifi-
able risk factors have been addressed.
135
Drug Update W W W .AACN ACCON LIN E .ORG

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

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

136
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
increased the probability of a transition to
delirium occurring. The transition from
“awake and without delirium” to “delirium”
occurred on 6% of ICU days. A 1-unit
increase in the Anticholinergic Drug Scale
demonstrated a nonsignificant increase in the
probability of a transition to delirium occur-
ring the following day (odds ratio, 1.05; 95%
CI, 0.99-1.10). However, the authors did not
evaluate whether the dose of the medication
affected the transition to delirium and also
did not consider patients who were already
delirious and remained delirious while receiv-
ing anticholinergic medications.25
Medications can also potentiate CIP and
CIM (Table 2). Neuromuscular blockers
enhance microvascular permeability, stimu-
lating denervation of the muscle in addition
to having direct toxic effects on the nerve.
Concomitant administration of steroids
enhances the toxic effects of neuromuscular
blockers on muscles. The risk of acute myop-
athy increases with coadministration of neu-
romuscular blockers and corticosteroids for
longer than 24 to 48 hours.26 Additionally,
hypermagnesemia, metabolic acidosis, and
concomitant medications including amino-
glycosides and clindamycin promote prolonged
neuromuscular blockade.27 Studies on the
effects of corticosteroids on CIP/CIM have
yielded both positive9,10 and negative28 results.
The clinical situation must be considered
when determining if the use of corticosteroids
is merited.
Careful review of the patient’s medication
list can identify potentially deliriogenic or
CIP/CIM-inducing medications. Drug/disease
state interactions and drug/drug interactions
resulting in delirium or CIP/CIM should be
considered when dosing and choosing medi-
cations.7,24 Hepatic and renal impairment can
lead to accumulation of medications, result-
ing in delirium and/or CIP/CIM if the medi-
cation dose is not adjusted appropriately.7,24
Transitions of Care
Although ADEs can occur at any time, it
has become evident in the past decade that a
significant risk for ADEs occurs during peri-
ods of transition of care.29 One of the first
studies that highlighted the medication errors
that occur during transitions of care demon-
strated that 54% of errors were made by pre-
scribers when ordering medications at hospital
admission.30 Further, many emergency room
137
Drug Update
visits and readmissions to hospitals following
discharge have been associated with medica-
tions. In response to the growing amount of
data demonstrating medication errors at tran-
sitions of care, The Joint Commission on
Accreditation of Healthcare Organizations
declared “sustaining and properly communi-
cating correct medication information” to be
a National Patient Safety Goal in 2011.
Patients with cognitive impairment or those
taking more than 5 medications per day (also
known as polypharmacy) are 2 examples of
populations of patients at higher risk for an
ADE during transitions of care.29 Addition-
ally, the number of medications a patient is
receiving is an independent risk factor for
delirium.31 “Deprescribing” is defined as the
process of tapering or discontinuing medica-
tions to minimize polypharmacy and improve
patients’ outcomes. The following 5-step pro-
tocol for deprescribing has been suggested:
(1) determine that each medication has an
indication; (2) consider the overall potential
harm of the medications in determining how
many agents should be discontinued; (3) assess
each individual drug to determine if it should
be discontinued; (4) prioritize the order of
medications to be discontinued; and (5) initi-
ate and monitor a drug discontinuation plan.
Deprescribing can be further enhanced in the
ICU by determining if medications have a cur-
rent indication. For example, a patient taking
an antihistamine at home for allergies and an
anticholinergic agent for an overactive bladder
may not need these medications when admit-
ted to an ICU with a urinary catheter.32
A single-center study33 of 120 elderly adult
ICU survivors evaluated the frequency of
prescribed potentially inappropriate medica-
tions (PIMS) and actually inappropriate med-
ications (AIMs). PIMS were defined as those
medications potentially harmful to the elderly
according to prior research and knowledge
of pharmacological effects. PIMs could then
be classified as AIMS if the benefit of the drug
was outweighed by the harm after consider-
ing a patient’s clinical circumstances. Charts
were reviewed and medications were identi-
fied as PIMS by using the 2003 Beers criteria
and medication safety data published since
2003. In order to determine where AIMS were
initiated, medications were identified at 5 dis-
tinct points during the hospital stay: admission,
medical/surgical unit admission, ICU admis-
sion, ICU discharge, and hospital discharge.
Drug Update
The most common categories of PIMS
identified at hospital discharge were the fol-
lowing: opioids, anticholinergic medications,
antidepressants, and drugs causing orthosta-
sis. The clinical panel, consisting of a hospi-
talist, geriatrician, and clinical pharmacist,
determined that 36% of these PIMs were
considered to be AIMs. At hospital discharge,
the PIM categories with the highest positive
predictive values for being AIMs included
anticholinergics (55%), nonbenzodiazepine
hypnotics (67%), benzodiazepines (67%),
atypical antipsychotics (71%), and muscle
relaxants (100%). The number of discharge
PIMS was independently predicted in multi-
variate analysis by the number of preadmis-
sion PIMs (P < .001), discharge to somewhere
other than home (P = .03), and discharge from
a surgical service (P < .001).
Also, nearly two-thirds of AIMs were initi-
ated in the ICU. It is likely that many of these
medications initiated in the ICU or at any other
time during the hospital stay may have been
appropriate for temporary or short-term use
depending on the patient’s clinical situation.
However, the failure to discontinue these
medications once no longer indicated led to
inappropriate and prolonged use. This study
further highlights the need to review patients’
medication lists daily and during transitions
of care to determine if deprescribing is merited.
In addition to the continuation of unneces-
sary medications following hospital discharge,
patients’ home maintenance medications may
not be initiated upon hospital admission. In
a large population-based Canadian cohort
study of 396 380 patients aged 66 years or
older, researchers looked at records of hospi-
tal and outpatient medications prescribed
from at least 1 of 5 of the following groups:
(1) statins, (2) antiplatelet/anticoagulant agents,
(3) levothyroxine, (4) respiratory inhalers,
and (5) gastric acid–suppressing drugs.34
Patients were divided into 3 groups: hospital-
ization with an ICU admission, hospitalization
without ICU admission, and nonhospitalized
patients (controls). Patients admitted to a
hospital without an ICU stay were significantly
more likely to have medications discontinued
among all 5 of the medication groups com-
pared with control patients. Also, patients
admitted to a hospital with an ICU stay were
significantly more likely to have medications
discontinued among all 5 of the medication
groups compared with control patients.
138
W W W .AACN ACCON LIN E .ORG
The risk of medication discontinuation
was higher in all medication groups with the
exception of respiratory inhalers in patients
hospitalized with an ICU admission, compared
with patients hospitalized without an ICU
admission. The composite risk of death,
hospitalization, and emergency department
visits up to 1 year after hospital discharge
in all study patients was significantly higher
in patients in whom a statin or antiplatelet
or anticoagulant was discontinued. As this
study was retrospective, the clinical reasons
why long-term medications were discontin-
ued could not be delineated. However, this
study highlights the importance of medication
reconciliation with changes in patients’ status
and transitions of care to prevent errors of
omission in the patient’s discharge medication
list when leaving the hospital.
Post-ICU Clinics
Fifty percent of patients who are readmitted
within 30 days of discharge did not have a
posthospitalization visit to a primary care
provider. Lack of understanding of home and
discharge medications was a contributing fac-
tor to readmissions.29 Readmissions occurred in
20% of Medicare recipients within 30 days of
discharge and in 34% within 90 days of dis-
charge in 1 study.35
One method of smoothing the transition
back to a primary care provider following an
ICU stay is use of a post-ICU clinic. Primary
care providers may not be familiar with the
specific critical care issues seen in patients
following critical illness and may not have the
tools to assess and manage these complications.
An interdisciplinary team of individuals in a
post-ICU clinic can use their expertise about
specific complications related to critical care
to aid in the diagnosis and treatment of PICS.
Medication therapy review, reconciliation,
and counseling should all be considered cru-
cial parts of a patient’s visit to a post-ICU
clinic. These functions are ideally performed
by a pharmacist. The steps of the complete
medication use process are listed in Table 3.
Patient Testimonial
Scottie Grayson is a 42-year-old man who
had a 30-day hospitalization after a witnessed
ventricular arrest with subsequent acute kidney
injury, prolonged ventilation, and heparin-
induced thrombocytopenia who was seen
at the ICU Recovery Center at Vanderbilt
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table 3: The Complete Medication Use
Process
1. Before clinic visit: review of patient’s chart for
medical history, hospital course, and medications
2. Medication reconciliation: compare and recon-
cile medication lists before, during, and after
hospitalization
3. Medication therapy review: ensure that each
medication has an appropriate indication
4. Patient interview: identify adverse drug events,
identify any untreated problems
5. Patient counseling: review medication indica-
tion, directions, potential adverse effects, and
monitoring
6. Assessment: review barriers to obtaining medi-
cations, promote medication regimen adherence,
and order any needed laboratory tests
7. Conclusion of visit: discuss medication changes
and patient’s follow-up plan
University Medical Center. The following is
Mr Grayson’s testimonial regarding how tar-
geted medication interventions affected his
post-ICU recovery:
Recently I suffered a cardiac arrest and
spent 30 days in Vanderbilt Medical
Center. When I returned home I was
shocked to learn that I was bringing
home 11 prescriptions for a total of
24 pills a day. For someone who was
taking zero prescriptions previously,
it was very overwhelming. I repeatedly
had to ask my wife what all these pills
were for and if I really needed them.
Although the staff had gone over all
these medications with my wife, I was
in the dark. During my first few weeks
home, I was in a fog. I don’t know
how much of it was the medication
and how much of it was my body still
healing from the trauma. I believe I
would have been less anxious and
overwhelmed if I personally would
have had a better understanding of
what all the medications had been for.
The complete medication review by the
pharmacist at the ICU Recovery Center
at Vanderbilt helped me to feel better
about my medications.
During his visit at the ICU Recovery Center at
Vanderbilt, Mr Grayson was provided a pill
139
Drug Update
caddy to help organize his medications. Addi-
tionally, 3 medications, omeprazole, sodium
bicarbonate, and quetiapine, started for acute
needs in the hospital, were discontinued.
Conclusion
Medication management strategies in the
ICU, upon transition to the medical/surgical
unit, and after hospitalization are critical to
preventing and treating PICS. Glucose man-
agement strategies, delirium prevention and
treatment, and avoidance or proper dosage
adjustment of deliriogenic or neuromuscular
weakness–inducing medications are all strate-
gies to prevent PICS.
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Critical care and the global burden of critical illness in
adults. Lancet. 2010;376(9749):1339-1346.
2. Needham DM, Davidson J, Cohen H, et al. Improving
long-term outcomes after discharge from intensive
care unit: report from a stakeholders’ conference. Crit
Care Med. 2012;40(2):502-509.
3. Hopkins RO, Suchyta MR, Snow GL, Jephson A, Weaver
LK, Orme JF. Blood glucose dysregulation and cognitive
outcome in ARDS survivors. Brain Inj. 2010;24(12):
1478-1484.
4. Duning T, van den Heuvel I, Dickmann A, et al. Hypo-
glycemia aggravates critical illness-induced neurocog-
nitive dysfunction. Diabetes Care. 2010;33(3):639-644.
5. Pandharipande PP, Girard TD, Jackson JC, et al. Long-
term cognitive impairment after critical illness. N Engl
J Med. 2013;369(14):1306-1316.
6. Jackson JC, Girard TD, Gordon SM, et al. Long-term
cognitive and psychological outcomes in the awakening
and breathing controlled trial. Am J Respir Crit Care
Med. 2010;182(2):183-191.
7. Apostolakis E, Papakonstantinou NA, Baikoussis NG,
Papadopoulos G. Intensive care unit-related generalized
neuromuscular weakness due to critical illness poly-
neuropathy/myopathy in critically ill patients. J Anes-
thesia. 2015;29(1):112-121.
8. Jackson JC, Ely EW. Cognitive impairment after critical
illness: etiologies, risk factors, and future directions.
Semin Respir Crit Care Med. 2013;34(2):216-222.
9. Van den Berghe G, Schoonheydt K, Becx P, Bruyninckx
F, Wouters PJ. Insulin therapy protects the central and
peripheral nervous system of intensive care patients.
Neurology. 2005;64(8):1348-1353.
10. Hermans G, Wilmer A, Meersseman W, et al. Impact of
intensive insulin therapy on neuromuscular complica-
tions and ventilator dependency in the medical inten-
sive care unit. Am J Respir Crit Care Med. 2007;175(5):
480-489.
11. NICE-SUGAR Study Investigators, Finfer S, Chittock DR,
et al. Intensive versus conventional glucose control in
critically ill patients. N Engl J Med. 2009;360(13):1283-1297.
12. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the
use of an insulin infusion for the management of
hyperglycemia in critically ill patients. Crit Care Med.
2012;40(12):3251-3276.
13. Barr J, Fraser GL, Puntillo K, et al. Clinical practice
guidelines for the management of pain, agitation, and
delirium in adult patients in the intensive care unit.
Crit Care Med. 2013;41(1):263-306.
14. Chanques G, Jaber S, Barbotte E, et al. Impact of sys-
tematic evaluation of pain and agitation in an intensive
care unit. Crit Care Med. 2006;34(6):1691-1699.
Drug Update W W W .AACN ACCON LIN E .ORG

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

CE Test Instructions

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

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

140
 AACN Advanced Critical Care
Volume 27, Number 2, pp. 141-144
© 2016 AACN

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

Today CNS, CPHQ, CENP, CPHIMS
Department Editor

Analytics 1.0, 2.0, 3.0

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

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

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

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

Nomenclature of 1.0, 2.0, 3.0

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

Linda Harrington is an Independent Consultant, Health Informatics and Digital Strategy, and Professor,
Baylor College of Medicine, One Baylor Plaza, Houston, Texas 77030 (linda.harrington@gmail.com).
The author declares no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016285
141
Technology Today
Analytics 1.0: Descriptive Analytics
Analytics 2.0: Predictive Analytics
Traditional approach
Uses small amounts of Enabled by big data
retrospective data
Provides information on trends
Does not directly yield
Does not directly yield
actionable information
actionable information
Figure: Key differences in analytics 1.0, 2.0, and 3.0.
nomenclature has been around for years and is
denoted as 1.0, 2.0, and so on, signifying sub-
stantial changes in the software or program-
ming. Minor changes, updates, or upgrades are
more often denoted as 1.1, 1.2, and so on and
are sometimes broken down further into 1.1.1
and 1.1.2. The nomenclature of 1.0, 2.0, and
3.0 is similarly used here to outline significant
changes in analytic endeavors within a health
care organization.
Analytics 1.0, 2.0, 3.0
The 3 currently recognized stages of analyt-
ics are illustrated in the Figure. Each type of
analytic denotes significant advancements from
the previous stage. As can be seen, descriptive
analytics will continue but will play a smaller
and smaller role as the more valuable predictive
and then prescriptive analytics come into play.
Analytics 1.0: Descriptive Analytics
Traditional-data analytics use descriptive
statistics that are based on a small amount
of historical or retrospective data to identify
issues and/or generate reports.1 Data are
extracted that occur at one particular point
in the past or several points over longer peri-
ods of time but are predefined in terms of
the data being captured from the past. Data
extraction often uses manual processes.
Analytics 1.0 does not directly yield action-
able information. Decisions based on the
descriptive analyses of 1.0 are identified by
using root cause analyses, best practices, or
evidence-based practices affording limited
amounts of change. Data analysts focus largely
142
W W W .AACN ACCON LIN E .ORG
Analytics 3.0: Prescriptive Analytics
Uses big data
Enabled by real-time, streaming data
Optimal behaviors or actions are
suggested at the point of decision
Important for individuals involved
in self-management of their health
Drives transformation
on collecting and preparing data for analysis
and reporting.
Analytics 2.0: Predictive Analytics
Analytics 2.0 is powered by big data allow-
ing predictive analytics.2 The term big data is
defined as “data . . . too big to fit on a single
server, too unstructured to fit into a row-and-
column database, or too continuously flow-
ing to fit in a static data warehouse.”2(p1) It is
often described by the so-called “3 V’s” of
volume, variety, and velocity or “4 V’s” if
you add value; however, this simplistic descrip-
tion is lacking. How precisely can we define
variety and will a large volume of data today
be a large volume tomorrow?
Big data analytics differs markedly from
the traditional analytics 1.0. Analytics 2.0
includes unstructured data, such as radiology
images and electrocardiograms, is 100 tera-
bytes to petabytes, deals with a constant flow
of data, and the data are analyzed by using
technologies specific for big data that differ
from the technologies used with traditional
analytics.2 An example is natural language
processing used to analyze free text entered
into the EHR by clinicians.
Predictive analytics provide illustrations
of trends in data that inform users of past
tendencies and can be used to predict future
tendencies. Similar to descriptive analytics,
predictive analytics do not directly yield
actionable information. Clinicians combine
the prediction with best evidence and the
individual’s unique circumstances to deter-
mine what actions to take.
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Making the transition from descriptive ana-
lytics to predictive analytics should be part of
nursing’s strategic plan. If an organization is
currently using descriptive analytics, the
addition of predictive analytics is important
for providing more advanced information. This
transition is essential not only for nursing prac-
tice but also for advancement of the discipline.
Nursing’s participation in the big
data and data science initiatives
now underway is essential to
ensure that the discoveries not
only be shaped by our profession’s
unique understanding of the
patient experience but also that
the discoveries lead to knowledge
that is useful to nursing.3(p477)
Analytics 3.0: Prescriptive Analytics
Analytics 3.0 makes a significant advance-
ment by adding the more beneficial prescrip-
tive analytics at the point of decision.1,4
Prescriptive analytics are embedded in opera-
tional and decision processes suggesting opti-
mal behaviors and actions both for clinicians
and for people involved in self-management
of their health or illness.
Prescriptive analytics are enabled by incor-
porating real-time, streaming data composed
of continuous, rapid data from a variety of
sources. The physical data of humans is contin-
uous and can change quickly and insidiously.
The vast majority of real-time or continuous
data are not currently collected, stored, and
analyzed but they will be in the future because
these continually streaming physical data are
what make real-time analytics for prescribing
decisions possible at the point of care.
The ultimate benefit of prescriptive analytics
surrounds speed and impact.4 In health care,
this equates to prompt and effective preven-
tion, early intervention, avoidance of compli-
cations, value, and transformation. Decisions
about individuals built on their historical
data, such as occurs with descriptive and
predictive analytics, are insufficient to affect
the individuals’ current situation.
Discussion
Achieving the purpose of better decision
making through analytics requires careful
consideration. This requirement is in part
due to competing demands for resources in
building analytic systems to answer questions
and in part due to the accessibility of
143
Technology Today
necessary data to provide sound answers.
Many decisions in patient care require addi-
tional factors that may not be readily avail-
able, such as whether or not the decision is
locally obtainable, are costs incurred, who
pays, are there cultural or religious implica-
tions for the patient, does it require clinician
expertise and is that expertise available,
and is it legal in the state in which it will
be delivered? Although analytics can move
health care forward in making better deci-
sions, electronic analyses are limited to the
adequacy of the data available.
Underlying all analytics is the quality of
the data being analyzed. As the saying goes,
“garbage in, garbage out.” The data should
be accurate, relevant, and timely.5 To achieve
quality data requires sound data capturing,
removal of errors, a sound method for exam-
ining outliers, appropriate capture and analy-
ses of free text and unstructured data, the
ability to capture data from multiple and
sometimes disparate applications, and more.
It may be surprising that this column does
not further define analytics 1.0 as “nursing
analytics.” The jury may be out on this, but
it seems highly unlikely that the silos of doc-
umentation data seen today in EHRs will
continue. Data used in analytics 1.0, 2.0,
and 3.0 are about health care consumers and
are driven by patients’ goals and the contri-
bution of each health care discipline as well
as the patient and the patient’s family.
Key takeaways from this column on ana-
lytics include using the analytics framework to
evaluate where your organization is in its ana-
lytics journey and develop a sound strategy
and operational plan for using analytics and
for how you may contribute. Consider starting
now to acquire or develop the nursing talent to
move analytics forward, because current oppor-
tunities are outpacing current preparation in
the health care industry. Nurses involved in
quality improvement roles may be poised to
add analytics knowledge to their repertoire of
skills. The role of a chief nursing informatics
officer is evolving to meet the needs of health
care organizations analyzing data, including
EHR data, to meet the demands of population
health management.6 Multiple professional
development opportunities are available
through professional organizations such as
the International Institute for Analytics (www
.iianalytics.com) and continuing education or
formal education/degree programs in analytics.
Technology Today
Conclusion
The continuing addition of new and
improved technologies, increasing interop-
erability, and data analytics are changing
what is possible in nursing and health care
and what is possible for the people we serve.
The promises of the digital age are truly trans-
formational but can be costly in terms of time,
energy, and money, especially if not effectively
planned and managed. This Technology Today
column depicts a framework for analytics and
provides nurses with a roadmap for advancing
practice and improving outcomes by success-
fully navigating the digital terrain of analytics.
144
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REFERENCES
1. Davenport TH. The Rise of Analytics 3.0: How to
Compete in the Data Economy. Portland, OR: Inter-
national Institute of Analytics; 2013.
2. Davenport TH. Big Data at Work: Dispelling the
Myths, Uncovering the Opportunities. Boston, MA:
Harvard Business Review Press; 2014.
3. Brennan PF, Bakken S. Nursing needs big data and
big data needs nursing. J Nurs Scholarsh. 2015;
47(5):477-484.
4. Davenport TH. Analytics 3.0. Harv Bus Rev. https://hbr
.org/2013/12/analytics-30. Accessed February 23, 2016.
5. Harrington L. Clinical intelligence. J Nurs Adm.
2011;41(12):507-509.
6. Stempniak M. More nurse technology experts
move to the C-suite. Hosp Health Netw. http://www
.hhnmag.com/articles/6581-more-nurse-technology
-experts-move-to-the-c-suite. Accessed February
23, 2016.
 AACN Advanced Critical Care
Volume 27, Number 2, pp. 145-151
© 2016 AACN

Issues in
Advanced
Practice
Valerie K. Sabol, RN, PhD, ACNP-BC,
GNP-BC, CCNS, CCRN
Department Editor

Strategies for Success: Cultivating Emotional

Competence in the Clinical Nurse Specialist Role
Elizabeth Kozub, RN, MS, CCNS, CCRN, CNRN
Leah Brown, RN, MSN, CNS, ACCNS-AG, CCRN
Laurie Ecoff, RN, PhD, NEA-BC

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

Emotional Intelligence Versus Emotional Competence

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

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

DOI: http://dx.doi.org/10.4037/aacnacc2016771

145
Issues in Advanced Practice
Table 1: Emotional Competence Attributesa
Self-awareness
Humility
Resiliency
Passionate optimism
Appreciation of ambiguity and paradox
Appreciation of knowledge
Mindfulness
Openness
Impulse control
Willpower
Compassion
a
Based on information from Porter-O’Grady and Malloch.5
The individual must then display openness
and appreciate ambiguity with the informa-
tion discovered. Finally, as the information
is shared with colleagues, passionate optimism
and compassion are required to convey the
intended message effectively.
Emotional Competence in the
CNS Role
The importance of emotional competence
in health care leadership must be fully appre-
ciated for organizations to thrive in its current
changing landscape. For example, emotional
intelligence has been correlated with positive
individual, nurse leader, and organizational
outcomes.6-14 Person-specific emotional intel-
ligence outcomes include increased job satis-
faction, increased work engagement, increased
retention, and reduced burnout.6-8 In clinical
practice, collective emotional intelligence has
been associated with improved organizational
performance on nursing-sensitive indicators,
including decreased infections, falls, and
improved pressure ulcer screening.9 In nurs-
ing leaders, emotional intelligence has a posi-
tive effect on quality of care, teamwork, nurse
satisfaction, turnover, and burnout.10-14 When
leaders possess high emotional intelligence,
outcomes for patients, nurses, and organiza-
tions may improve.
Emotional competence is a fundamental
prerequisite to actualizing the CNS core com-
petencies including consultation, systems
leadership, collaboration, and coaching. For
example, in systems leadership, the CNS is
tasked with using “effective strategies for
changing clinician and team behavior to
encourage adoption of evidence-based prac-
tices and innovations in care delivery.”15(p20)
To successfully facilitate teams and lead change,
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W W W .AACN ACCON LIN E .ORG
the CNS must have emotional awareness of
the group dynamics to optimize contribution
of all team members while navigating any
potential controversy. In the authors’ experi-
ence, emotional competence is vital to create
effective and collaborative relationships with
all members of the health care team.
CNSs are in a unique leadership position
to create a healthy work environment, which
can be accomplished through emotional com-
petence.16 The healthy work environment
(HWE) standards are evidence-based strate-
gies for creating an atmosphere that supports
excellent nursing practice and patient out-
comes.17 The authors propose that emotional
competence is critical to actualizing several
of the HWE standards, including skilled
communication, authentic leadership, true
collaboration, and meaningful recognition.
For example, in the skilled communication
domain of the HWE standards, skilled com-
municators must focus on finding solutions
and hearing relevant perspectives, which aligns
with the emotional competence attributes of
appreciation of knowledge and openness. Fur-
thermore, the CNS can contribute to an
HWE through leading by example. An emo-
tionally competent CNS is in a position to
assess the emotional competence of others
and offer strategies for development.
The journey to emotional competence
involves critical self-appraisal and an assess-
ment of current level of performance before
learning and growing in capability. In an effort
to assist CNSs in developing and realizing
emotional competence, 3 attributes will be
highlighted, with key questions to assess
one’s current state and strategies for expand-
ing emotional competence.
Self-awareness
Emotional competence and success in the
CNS role build on a foundation of self-
awareness. In order to understand and relate
effectively to those within their spheres of
influence, successful CNSs must first take
the time to thoughtfully examine their per-
sonal experiences and further delve into the
emotions surrounding them, acknowledging
their impact.18 The ability to honestly feel
and admit one’s own emotions allows an
individual with emotional competence to
separate the emotions from the event, assist-
ing the CNS to navigate emotionally charged
situations successfully, and also leads to the
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table 2: Emotional Competence Self-Assessment Questionsa
Self-Assessment Questions
Self-Awareness
How does my mood affect my performance at work?
What situations have the potential to make me very
angry at work?
What are my strengths? Weaknesses? Blind spots?
Humility
How quickly do I ask for help with a project?
How easily and/or quickly can I admit when I do not
know enough about a topic?
How willing am I to learn from others?
Resilience
Do I seek feedback when things don’t go as planned?
Can I receive that feedback graciously, incorporating
it into future initiatives?
Am I willing to fail when planning new projects or
anticipating a practice change?
a
Based on information from Porter-O’Grady and Malloch.5
ability to sense and anticipate how a situation
may affect others. This ability is the basis of
empathy and an important attribute of an
effective collaborator and consultant.19 Only
with an accurate assessment of self can an
individual act decisively and with authentic-
ity.19 The questions in Table 2 may be used
to prompt self-assessment and gauge an indi-
vidual’s level of self-awareness.
The development of self-awareness as a
strategy to succeed in the CNS role is affected
largely by the practice of reflection. Reflection
on practice or reflective learning is a method
based on educator and philosopher John Dew-
ey’s practice of purposeful and careful consid-
eration of beliefs and knowledge.20 Current
literature recommends reflective learning for
practicing nurses and nursing leaders for its
effectiveness in promoting thoughtful prac-
tice.21 Fruitful reflection involves thinking
about the experience and allowing the identi-
fication of emotions, motivations, and inten-
tions, which may then lead to the uncovering
of deeply held beliefs and values.20,22 Analysis
and synthesis of situations and perspectives
then assists a self-aware leader in uncovering
147
Issues in Advanced Practice
Implications of Self-Assessment Answers
Recognition of how emotions can drive thoughts
and actions.
Once recognized, emotions and mood can be
controlled.
When emotionally competent leaders understand
themselves, it allows them to anticipate what will
work for others.
Emotional competence allows leaders to maintain
focus on the organization.
Leaders with emotional competence realize that
continued growth is possible only with a constant
flow of new information.
An organization’s collective wisdom is valued over
individual talent.
Feedback and sharing of ideas allows an organization
to address disappointments as a whole not as
individual failure.
Emotionally competent leaders seek feedback as
essential to growth.
Analysis of failures increases an organization’s
capacity to minimize future errors.
strengths and limitations, with appreciation
for the experiences and emotions of others.
To engage in reflection and thus grow in
self-awareness, it is helpful to use a structure
or model. The model in Figure 1 may be used
to guide the CNS when examining a situa-
tion or experience.23 For example, in con-
sulting on a challenging situation involving
a patient, a CNS may find himself or herself
assuming direct patient care without includ-
ing the bedside nurse. A confrontation may
occur or there may be unspoken resentment
from nursing staff. In reflecting on the event
and examining what occurred in comparison
to what the standards define, a self-aware
CNS may recognize a desire to feel clinically
relevant and demonstrate skills and knowl-
edge that made the clinical staff feel excluded
or dismissed.
Reflection allows an honest appraisal of
the self and the emotions and motivations
involved, and it ideally results in a changed
perspective.21 With an accurate awareness of
self, a CNS offers honesty and authenticity
to others. Honesty fosters humility, another
important attribute of emotional competence.5
Issues in Advanced Practice
1) What 2) What did I
happened? see myself
doing?
Experience Observation
Learning Reflection
4) What will I 3) How do my
do differently actions relate
in the future? to standards/
expectations?
Figure 1: Reflective learning model.
Used with permission from Sharp Memorial Hospital,
San Diego, California.
Humility
Humility may bring to mind self-deprecation,
or someone of little value; however, humility
can be considered the epitome of self-confidence
and a major contributor to success. With
self-awareness and an accurate appraisal of
knowledge, skills, and abilities, humble leaders
do not feel the need to boast or demand rec-
ognition for their accomplishments. An accu-
rate assessment of the self is one part of the
definition of humility put forth by Smith.24
Other behaviors representative of humility
are willingness to learn and showcasing the
strengths of others.5 In the leadership of
large and successful companies, personal
humility also can take a company from
good to great. The characteristics described
by Collins25 include modesty, not aspiring for
individual success, and when assigning the
responsibility for poor results, never blaming
other individuals or external factors, looking
“in the mirror, not out the window.”
To assess one’s level of humility and ascer-
tain any opportunity to cultivate this attribute
of emotional competence, ask the questions
in Table 2. The last question provides a key
tactic to cultivate humility. It is an insatiable
curiosity and constant seeking of new knowl-
edge that activates the humility of a leader.24
Through reflection and the process used to
develop self-awareness, honest leaders must
admit there are things they don’t know. Admit
these knowledge or skill deficits, and recognize
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W W W .AACN ACCON LIN E .ORG
their presence in others. Know when to defer
or delegate to the gifted people surrounding
you and welcome what they can teach you!
Persisting with the usual or comfortable pat-
terns of problem solving and the “same way
of doing things” stifles humility and hinders
success.26 Leadership is not focused on being
right, it is focused on doing the right thing,
coupled with the ability to understand that
other people may have greater insight about
a situation.27 Doing so creates a CNS who is
a good role model for safe nursing practice
and a CNS on the path toward possessing
emotional competence.
Resilience
As nurse leaders risk exposing their flaws
or failures by exercising humility, another
vital attribute of emotional competence is
being developed. Resilience may be defined
as the ability to move forward in a positive
manner, adapting to adversity and maintain-
ing equilibrium.28 Confronting adversity in a
leadership role is often inevitable. However,
emotional competence allows CNSs to main-
tain a sense of control over their environment,
measuring their responses and exhibiting a
strong sense of self even when facing difficul-
ties. When working in the organizational
sphere, barriers to optimal nursing practice
or patient care may arise. Examples of barri-
ers include medical resistance to adopting
new evidence-based practices or the lack of
usability of an electronic medical record.
An emotionally competent CNS recognizes
that questions and resistance may allow fur-
ther beneficial developments in practice or
that persistence in advocating for enhance-
ments of electronic medical records can facili-
tate future workflow improvements.
The CNS actualizes the role in 3 spheres of
influence: patient/client, nurse/nursing practice,
and organizations/systems.18 The relationships
fostered by a CNS within the spheres of
influence benefit from the cultivation of resil-
ience as resistance and disappointment may
occur in the care of a patient, development
of the nursing staff, or in working within a
system. Again, as a role model, the nurse leader
who exhibits resilience or hardiness helps
the nursing staff to respond to challenges
creatively and energetically.29 Resilience can
also have a positive effect on organizational
outcomes and patients’ experience.29 To self-
assess the current state of one’s resilience,
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Issues in Advanced Practice

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

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

Table 4: Emotional Competence Behaviorally Based Interview Questionsa

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

149
Issues in Advanced Practice
of emotional competence, are useful to evalu-
ate employee attributes and ongoing growth.
An effective competency format incorporates
all 3 domains of learning and ensures that
emotional competence is evaluated. Figure 2
provides an excerpt of a competency used to
assess the attitude (affective) domain of an
emotional competence attribute. Integration
of Benner’s novice to expert framework
facilitates assessment of progressive growth
of emotional competence.34
When an performance gap in emotional
competence is identified, it is important for
leaders to support employees to develop desired
attributes. According to Daniel Goleman,35
emotional competence can be enhanced and
starts with a personal commitment to change
followed by an assessment of associated
attributes or competencies. Many strategies
exist for ongoing development of emotional
competence and include engaging in reflective
learning, enlisting a mentor, attending courses,
reading books, and reviewing online content.
If it becomes apparent that an employee is
unable or unwilling to demonstrate or develop
emotional competence, it is incumbent upon
a nurse leader to jointly develop a remedia-
tion plan with the employee. The plan, with
defined objectives, action steps, and comple-
tion dates, should include regular progress
evaluation meetings with the employee and
nurse leader. If the plan is ineffective, the
nurse leader may use the corrective action
process to remove the employee from the
organization to maintain the integrity and
functioning of the team.
Summary
The importance of emotional competence
in the role of the CNS cannot be minimized.
Emotional competence increases an individu-
al’s job satisfaction and work engagement
and decreases burnout.6-8 As CNSs lead and
facilitate teams, emotional competence is
required to achieve desired outcomes and
create lasting change.9 Development of emo-
tional competence, starting with self-assessment,
therefore, is a worthwhile endeavor for achiev-
ing success in the CNS role. Furthermore, from
an organizational perspective, interviewing
for emotional competence by using behavior-
ally based questions is one tactic to ensure a
good fit within the organization. As with ongo-
ing competency development in nursing staff,
using a leadership competency that includes
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W W W .AACN ACCON LIN E .ORG
Attitude (Affective)
■Affective skills to obtain information, understanding,
or assistance; meet need of other
Novice Performance Criteria
(Receiving)
r Notices different styles of communication
r Accepts the contributions of self and others to
effective team function
r Focuses on being an effective team member
r Open to continually assessing and improving
skills as team member and leader
Figure 2: Excerpt of a competency used to assess
the attitude (affective) domain.
Used with permission from Sharp Memorial Hospital,
San Diego, California.
the tenets of emotional competence also facil-
itates development of emotional competence
in the newly hired CNS. In these ways, indi-
viduals and the organization in which they
function can foster emotional competence
and contribute to successful role implementa-
tion of the CNS.
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14. Bulmer Smith K, Profetto-McGrath J, Cummings GG.
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 AACN Advanced Critical Care
Volume 27, Number 2, pp. 152-157
© 2016 AACN

Creating a Healthy

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

Department Editor

Shared Governance for a Healthy Work

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

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

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

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

Nida Sulit Oriza is Lead Charge Nurse, Cardiothoracic Intensive Care Unit, Heart Institute, Children’s
Hospital Los Angeles, 4650 Sunset Blvd, #74, Los Angeles, CA 90027 (noriza@chla.usc.edu).
Victoria Winter is Relief Charge Nurse, Cardiothoracic Intensive Care Unit, Heart Institute, Children’s
Hospital Los Angeles, Los Angeles, California.
Flerida Imperial-Perez is Clinical Manager and Clinical Nurse Specialist, Children’s Hospital Los Angeles,
Los Angeles, California.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016968

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Shared Governance Council
Shared governance is a care system model
based on professional values and ideals of
autonomy, decision making, and participa-
tion.3 Nurses have the freedom to participate
fully in the practice of nursing and in shaping
their work environment.4 An HWE must meet
6 standards: skilled communication, true col-
laboration, effective decision making, appro-
priate staffing, meaningful recognition, and
authentic leadership.1 These 6 attributes were
used as the guiding principles in implement-
ing the unit-based shared governance council.
Unit leaders and nursing staff worked
together to transform the unit into an HWE,
1 standard at a time. A staff survey was devel-
oped with questions based on the 6 HWE
standards. The staff response from the survey
confirmed the unhealthy state of the work
environment and served as a driving force in
addressing and implementing changes in the
workplace. An oversight group was developed
to assist with this process, and it included
nurses, unit nursing leaders, physicians, and
respiratory care practitioners. The group devel-
oped a mission statement that served as a
guide to implementing change and achieving
the goal of providing excellent care to patients
and their families.
A formalized shared governance structure
was implemented in the CTICU to provide a
venue for the CTICU staff to bring up clinical
practice issues. A core group of staff nurses
met with the clinical nurse specialist to develop
a shared governance council model in align-
ment with the house-wide collaborative gov-
ernance council model. The CTICU’s shared
governance council structure provides nurse-
driven solutions to practice issues, evidence-
based nursing care standards, and Lean measures
of care delivery. It provides a forum where
all staff can bring any concerns or questions
related to patients. As concerns in current
practice are identified, proposed changes are
collaboratively developed, and strategies for
implementation of the changes are discussed
in the monthly meetings of the shared gover-
nance council. Every year, the shared governance
committee selects goals for the year. For 2015,
3 main goals were identified.
Goal 1: Focus on Transforming
Care at the Bedside
Objective: Develop Transformational
Leaders or Staff Champions Who Can
153
Creating a Healthy Workplace
Develop Evidence-Based Practice Standards.
Staff champions developed standards of care
for safe sleep, prevention of hospital-acquired
pressure ulcers, and care of patients with the
HeartWare ventricular assist device (Heart-
Ware International Inc). After deliberations
among council members, they assign the
strength of the evidence using the evidence
rating scale of the Johns Hopkins Nursing
Evidence-Based Practice Model and Guide-
lines.5 Nurses are engaged in the review of
current research and in the development of
clinical guidelines to better align nursing
practices with the best available scientific
evidence. Working with the clinical nurse
specialist and the rest of the CTICU nurse
managers, the staff nurses are empowered
to identify performance gaps with the goal
of establishing interventions that are based
on best evidence.
Goal 2: Engage in Interdisciplinary
Interventions to Prevent Hospital-
Acquired Complications
Objective: Achieve, Exceed, and Sustain
Core Measure Targets. The unit-based inter-
disciplinary performance improvement com-
mittee defines and compares patient outcome
measures with the Centers for Disease Con-
trol and Prevention, AACN Healthy Work
Environment, and the Agency for Healthcare
Research and Quality. Staff nurse champions
work closely with the unit-based clinical
nurse specialist and where applicable present
and publish results of outcome measures
studied. They continue to measure key patient
outcomes, including hospital-acquired infec-
tions, addressing hand hygiene compliance,
ventilator-associated pneumonia, catheter-
related bloodstream infections (CR-BSIs),
urinary tract and surgical site infections,
reduction of medical errors, and improve-
ment of hand-off communications. Different
staff members are involved in implementation
of processes for monitoring compliance and
improvement of current practices.
One example of ongoing work is the
implementation of evidence-based practices to
decrease CR-BSIs that was started in 2005.
The outcomes were presented at AACN’s
National Teaching Institute and Critical Care
Exposition in 2009, in the poster titled “The
Impact of Evidence-Based Practices in Reduc-
ing Catheter-Related Blood Stream Infections
in a Pediatric CTICU.” Since then, CR-BSI
Creating a Healthy Workplace
rates have ranged from 0 to 1.5 per 1000
catheter days; however, by July 2015, the
CTICU had experienced an increase in CR-BSIs.
The shared governance council engaged staff
champions to address the current problem.
The group used the fishbone diagram, also
known as cause and effect analysis, introduced
by Dr Kaoru Ishikawa.6 The diagram is a
graphic illustration of the relationship between
the many potential causes and all factors that
affect the increase in CR-BSIs. The staff
champions assessed the knowledge and com-
pliance of nursing staff and reviewed the
quality of our current evidence-based practices.
Key causes were prioritized and action plans
were developed. The CTICU is currently in
the implementation phase of the campaign to
decrease the rate of CR-BSIs to zero. This
program remains a collaborative effort
between the nursing staff, nursing leaders,
the physician group, and the hospital’s infection
control department. We continue to monitor
CR-BSI events closely, and for every confirmed
infection, a root cause analysis is done and
presented to the CTICU’s performance improve-
ment committee and the staff for follow-up.
More emphasis is placed on compliance with
best practices and staff accountability.
Goal 3: Focus on the Top 5
Problem List
Objective: Use “I” Reports as a Platform
to Identify Measures to Improve Patient
Safety. From incident reports, the shared gov-
ernance council can identify the top 5 prob-
lems related to patient safety in the unit. Staff
members are encouraged to identify various
staff champions and team members who will
work on the problems identified. They work
on finding solutions and identifying and pre-
senting standards of care needed. Staff
champions are currently working on stan-
dardization of parenteral and lipid infusions,
interhospital transport guidelines, and a stan-
dard of care for pacer wires.
Magnet and Beacon Designations
CHLA is a Magnet-designated hospital
and the CTICU is an AACN Gold Beacon
awardee. In 2002, McClure and Hinshaw7
reported results of a national survey indicat-
ing that 55% of units surveyed had formal-
ized shared governance structures, legitimizing
nurses’ decision-making control over their
professional practice. Magnet-designated
154
W W W .AACN ACCON LIN E .ORG
facilities have shared governance as the most
common structure reported. Involving nurses
in effective decision making through the use
of shared governance structures also meets a
crucial requirement of the AACN Standards
for HWE.1 Embracing the shared governance
model has resulted in increased staff partici-
pation in identifying and presenting patient
care issues, identifying ways to participate in
finding solutions, attending meetings, and
providing feedback. Participation and engage-
ment of the staff nurses on the night shift in
various unit projects has also increased. Vari-
ous structures and processes are in place in
the unit that support an HWE and are in line
with the AACN HWE standards. Numerous
initiatives spearheaded by the CTICU’s
shared governance council are described in
the next section.
CTICU Projects Categorized by
HWE Standard
True Collaboration and Effective
Decision Making
The shared governance council uses true
collaboration and effective decision making,
with every CTICU staff member contributing
to the overall achievement of any given proj-
ect. An example is the withdrawal prevention
protocol, developed and instituted by a team
of physicians, nurse practitioners, pharmacists,
and bedside nurses. Implementation of this
protocol resulted in a decrease in overall
ICU days and length of hospital stay.
True Collaboration and Skilled
Communication
Another example of true collaboration is
the CTICU daily goal sheet (DGS). Following
the implementation of nurse-led daily rounds,
the DGS was developed by nursing staff
champions, nurse leaders, and the CTICU’s
medical team. Daily interdisciplinary rounds
allow a real-time exchange of information,
making the goals and plan of care clear to
every member of the health care team. Before
this work, communication between members
of the health care team was suboptimal, but
communication has improved with the use
of the structured form. Use of the DGS was
intended to close the loop of the team’s plan
of care for the upcoming 24 hours. The aims
of the project included (1) development of the
DGS as a tool for communicating the daily
plan of care among all of the child’s caregivers,
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
including consultants and team members who
may not have been present during the daily
rounds, (2) facilitating communication with
team members on the night shift, and (3)
encouraging and reminding nurses and physi-
cians about timely interventions and altera-
tions to the plan of care for changes in clinical
status. The work group has used staff input
through online surveys to revise the DGS to
make it user-friendly and to increase aware-
ness of the DGS. Through efforts such as
these, the nursing staff has opportunities to
influence decisions that affect the quality of
patient care. Staff members feel that they are
valued and committed partners in care.
In 2005, the CTICU had a 30% turnover
rate. Lack of effective communication was
identified as a unit problem. Reports of The
Joint Commission on Accreditation of Health
Care Organizations8 cited inadequate com-
munication as the most frequent root cause
of sentinel events. Skilled effective communi-
cation is the key to develop and ensure high-
quality, patient-centered care while engaging
and retaining staff. The CTICU uses multiple
strategies to improve communication, team-
work, and patient safety.
Rounding for Outcomes. Developed by the
unit nursing managers and the medical direc-
tor, weekly rounding with staff for day and
night shifts initiates discussions between staff
and unit managers regarding patient safety
issues and staff dissatisfiers. Feedback is
solicited in relation to concerns with unit work
flow, process improvement, and staff morale.
Staff members are also given opportunities to
identify what is positive and working well in
the unit and recognize their coworkers who
have made a difference in their work.
Unit Huddles. Unit huddles are started
before each shift. Assignments are given to the
incoming nurses, and the needs of the unit and
patient throughput are also presented.
Situational Awareness. A charge nurse also
leads a situational awareness session with the
CTICU’s multidisciplinary team at the begin-
ning of each shift. The charge nurse presents
the unit census, availability of staff and beds
for admissions, discharge/transfer plans to
be approved, in-house patient transports for
diagnostic imaging, and planned patient pro-
cedures such as sternum closure or balloon
septostomy to be done at the bedside. Patients
who may need closer monitoring to prevent a
more critical event are also identified. These
155
Creating a Healthy Workplace
processes are examples of ways to improve
communication and collaboration among the
team members and facilitate efficient patient
and unit work flow.
Appropriate Staffing
Inadequate staffing is “one of the most
harmful threats to patient safety and the
well-being of the nurses.”1 The CTICU pro-
vides care for patients with the highest mean
acuity at CHLA. To meet this challenging
demand, a highly skilled nursing staff is
required. The AACN Staffing Blueprint:
Constructing Your Staffing Solutions9 and
the AACN Synergy Model for Patient Care10
provide resources for best practices that guide
CTICU staffing. Patients’ outcomes are
optimized when patients’ needs and nurses’
competencies are matched with one another.
Staffing practices are designed to meet the
needs of patients and their families, address
the needs of the nursing work force, and
promote the health and well-being of every
staff member involved.1 The CTICU staffing
guidelines updated in 2015 are based on the
changing conditions of patients’ acuity; nurses’
skills, training, and experience; availability
of support staff; and the physical layout of
the unit.
The charge nurses continuously assess the
work flow of the unit and consistently match
patients to nurses to ensure safety and best
outcome. They evaluate and obtain real-time
updates that are based on changing patient
acuity. The charge nurse collaborates with the
CTICU’s attending physician and the bedside
nurses to make adjustments in response to
changes in patient acuity, as well as in the
needs of patients’ families. The CTICU’s
managers are available 24 hours a day for
support and assistance with staffing demands.
Onboarding. One strategy used by the unit
for recruitment and retention is the concept
of onboarding. Onboarding is defined as a
holistic approach that combines people, pro-
cess, and technology to optimize the impact
of a new hire to the organization. Onboard-
ing requires more than just an orientation.
It also requires long-term employee support
and follow-up. New hires all have a bachelor
of science degree in nursing. Schmalenberg
and Kramer11 cited the reports of Aiken and
Tourangeau that hospitals with lower mortal-
ity rates have higher percentages of nurses with
bachelor’s degrees in nursing. The CTICU’s
Creating a Healthy Workplace
managers have included staff bedside nurses
in the interview process for potential nursing
staff for early identification of the applicant’s
core values, attitudes, and behavior in rela-
tion to the CTICU’s mission and its values.
This process ensures early alignment and
accountability of new nurses.
Residency Program. The CTICU has a staff-
driven, preceptor-based residency program
for new hires. The postorientation debriefing
serves as a venue to discuss difficult situations
and to have crucial conversations to develop
trusting relationships. When problems are
identified, strategies are discussed for resolu-
tion and resources are identified to assist the
new staff member. Open communication is
maintained throughout the onboarding process.
Advancement Programs. Another strategy
to improve retention is the implementation
of various advancement programs for CTICU
nurses. Members of the CTICU’s education
committee develop processes for recognizing
nurses’ development from novice to expert
in providing or influencing patient care. The
CTICU’s pull-back program is a specialized
unit-based continuing education program
for staff who are within 2 years of hire. This
program addresses concerns about knowl-
edge gaps of novice nurses. An advancement
resource nurse is assigned to new staff who
recently completed their orientation, to sup-
port them in time management, prioritization
skills, performance of CTICU standards of
care, delegation, and documentation. Staff-
driven, 8-hour heart conferences and sympo-
siums, supported by the Heart Institute and
held annually during the congenital heart
disease month of February, are well attended
by nursing staff and other disciplines. The
symposium presents current innovations and
strategies with regard to excellent care of
patients with congenital and acquired heart
disease. Highlights include a continuum of
care including fetal diagnosis and surgical/
medical interventions to discharge. Families
are also invited to share the challenges of their
journey as they deal with the care of their child.
New technologies of care such as the Berlin
Heart (Berlin Heart GmbH) and HeartWare
ventricular assist devices are also presented.
A road-to-leadership training program to
prepare staff to take on informal leadership
roles in the unit by developing the knowledge
and skills required to meet leadership respon-
sibilities is another advancement program
156
W W W .AACN ACCON LIN E .ORG
provided to staff after they have 2 years of
clinical experience in the unit. The curriculum
includes more leadership concepts of emotional
intelligence, servant leadership, and tools for
effective communication and conflict resolution.
Our highly acute and fast-paced CTICU
creates challenges that potentially impede the
growth and development of staff at all levels
of experience. We have an increase in novice
nurses, diverse and individualized professional
development needs, and some feelings of
inadequate management support. Attention
to the growth and development of each mem-
ber of the nursing staff increases job satisfac-
tion and is a predictor of the nurses’ intent
to stay. Staff champions in collaboration with
nursing managers developed color-coded
professional development teams. Nurses are
divided into 3 color-coded teams. One team
is highlighted every 6 weeks of the current
schedule. The nurses discuss with a specific
manager their development needs and goals
that can be addressed during the rotation.
The goals can vary from more opportunities
to care for higher acuity patients to advance
their clinical growth or assigning them to serve
as a preceptor, shift resource nurse, or team
leader to advance their leadership skills. The
goals are accessible to charge nurses, who can
help provide the opportunities as they make
assignments for the shift. This program facili-
tates open communication between manage-
ment and staff. It also encourages the staff
to be more accountable and empowered to
reflect on their own professional and personal
development. It offers development related to
advanced critical thinking skills as the nurses
are given higher acuity patient assignments and
leadership opportunities. This nurse advance-
ment program incorporates the 6 strategies
of the AACN HWE, creating an environment
of nurse empowerment. This program was
presented to the Association of California
Nurse Leaders (ACNL) in February 2015,
titled “Promoting Staff Engagement and
Professional Development Teams in CTICU.”
Meaningful Recognition and
Authentic Leadership
Leaders in the unit are strong advocates for
HWEs and they truly model the behavior they
expect from the staff. These authentic leaders
do what they can on a regular basis to sup-
port the staff and celebrate their successes.
They give kudos to their staff when they have
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
done something that is worthy of meaningful
recognition, and staff members feel supported
as a result of this recognition.
Summary
Each member of the CTICU nursing team
is committed to the principles of HWEs. The
shared governance council has facilitated con-
trol of their nursing practice. Shared gover-
nance enables the CTICU nurses to use
evidence-based practices to improve the qual-
ity of care they provide to patients and
patients’ families. Team members are respon-
sible and accountable for the shared decisions
of the team. This arrangement affects patient
care as well as patient/family and staff satis-
faction. The CTICU has increased its recruit-
ment and retention rate and decreased its
turnover rate from 30% in 2005 to 5% in
2015. With progress and improvement, the
challenge remains for all of the staff to be
accountable as a team, sustaining the success
of having an HWE in the pediatric CTICU.
157
Creating a Healthy Workplace
REFERENCES
1. American Association of Critical-Care Nurses. AACN
standards for establishing and sustaining healthy work
environments: a journey to excellence. Am J Crit Care.
2005;14(3):187-197.
2. Collins J. Good to Great and the Social Sectors. Boulder,
CO: A Monograph Company; 2005.
3. Anthony MK. Shared governance models: the theory, prac-
tice and evidence. Online J Issues Nurs. 2004;9(1):138-153.
4. Kramer M, Schmalenberg C, Maguire P, et al. Walk the
talk: promoting control of nursing practice and patient-
centered culture. Crit Care Nurse. 2009;29(3):77-93.
5. Dearholt S, Dang D. Johns Hopkins Nursing Evidence-
Based Practice Model and Guidelines. 2nd ed. Indian-
apolis, IN: Sigma Theta Tau International; 2012.
6. Ishikawa K. Guide to Quality Control. 2nd ed. Tokyo,
Japan: Asian Productivity Organization; 1986. 
7. McClure MI, Hinshaw AS. Magnet Hospitals Revisited:
Attraction and Retention of Professional Nurses. Wash-
ington, DC: American Nurses Publishing; 2002.
8. Joint Commission on Accreditation of Health Care Organi-
zations (JCAHO). Statistics: Root Cause of Sentinel Events
(All Categories). Oak Brook Terrace, IL: JCAHO; 2005.
9. American Association of Critical-Care Nurses. Staffing
Blueprint: Constructing Your Staffing Solutions.
Aliso Viejo, CA: AACN; 1999.
10. Hardin SR, Kaplow R. Synergy for Clinical Excellence:
The AACN Synergy Model for Patient Care. Boston,
MA: Jones & Bartlett Publishers Inc; 2005.
11. Schmalenberg C, Kramer M. Clinical units with the healthi-
est work environments. Crit Care Nurse. 2008;28(3):65-71.
 AACN Advanced Critical Care
Volume 27, Number 2, pp.158-161
© 2016 AACN

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

Perspectives NNP-BC
Department Editor

Impact of Family-Centered Care on Pediatric

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

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

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

Lori Williams is Clinical Nurse Specialist, Universal Care Unit, American Family Children’s Hospital,
University of Wisconsin Hospital and Clinics, Mail Code C850, 1675 Highland Avenue, Madison, WI
53792 (lwilliams3@uwhealth.org).
The author declares no conflicts of interest.

DOI: http://dx.doi.org/10.4037/aacnacc2016579

158
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
are to be kept informed and actively involved
in decision making and self-management,
patient care is coordinated and integrated
across providers, delivery systems provide
for the physical comfort and emotional sup-
port of the patient/family, providers have a
clear understanding of the patient’s concept
of illness and cultural beliefs, and providers
understand and apply the principles of dis-
ease prevention and behavioral change appro-
priate for diverse populations.9
Currently, many neonatal intensive care
units (NICUs) continue the practice of clos-
ing the unit to parents, siblings, and visitors
during shift changes, report, medical rounds,
admissions, emergencies and deaths. The ratio-
nale for this practice is to protect the privacy
of the infants. Parents are often still asked to
step out during medical procedures despite
evidence that parental presence can reduce
the child’s pain and parental anxiety.1 NICU
culture is inconsistent within and among units.
Parents report dissatisfaction with their oppor-
tunities for involvement, physician to parent
communication, availability of information,
and planning for the transition home.10
Impact on Unit Design and
Culture
Family-centered care concepts have brought
about many changes over the years. Unit designs
for pediatric intensive care units (PICUs) and
NICUs have changed from large open bays
separated by curtains to single/private room
designs. Unit design includes space for the
patient and space designed with amenities
for parents to be able to stay overnight in
the patient’s room. This encourages parental
participation in daily care such as feeding
and presence at procedures. Parental presence
and participation in caregiving builds parents’
confidence long before discharge.11-13 Having
parents at the bedside decreases the child’s
emotional distress, increases the child’s coping
during procedures, and improves the child’s
adjustment during the hospitalization, after
hospitalization, and during recovery.3 Families
are also encouraged to personalize the hospital
experience by personalizing the patient’s space.
Best-practice standards for NICU design
recommend provision of a family library or
education area.14 Medical rounds and nursing
shift reports have moved from conference rooms
to the bedside and include parents and their
patients as active participants. The inclusion
159
Pediatric Perspectives
of parents in bedside rounds and discharge
planning rounds increases parents’ satisfac-
tion with the time spent with the team, the
number of questions the team answered,
how well the child was respected, and how
seriously staff took parents’ concerns.15,16
Videoconferencing technology helps families
stay connected with their child and the day-
to-day changes that occur during medical
rounds when parents cannot be present.4
Parents are no longer viewed as visitors, but
are invited to be present at the bedside 24
hours per day. Visiting hours for other per-
sons identified by the family as supports have
been expanded. Siblings are now included
as important visitors.12,17 When siblings are
allowed to visit, research has reported fewer
behavioral problems, decreased aggressive
and regressive behavior among siblings,18
and increased sense of family as a unit.15
Implementation of Kangaroo
(Skin-to-Skin) Care and
Lactation Support
Support for exclusive breastfeeding or the
provision of breast milk has increased. Lacta-
tion support has improved with the hiring
of lactation counselors and consultants in
many hospitals. Kangaroo care (skin-to-skin)
has been implemented as a means to help
mothers maintain their milk supply. Skin-to-
skin holding contributes to a parental sense
of well-being, confidence, and competence
while reducing stress.19 Skin-to-skin contact
also decreases maternal postpartum depres-
sion and anxiety20,21 and increases maternal
sensitivities, affectionate behaviors, and bond-
ing.19,22 Fathers report decreased fear of hold-
ing and harming their infant when they are
participating in skin-to-skin care.23
Parent and Family Education
Resources
The provision of education for parents
increases their participation in discussion
and decreases maternal stress.2,11,24 Education
can also lead to more effective use of health
care resources and improved follow-through
with the collaborative discharge plan.3 Health
information is now being provided via a
variety of means such as hospital kiosks and
websites with a consumer focus. Classes may
include cardiopulmonary resuscitation, sud-
den infant death syndrome prevention/safe
sleep, how to have a smoke-free home, and
Pediatric Perspectives
car seat safety. Many hospitals have new NICU
parents spend the night in a transition room
before discharge.25
Family Support Resources
Support for parents comes in a variety of
forms also. Families may be provided with
books, scrapbooking materials, craft projects,
or journals to fill the long days. Support may
focus on specific populations such as children
with congenital heart disease, spinal muscle
atrophy, or prematurity. Families may now
have a designated family support person to
help them navigate the health care system.26
The role of the family support specialist is to
decrease parental stress and increase parent-
ing confidence.26 Support groups or parent-
to-parent support offers contact with other
families who have or had a child in the
NICU/ PICU. These supports have effectively
adapted to or integrated the experience and
can be a valuable source of information,
advice, hope, and support.1,11,26,27 Active mes-
sage boards with online communities offer
an alternative to face-to-face support groups.
Parents with peer support experience less
state anxiety, less depression, and greater
social support.28
Outcomes of Implementation of
Family-Centered Care
When family-centered care is implemented,
length of stay has decreased in many stud-
ies,13,24,29 thus decreasing health care costs.3
A significant reduction in nonurgent visits
to the emergency department has also been
reported.30 Parental satisfaction with overall
care increased in many studies.26,31,32 Parents
had an improved perception of the provid-
ers’ competence.33 Staff also benefit when
family-centered care is implemented. Many
studies report improved staff satisfaction as
evidenced by more positive feelings about
work,1 a decrease in the number of nursing
vacancies,5(pp14-15) improved job performance,1
and an increased ability to recruit and
retain staff.26
Have we gained from implementing family-
centered care in our intensive and acute-care
pediatric environments? Looking back over
32 years, I say yes. The evidence also suggests
that there is much to gain when patients, par-
ents, and health care providers partner to
restore health.
160
W W W .AACN ACCON LIN E .ORG
REFERENCES
1. American Academy of Pediatrics Policy Statement.
Family-centered care and the pediatrician’s role. Pedi-
atrics. 2003;112:691-696.
2. Johnson B. Family-centered care: four decades of pro-
gress. Fam Syst Health. 2000;18(2):133-156.
3. Committee on Hospital Care and Institute for Patient-
and Family-Centered Care. Patient- and family-centered
care and the pediatrician’s role. Pediatrics. 2012;129(2):
394-404.
4. Phillips C. Family-Centered Maternity Care. Boston,
MA: Jones and Bartlett Publishing; 2003.
5. Conway J, Johnson BH, Edgmon-Leviton S, et al. Part-
nering With Patients and Families to Design a Patient-
and Family-Centered Health Care System: A Roadmap
for the Future—A Work in Progress. Bethesda, MD:
Institute for Family-Centered Care and Institute for
Healthcare Improvement; 2006. http://www.ihi.org/resources
/pages/publications/partneringwithpatientsandfamilies
.aspx. Accessed January 30, 2016.
6. Pollack MM, Koch MA. Association of outcomes with
organizational characteristics of neonatal intensive care
units. Crit Care Med. 2003;31:1620-1629.
7. Stewart M, Brown JB, Donner A, et al. The impact of
patient-centered care on outcomes. J Fam Pract. 2000;
49:796-804.
8. Institute of Medicine. Crossing the Quality Chasm: A
New Health System for the 21st Century. Washington,
DC: National Academies Press; 2001.
9. Davidson JE, Powers K, Hedayat KM, et al. Clinical
practice guidelines for support of the family in the
patient-centered intensive care unit: American College
of Critical Care Medicine Task Force 2004-2005. Crit
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JL, Berns SD. Family support and family-centered care
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controlled trial of bedside versus conference-room
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Effect of kangaroo mother care on postpartum depres-
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(kangaroo care) shortly after birth on the neurobehavioral
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responses of the term newborn: a randomized, controlled
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2000;173:244-250.

Evaluation of Pain Assessment
Tools in Patients Receiving
Mechanical Ventilation
Zainab Q. Al Darwish, RN, MSc
Radwa Hamdi, MD
Summayah Fallatah, MD
ABSTRACT
Pain assessment poses a great challenge for
clinicians in intensive care units. This descrip-
tive study aimed to find the most reliable,
sensitive, and valid tool for assessing pain.
The researcher and a nurse simultaneously
assessed 47 nonverbal patients receiving
mechanical ventilation in the intensive care
unit by using 3 tools: the Behavioral Pain
Scale (BPS), the Critical-Care Pain Observa-
tion Tool (CPOT), and the adult Nonverbal
Pain Scale (NVPS) before, during, and after
turning and suctioning. All tools were found
to be reliable and valid (Cronbach = 0.95 for
P atients in critical care settings confront a
variety of stressors that can cause pain
and suffering. Many routine procedures, such
as turning and tracheal suctioning, are known
to be painful to patients in intensive care units
(ICUs).1 Furthermore, the pain experienced
by critically ill patients can be complicated
by many other factors, such as underlying
disease, surgical interventions, wounds, inva-
sive catheters, and endotracheal intubation.2
Inadequately treated pain in critically ill patients
can lead to marked alterations in immunity
and cardiovascular, neurological, and pulmo-
nary function.2
Unfortunately, pain assessment poses a great
challenge for clinicians in ICUs.3 Communi-
cation barriers can exist owing to the com-
plexity of patients’ conditions, as many ICU
patients are either undergoing mechanical
ventilation, heavily sedated, or cognitively
162
AACN Advanced Critical Care
Volume 27, Number 2, pp. 162-172
© 2016 AACN
both the BPS and the CPOT, = 0.86 for the
NVPS), and all subscales of both the BPS and
CPOT were highly sensitive for assessing
pain (P < .001). The NVPS physiology (P = .21)
and respiratory (P = .16) subscales were not
sensitive for assessing pain. The BPS was the
most reliable, valid, and sensitive tool, with
the CPOT considered an appropriate alterna-
tive tool for assessing pain. The NVPS is not
recommended because of its inconsistent
psychometric properties.
Keywords: pain, pain assessment tools,
turning, suctioning, BPS, CPOT, NVPS
impaired.4 Thus nonverbal pain assessment
tools are needed. Much attention has been
paid to the development of standardized pain
assessment scales for critically ill patients;
however, some of these tools show limitations
and lack generalizability.5
Zainab Q. Al Darwish is Nursing Lecturer, The Saad College
of Nursing & Allied Health Sciences, Al Khobar 31952, Saudi
Arabia (zainabdarweish@hotmail.com).
Radwa Hamdi is Assistant Professor, Department of Intensive
Care Medicine, College of Nursing, University of Dammam,
Al Khobar, Saudi Arabia.
Summayah Fallatah is Assistant Professor, Department of
Anesthesia and Pain Management, College of Medicine,
University of Dammam, Al Khobar, Saudi Arabia.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016287
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Because inadequately managed pain can
cause many adverse physiological effects and
undesirable consequences, it is important to
investigate the reliability and validity of the
existing nonverbal pain assessment tools such
as the Behavioral Pain Scale (BPS), the Adult
Nonverbal Pain Scale (NVPS), and the Critical
Care Pain Observation Tool (CPOT) in order
to assess pain optimally in critically ill non-
verbal patients.
Setting and Design
Setting
The study was conducted in the medical,
surgical, and cardiac ICUs at King Fahd Uni-
versity Hospital in Al Khobar, Kingdom of
Saudi Arabia. King Fahd University Hospital
is one of the major health care centers in the
Kingdom of Saudi Arabia with 600 beds. It
includes 14 ICU beds with 6 beds and 1 iso-
lation room each in the surgical and medical
ICUs. The surgical ICU provides care to neu-
rosurgical, trauma, and critically ill surgical
patients. The medical ICU receives patients
with respiratory disorders such as pneumonia,
respiratory failure, and chronic obstructive
pulmonary disease, as well as gastrointestinal
and nontrauma neurological cases. The cardiac
ICU is a 10-bed unit, providing care and mon-
itoring for critically ill cardiac patients such
as those with heart failure or coronary artery
diseases and after open heart surgeries and
percutaneous cardiac interventions.
The study was approved by the local
committee of biomedical ethics at Dammam
University and King Fahd University Hospi-
tal. Informed consent was obtained from
each patient’s first-degree relatives during
the hospital’s visiting hours.
Design
A descriptive research design was used
for this study, and a convenience sample of
ICU patients was recruited during a 3-month
period, from January 2014 through March
2014. The sample included all patients under-
going mechanical ventilation who were unable
to self-report pain, were more than 18 years
old, and whose condition was hemodynamically
stable. Patients receiving neuromuscular block-
ers and patients who were quadriplegic,
exhibited brain death, or had conditions that
mask behaviors or facial expressions were
excluded from the study.
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E VA LUAT ION OF PA IN ASSE SSM E NT TOOLS
Tools
A data collection tool was designed to
document demographic and medical data,
including age; sex; medical diagnosis; score
on the Ramsay Sedation Scale; score on the
Glasgow Coma Scale (GCS); hemodynamic
data; onset, duration, and setting of mechani-
cal ventilation; analgesic and sedative agents;
and score on the Acute Physiology and Chronic
Health Evaluation II (APACHE II).
The reliability, validity, and sensitivity of 3
pain assessment tools (BPS, CPOT, and NVPS)
were studied.
BPS. The BPS was developed by Payen et al6
to assess pain in patients who were sedated
or receiving mechanical ventilation. The BPS
contains 3 behavioral domains: Facial Expres-
sion, Upper Limb Movement, and Compliance
With the Ventilator. Each domain is rated from
1 to 4. The minimum score is 3, indicating
no pain, and the maximum is 12, indicating
the worst pain. The Facial Expression domain
was based on a study by Prkachin,7 who divided
the painful facial expressions into 4 catego-
ries: brow lowering, orbit tightening, closing
of the eyelids, and nose wrinkling/upper lip
rising. The other domains were adopted from
the COMFORT scale used to assess distressed
children in the ICU.8
CPOT. The CPOT was developed and vali-
dated by Gélinas et al.9 It has 4 subscales,
each rated on a 3-point Likert scale from 0 to
2, with a total score ranging from 0 to 8. The
subscales are Facial Expression, Body Move-
ment, Muscle Tension, and Compliance With
the Ventilator or Vocalization for Extubated
Patients.9 Each domain of the CPOT has an
operational definition to facilitate objective
rating. Gélinas et al9 note that some subscales
and their related descriptions were derived
from previously established pain assessment
tools such as the BPS and the COMFORT
scale,8,10 whereas other indicators were estab-
lished on the basis of a retrospective review
of medical records, interviews, and focus
groups with nurses and physicians to deter-
mine the most frequent pain indicators in
critically ill patients.9
NVPS. The NVPS was developed at Strong
Memorial Hospital/University of Rochester,
validated initially by Odhner et al11 and
revised by Kabes et al.12 The scale was based
on the Faces, Legs, Activity, Cry, Consolability
(FLACC) scale after some behavioral indicators
A L DA RWIS H E T A L
that are specific to children, such as cry and
consolability, were eliminated.13 The NVPS
consists of 3 behavioral and 2 physiological
domains with specific descriptions and defini-
tions. Published evidence regarding the process
of selection of these domains is insufficient.14
The behavioral component consists of Face,
Activity/movement, Guarding, and the physio-
logical indicators include Physiology/vital signs
and Respiratory. The physiological indicators
are described as any change in the past 4 hours
of more than 20 mm Hg in systolic blood
pressure or more than 20 beats per minute in
heart rate, and respiratory indicators as a
change of more than 10 breaths per minute
above baseline or a 5% decrease in oxygen
saturation as measured by pulse oximetry.12
Before the start of data collection, a teach-
ing and training session was given individually
to each primary ICU nurse who was responsi-
ble for each study patient. Twenty ICU nurses
were involved during the study period. The
duration of the teaching session was based
on the individual nurse’s needs, with a mean
duration of 30 minutes. Teaching strategies
included oral discussion regarding the impact
of pain on critical illness, description of the
aim of the study, and explanation of the
components of each pain assessment tool.
The oral discussion was supported with figures
of facial pain expression that were inspired
from Prkachin and used by the authors of
the BPS and the CPOT.6,7,9 Furthermore, the
published figures for BPS by Chanques et al15
were used as supportive educational tools to
clarify the other subscales of the BPS. The
published guidelines for the CPOT with the
facial figures in the study by Gélinas et al16
also were used during the teaching session.
The operational definitions of the NVPS were
explored in relation to the author’s descrip-
tion in the revalidated version of the scale.12
A trial of practical performance of pain assess-
ment at rest by using the 3 assessment tools
was included in the teaching session to clarify
any knowledge defects that could affect the
accuracy of the assessment.
Methods
Each patient was assessed for pain at 5
measurement points: at rest (baseline) before
the first procedure, during suctioning, 20
minutes after suctioning, during turning, and
20 minutes after turning. Each patient was
exposed only once to these 5 measurement
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W W W.A ACNACCONLINE .ORG
points that included both turning and suc-
tioning. Both nociceptive procedures were
performed only if the patient’s care required
them, with an interval of at least 30 minutes
between them. The 3 pain assessment tools
were continuously used throughout the 5
measurement points by both the researcher
and the ICU bedside nurse simultaneously,
without any communication between them.
Both assessors had identical, but separate
forms that contained the printed scales, with
consistent use in the following order: NVPS,
CPOT, and BPS. The hemodynamic data and
analgesic or sedative agents used were recorded
at each point of the assessment.
Statistics
SPSS version 19 (SPSS Inc) was used for data
analysis of descriptive and inferential statistics.
The reliability value (r) for each tool was
obtained from the Pearson correlation test.17
The interclass correlation coefficient (ICC),
defined as the r value, was used to examine
the reliability of the subscales of each tool in
all measurement points across the 2 raters.
Validity was established by calculating the
Cronbach to determine internal consist-
ency. The Student t test was used to examine
the sensitivity of each pain assessment tool.18
Each tool and its items were evaluated for
responsiveness, which is manifested by the
ability of the tool to respond to minor changes
in the pain level over time. Responsiveness is
calculated by the effect size coefficient; first
find the difference between the mean score at
rest and the score during the painful procedure,
and then divide that difference by the stand-
ard deviation at rest. The effect size is consid-
ered small when it is less than 0.2, moderate
when it is near 0.5, and large when it is more
than 0.8.19 Principal-factor analysis was used
to evaluate the scale dimension, by identify-
ing the large contributing factors to overall
pain scores.20 All results were considered sig-
nificant when P was less than .05 and highly
significant when P was less than .001.
Results
Demographics
Forty-seven patients from the medical, sur-
gical, and coronary ICUs at King Fahd Univer-
sity Hospital who were receiving mechanical
ventilation were recruited to the study. Most
of the patients (49%) were recruited from the
surgical ICU (Table 1). Patients assessed within
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Table 1: Demographic Data and Sample (1.2) on the Ramsay Sedation Scale (Table 1).
Characteristics Unconscious patients who scored 5 to 6 on
the Ramsay Sedation Scale constituted 64%
Sample Characteristics Valuea of the study sample.
Age, mean (SD), years 55.5 (20.2)
Pain Assessment
Sex All 3 nonverbal pain assessment tools were
Female 20 (43) adequately reliable and valid with both
Male 27 (57)
Cronbach and r values greater than 0.85
APACHE II score, mean (SD) 20.6 (6.3) (Table 2).
Mortality rate, No. (%) of patients BPS. The sensitivity of the BPS to the
15%-25% 22 (47) presence of pain was established by a signifi-
40%-55% 21 (45) cant increase in the mean pain scores during
75% 4 (9) suctioning and turning (P < .001). These signif-
Glasgow Coma score, mean (SD) 6.38 (2.6)
icant differences in the scores indicate that
the tool and its components are a valid instru-
Ramsey Sedation score, mean (SD) 4.77 (1.2) ment to measure pain. In addition, the BPS
Patients’ intensive care unit was adequately responsive to minor changes
Surgical 23 (49) in pain level over the period of measurement
Medical 17 (36) points (Table 3). The ICC was excellent at rest
Cardiac 7 (15) across Facial Expression, Upper Limb Movement,
Diagnosis and Compliance With the Ventilator with r
Respiratory disorder 14 (30) values of 0.95, 0.92, and 0.90, respectively.
Cardiovascular disorder 7 (15) Lowest agreement was found in the Facial
Trauma 8 (17) Expression subscale during suctioning with
Neurological disorder 8 (17) an r value of 0.77; the r value for Upper Limb
Miscellaneous 10 (21) Movement was 0.85, and the r value for
Doses of sedative and analgesic agents, Compliance With the Ventilator was 0.80.
mean (SD) During the turning procedure, the ICC was 0.88
Fentanyl, µg/h 85 (42.6) for the Facial Expression subscale, 0.94 for
Midazolam, mg/h 3.5 (1.58) the Upper Limb Movement subscale, and 0.80
for the Compliance With the Ventilator subscale.
Abbreviation: APACHE II, Acute Physiology and Chronic Health
Evaluation II.
The correlation matrix of the BPS compo-
a
Values are No. (%) of patients unless otherwise indicated in the first nents was positively correlated at P less than
column.
.001. The principal contributing factor to
pain was the Facial Expression subscale with
24 hours of intubation constituted 15% of the an r of 0.84, while the Compliance With the
study sample, 21% of patients were assessed Ventilator was the lowest contributing sub-
for pain during the first 24 to 48 hours, whereas scale (r = 0.70; Table 4).
64% of patients were assessed more than 48 CPOT. The CPOT and its subscales were
hours after mechanical ventilation was started. highly sensitive (P < .001), with variable respon-
With regard to the analgesic and sedative siveness to pain, ranging from moderate to
agents used in this study, it was noted that large (Table 5), with a Cronbach of 0.95,
19 patients (40%) were not receiving any sed- and an r value of 0.93. The interrater reliabil-
ative or analgesic agents; however, these 19 ity (r value) at rest was 0.94 for Facial
patients had a mean (SD) score on the GCS Expression, 0.99 for Body Movement, 0.74 for
of 6.94 (2.09). A total of 28 patients (60%) Muscle Tension, and 0.99 for Compliance
were receiving a variety of agents that were With the Ventilator. During suctioning, the r
administered as continuous infusions only, values were 0.81 for Facial Expression, 0.92
with most (40%) receiving a combination of for Body Movement, 0.47 for Muscle Ten-
fentanyl and midazolam infusions. The patients’ sion, and 0.83 for Compliance With the Ven-
consciousness level (GCS scores) were from 3 tilator. During turning, the r values were 0.82
to 11 with a mean (SD) score of 6.38 (2.6) for Facial Expression, 0.98 for Body Move-
on the GCS and a mean (SD) score of 4.77 ment, 0.69 for Muscle Tension, and 0.89 for

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

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

Table 3: Psychometric Properties of the Behavioral Pain Scale

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

Abbreviation: ICU, intensive care unit.

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

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

Facial Upper Limb Compliance Correlation

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

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

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

Abbreviation: ICU, intensive care unit.

a
Moderate responsiveness.
b
Small responsiveness.
c
Large responsiveness.

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

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

Critical-Care Pain Observation Facial Body Ventilator Muscle Correlation

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

Table 7: Psychometric Properties of the Nonverbal Pain Scale

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

Abbreviation: ICU, intensive care unit.

a
Moderate responsiveness.
b
Small responsiveness.

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

168
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table 8: Correlation Matrix of the Nonverbal Pain Scale and the Principal Contributing
a
Factor
Nonverbal Pain Facial
Scale Subscale Expression
Facial expression 1 0.87
Activity 0.54
Guarding 0.44
Physiology 0.05
Respiratory 0.01
a
All correlations are significant at P < .001.
(0.95) and ICCs of at least 0.80 for all sub-
scales, except for the subscale of Facial
Expression, which showed lower agreement
during suctioning (r = 0.77). These results are
consistent with the work of Payen et al, who
developed and validated the BPS in a sample
of 30 critically ill sedated patients by expos-
ing the patients to nociceptive procedures
(suction, turning) and procedures that were
not nociceptive. Payen et al6 used a test to
measure the degree of agreement between
raters and found a statistically significant
P value less than .01. Ahlers et al21 reported
similar results when the BPS was evaluated in
49 conscious sedated and 126 unconscious
sedated nonverbal patients. That study dem-
onstrated a good internal consistency of the
BPS, with a Cronbach of 0.63 for the con-
scious patients and 0.66 for the unconscious
patients. The interrater reliability in the study
by Ahlers et al21 was excellent according to
the value. However, the results obtained in
our study reflect a higher Cronbach value
than reported in other studies; this difference
could be due to the difference in the sample
size, as well as the frequency of measurement
in each patient and the number of assessors.
Payen et al6 assessed pain 3 times in each
patient and involved 46 registered nurses
during the time frame of their study, whereas
in our study, 20 trained assessors assessed the
pain in all patients in the study.
Psychometric Properties of the CPOT
In this study, the CPOT was adequately
reliable, valid, and sensitive but showed vari-
able responsiveness. Variable responsiveness
may result in significant changes in patients’
pain severity level before the changes are
manifested in the CPOT score. Vazquez et al22
E VA LUAT ION OF PA IN ASSE SSM E NT TOOLS
Correlation
Activity Guarding Physiology Respiratory Coefficient (r)
1 0.77
0.58 1 0.73
0.22 0.07 1 0.36
0.23 0.07 0.35 1 0.36
evaluated the CPOT in 96 patients receiving
mechanical ventilation by assessing pain before,
during, and after turning. They reported results
similar to ours in terms of reliability and validity.
Unlike our results, Keane3 reported a low
reliability value of the tool and low interrater
reliability in a study of 21 patients after open
heart surgery. This discrepancy could be due
to the difference in sample size; limited patient
characteristics because the study participants
were only patients who had undergone heart
surgery; and the study design, which included
3 assessment points: on arrival from the
operating room, during mechanical ventila-
tion, and after extubation.3
Psychometric Properties of the NVPS
When examining the psychometric proper-
ties of the NVPS, the tool showed satisfactory
validity and reliability, but to a lesser extent
than the previous tools. The Physiology and
Respiratory subscales showed poor psychomet-
ric properties, with weak contributions to the
overall pain scores. Their described definitions
were not achieved by most of the study patients
during nociceptive procedures, even when other
subscales were scored the maximum 2 out of 2.
Additionally, these subscales were not sensitive
for detecting pain, with narrow responsiveness.
This observation has not been reported in
any previous studies that validated the NVPS;
however, Li et al23 argued that the descriptions
in these subscales were not justified or sup-
ported by evidence that explained these changes
in hemodynamic ranges.
Although the NVPS was sensitive and respon-
sive, most subscales showed moderate to small
effect size. This variable responsiveness could
affect the utility of the tool for detecting
changes in pain in different clinical settings.
169
A L DA RWIS H E T A L
Patients could experience severe pain before
they become agitated, rigid, or exhibit vital
sign changes as defined in the scale.
The work of Marmo and Fowler4 yielded
similar findings when both the CPOT and NVPS
were compared in 24 patients after open heart
surgery. The NVPS was highly reliable with a
Cronbach similar to the values obtained in our
study.4 Vranic et al24 reported contrary results
in a study evaluating the NVPS and CPOT in
66 neurosurgical patients. They reported low
and weak interrater reliability of the NVPS
scale. Although the NVPS showed statistically
significant results in their study in terms of
sensitivity, the internal consistency as indicated
by Cronbach was weak to moderate.24
Comparison of Psychometric
Properties Among the 3 Pain
Assessment Tools and Subscales
When examining the subscales of the BPS,
all components were highly sensitive during
both nociceptive procedures, making them
valid behavioral indicators in pain assessment
in nonverbal patients. The third component
of the BPS, Compliance With the Ventilator,
has similar descriptions in its parallel in the
CPOT subscale labeled as Compliance With
the Ventilator. In both tools, this subscale
was less responsive among the 2 raters. The
study by Payen et al6 yielded similar results;
they found this subscale to have the smallest
weight of contribution to pain scores. It is
unknown whether the mode of ventilation
affects the degree of responsiveness and
contribution.
In our study, the Muscle Tension subscale
of the CPOT was identified as the weakest
component in terms of all psychometric
properties. When comparing this scale with
its parallel in the NVPS, labeled Guarding,
the NVPS subscale also showed a lower degree
of responsiveness but satisfactory agreement
among raters. However, in both tools, this
subscale contains a general description and
common words such as tense, very tense, and
rigid. Evaluation of this behavioral indicator
implies a subjective property, and it is unknown
how ICU nurses would define and quantify
these terms. Marmo and Fowler4 also reported
the same observation when comparing the
CPOT and NVPS; however, they considered
the operational definitions of the Muscle Tension
subscale in the CPOT to be more specific and
reliable than was Guarding in the NVPS.
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W W W.A ACNACCONLINE .ORG
When evaluating the 3 assessment tools that
were used in our study, we found the BPS to be
the most valid, reliable, and sensitive tool to be
used appropriately in our ICUs, followed by the
CPOT, which can be an alternative to the BPS
because it showed excellent psychometric prop-
erties despite the presence of 1 weak subscale
(Muscle Tension). The NVPS was a weaker
tool than the BPS and CPOT in terms of all
psychometric properties.
Systematic reviews of the nonverbal pain
assessment tools have been published. Barr
et al25 critically analyzed the pain, agitation,
and delirium guidelines that were established
by the Society of Critical Care Medicine and
ranked these recommendations on the basis
of the quality of the existing evidence. Those
authors considered a scale as appropriate for
clinical use when it has moderate to very good
psychometric properties with a weighted score
of more than 12 points. They concluded that
both the CPOT and the BPS have moderate
psychometric properties and that they are the
most valid and reliable scales for pain assess-
ment in variable ICU populations except in
patients with brain injury and motor dys-
function. The NVPS was reported to have
very low psychometric properties.25
Clade14 systematically reviewed and evalu-
ated all pain assessment tools including the
BPS, CPOT, and NVPS and reported findings
similar to our results. The BPS was identified
as the most valid among other tools, as it
was tested in mixed clinical settings. Clade
further reported the CPOT as a promising
tool in pain assessment. However, Clade14
argued that the author of the tool did not
examine the factor analysis adequately to
test the structure of the entire tool, that the
studies undertaken to evaluate the NVPS
were inadequate, and that the design used
by the authors was generally weak.
Few reports of comparative studies that
combine these 3 tools have been published.26
In a recent study, Chanques et al26 compared
the BPS/BPS-NI (for nonintubated patients),
the CPOT, and the NVPS. The psychometric
properties of these tools were explored in
terms of validity, interrater reliability, respon-
siveness, and feasibility during turning and
endotracheal suctioning. The study involved
30 nonverbal medical ICU patients who were
either delirious, sedated, or receiving mechanical
ventilation. The BPS and CPOT were deemed
as superior to the NVPS. Furthermore, the BPS
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
had higher responsiveness than did the CPOT,
and the NVPS showed limited responsiveness.
The BPS was reported as more feasible for use
in clinical practice settings. However, the CPOT
and the BPS were considered adequately
applicable in both nonverbal intubated and
nonintubated adults.26
Marmo and Fowler4 reported results simi-
lar to ours: when the CPOT and NVPS were
compared, the CPOT showed higher agreement
and higher psychometric properties. They con-
cluded that the CPOT was more appropriate
than the NVPS for assessing pain in nonver-
bal ICU patients.4
Limitations of the Study
The major limitation of the current study
is the small sample size of ICU patients with
multiple diagnoses. In addition, further data
are needed to investigate the association
between those pain scores and the doses of
analgesic agents used in order to establish the
optimal analgesic doses for appropriate pain
management in this sample of ICU patients.
Conclusion and
Recommendations
The BPS was the most valid and appropri-
ate tool in pain assessment in nonverbal ICU
patients, with the CPOT considered an
appropriate alternative. The NVPS is not
appropriate as a pain assessment tool because
of its inconsistent psychometric properties.
Routine procedures such as turning and suc-
tioning were painful to all patients in this
study, regardless of the presence of an analge-
sic infusion. Therefore, repetitive exposure to
these painful procedures could expose
patients to the complications of unrelieved
pain. We recommend not excluding the possi-
ble presence of pain in those ICU patients
who cannot self-report, especially in challeng-
ing patients with neurological disorders.
Nurses are in the best position to assess
patients’ behaviors during their ICU stay.
Pain assessment and management are based
on the principle of beneficence that entitles
nurses to provide sensitive and empathetic
care to patients who cannot verbalize their
pain and needs. These principles cannot be
attained without the use of a valid and relia-
ble assessment tool. ICU nurses must be ade-
quately educated and trained to assess pain
using behavioral indicators in nonverbal
171
E VA LUAT ION OF PA IN ASSE SSM E NT TOOLS
patients by using recommended pain assess-
ment tools. Further research is warranted to
examine the BPS and CPOT in different clini-
cal settings in a larger sample.
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2. Pasero C, McCaffery M. No self-report means no
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15. Chanques G, Payen JF, Mercier G, et al. Assessing pain
in non-intubated critically ill patients unable to
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Intensive Care Med. 2009;35:2060-2067.
16. Gélinas C, Arbour C, Michaud C, Vaillant F, Desjardins S.
Implementation of the Critical-Care Pain Observation Tool
on pain assessment/management nursing practices in an
intensive care unit with nonverbal critically ill adults: a
before and after study. Int J Nurs Stud. 2011;48:1495-1504.
17. Pearson K. Notes on regression and inheritance in the
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ics. Dordrecht, Netherlands: Springer; 2001.
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Knibbe CA. The use of the Behavioral Pain Scale to
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Factors Related to Successful
Transition to Practice for Acute
Care Nurse Practitioners
Deborah L. Dillon, RN, DNP, ACNP-BC, CCRN, CHFN
Mary A. Dolansky, RN, PhD
Kathy Casey, RN, MSN
Carol Kelley, RN, PhD, CNP
ABSTRACT
The transition from student to acute care
nurse practitioner (ACNP) has been recog-
nized as a time of stress. The purpose of this
descriptive, correlational-comparative design
pilot study was to examine: (1) the relation-
ships among personal resources, commu-
nity resources, successful transition, and job
retention; (2) the difference between ACNPs
with 0 to 4 years and ACNPs with more than
4 years of prior experience as a registered
nurse in an intensive care unit or emergency
department; and (3) the skills/procedures
that ACNPs found difficult to perform
T he demand for acute care nurse practi-
tioners (ACNPs) has increased in the past
several years. This demand has been created
by an increase in hospitalized and critically
ill patients as well as duty-hour restrictions
for medical residents implemented by the
Accreditation Council for Graduate Medical
Education.1,2 It is vital that ACNPs working
in hospital settings be supported as they
transition into their new roles.
The Institute of Medicine’s report3 on the
future of nursing recommends transition-to-
practice residency programs to address health
care workforce shortages. The Institute of Med-
icine suggests that
healthcare organizations take
actions to support nurses’ comple-
tion of a transition-to-practice
program (nurse residency) after
173
AACN Advanced Critical Care
Volume 27, Number 2, pp. 173-182
© 2016 AACN
independently. Thirty-four participants were
recruited from a social media site for nurse
practitioners. Organizational support, com-
munication, and leadership were the most
important elements of successful transition
into the ACNP role. This information can
help ACNP faculty and hospital orientation/
fellowship program educators to help
ACNPs transition into their first position
after graduation.
Keywords: acute care nurse practitioner,
transition, practice, graduate nurse practi-
tioner, academic, nurse practitioner fellowship
they have completed an advanced
practice degree program or when
they are transitioning into new clini-
cal practice areas.4(p59)
Deborah L. Dillon is Assistant Professor, University of Virginia
School of Nursing, 225 Jeannette Lancaster Way, McLeod
Hall, Rm 4007, Charlottesville, VA (did6z@virginia.edu).
Mary A. Dolansky is Associate Professor, Frances Payne
Bolton School of Nursing, Case Western Reserve University,
Cleveland, Ohio.
Kathy Casey is Manager, Clinical Education, Lutheran Medical
Center, Wheat Ridge, Colorado.
Carol Kelley is Assistant Professor, Frances Payne Bolton
School of Nursing, Case Western Reserve University,
Cleveland, Ohio.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016619
D ILLO N E T A L W W W.A ACNACCONLINE .ORG

Meleis model

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

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

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

Hospital orientation or fellowship programs interpret electrocardiograms and other diag-

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

174
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Meleis24 defined 3 global indicators for
all successful transitions: (1) subjects’ well-
being, (2) role mastery, and (3) well-being of
relationships. The model for this particular
study (adapted from the Meleis model) exam-
ined factors related to successful ACNP tran-
sition to practice. The study model corresponds
to these indicators by identifying successful
transition variables as (1) comfort/confidence,
(2) patient safety, and (3) professional and
job satisfaction (see Figure).
Description of the Problem
Few reports of graduate nurse practitioners’
perception of the transition experience have
been published; thus little is known about
the factors related to successful transition for
any nurse practitioner, including the ACNP.18,25
Barnes20 explored the relationship between
experience as a registered nurse and the tran-
sition to the nurse practitioner role and found
that prior nursing experience did not affect
successful transition into practice. In an
unpublished dissertation, Duke18 used herme-
neutic phenomenology to examine the lived
experience of new graduate nurse practition-
ers to hospital-based practitioners in a group
of 12 nurse practitioners (adult, family, and
acute care) with at least 1 year of hospital-
based experience. She identified a transition
period that ranged from 6 to 18 months and
was most intense during the first 9 months of
practice. Challenges encountered during this
time frame included
navigating and negotiating a new
health care provider role, becoming
integrated into a hospital system
in what was a new role for the
practitioner and often a new role
for the system, learning how to
function effectively as a NP [nurse
practitioner] while working to re-
establish themselves as proficient
clinicians with a newly expanded
practice scope, building key rela-
tionships, and educating physi-
cians, hospital leaders, clinical
staff, patients and families about
the NP role.18(abstract)
Registered Nurse Transition
to Practice
The Casey-Fink Graduate Nurse Experience
Survey has been used extensively to examine
various factors that affected the transition
175
ACNP T RA NSIT ION TO P RACT ICE
from the student role to the registered nurse
role.21 Consistent with Casey and colleagues,
Newhouse et al22 also identified the new grad-
uate experience as stressful with high turnover
unless it was partnered with an internship. The
importance of a preceptorship in developing
a greater degree of perceived competence in
development of clinical skills was examined by
Kim.23 Casey et al21 reported that newly grad-
uated nurses require consistent support and
professional development during the first year
of practice. The Casey-Fink Graduate Nurse
Experience Survey was developed from themes
identified from the literature that influenced
the graduate nurse experience and included
consistency of role socialization support,21,26
the quality of the clinical orientation,27,28 and
the level of support from nursing leaders.27-30
Purpose of the Study
The purpose of this descriptive, correlational-
comparative design study was to identify
(1) the relationships among personal resources
(prior experience in intensive care unit [ICU]/
emergency department [ED] and stressors)
and community resources (organizational
support and communication/leadership), a
successful transition (comfort/confidence,
patient safety, and professional and job sat-
isfaction), and job retention experienced by
ACNPs within their first 6 months of
employment; (2) the differences in personal
and community resources, successful transi-
tion, and job retention between ACNPs with
0 to 4 years and ACNPs with more than 4
years of prior nursing experience in the ICU/
ED; and (3) skills and procedures that new
ACNPs found difficult to perform.
Tool Validation
No instrument is available in the literature
to evaluate the factors related to successful
ACNP transition, so the Casey-Fink Graduate
Nurse Experience Survey was modified, with
permission, to apply to the ACNP experience.
The Casey-Fink Graduate NP Experience
Survey was developed to evaluate the ACNP
role transition experience. Specifically, the
original instrument was modified to collect
data on personal resources (prior nursing
experience in the ICU/ED and stressors), com-
munity resources (organizational support
and communication/leadership), and success-
ful transition factors (comfort/confidence in
performing both clinical and relational skills/
D ILLO N E T A L
procedures, patient safety, professional and
job satisfaction, and job retention).21 The skills
or procedures in the modified instrument were
adopted from those published by Kleinpell
et al31 after a national survey.
After the modified survey was developed,
2 expert clinical faculty members and 5 ACNPs
evaluated the instrument for content validity.
A revised survey was pilot tested on 3 ACNPs
for applicability.
Methods
Design
A descriptive, correlational-comparative
design was used for this pilot study. Approval
was obtained from the institutional review
board at Case Western Reserve University and
from the group administrator of the social
media site used to recruit participants
(www.linkedin.com/groups).
Sample Characteristics
The study included a convenience sample
of 34 ACNPs who were members of an Acute
Care Nurse Practitioner Network social
media site. Respondents were eligible to
participate if they met the following inclu-
sion criteria:
1. Board-certified ACNP or adult-gerontology
ACNP (AG-ACNP) with more than 6 months
and less than 3 years of active practice in an
ACNP or AG-ACNP role.
2. Member of the social media ACNP
Network.
Data Collection and Procedures
Participants were recruited through an intro-
ductory cover letter on the ACNP Network’s
social media site. They were informed of the
purpose of the web survey, what participation
entailed (completion of the Qualtrics survey),
and the survey length (20 minutes). Respond-
ents were asked to recall their first 6 months
of employment as an ACNP when answering
the survey questions. Voluntary consent was
implied by the participant’s completion of
the survey. Participants were assured that the
data would be confidential and that no iden-
tifiers were linked to e-mail addresses or par-
ticipants’ data.
Instrument
The Casey-Fink Graduate NP Experience
Survey was used for data collection and to
identify factors related to successful ACNP
176
W W W.A ACNACCONLINE .ORG
transition to practice. The survey consisted
of 5 sections: (1) demographic information;
(2) skills/procedure performance (drop-down
list of 30 items); (3) subscales related to suc-
cessful transition (comfort/confidence, patient
safety, professional satisfaction, job retention);
(4) subscales related to community resources
(organizational support and communication/
leadership); and (5) subscales related to per-
sonal resources (stressors and prior work
experience as a nurse in the ICU/ED). All
responses on subscales were added to calcu-
late total scores for each subscale. Table 1
describes the concepts, gives example of items,
and specifies the reliability and validity of
the study variables.
Statistical Analysis
Statistical analyses were performed by
using IBM Statistical Package for Social Sci-
ences version 22 (IBM SPSS Inc). Survey items
and demographics were summarized by using
descriptive statistics. Bivariate correlations
and nonparametric tests were used to exam-
ine the research questions.
Results
A description of the demographic varia-
bles is displayed in Table 2. The sample was
predominantly white women between 41 and
50 years old. Fifteen states and Puerto Rico
were represented. Most participants had a
master of science degree in nursing. Eighty-
two percent had more than 5 years of nurs-
ing experience, and 75% had more than 5
years of nursing experience in an ICU or ED.
Most had an orientation that lasted 8 weeks
or less. Twenty-nine percent of the respond-
ents reported no orientation. Fifty-two per-
cent of the respondents remained in their
first position after graduation for less than 2
years. Forty-six percent of the respondents
reported experiencing stress, with job perfor-
mance and personal finances reported as the
top 2 stressors.
The relationships among personal and
community resources and successful transi-
tion and job retention are listed in Table 3.
Statistically significant positive correlations
were found among organizational support
and comfort/confidence (r = 0.49; P < .01),
patient safety (r = 0.38; P < .05), professional
satisfaction (r = 0.72; P < .05), and job satis-
faction (r = 0.53; P < .01). The relationship
between communication/leadership was also
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 ACNP T RA NSIT ION TO P RACT ICE

Table 1: Reliability and Validity of Study Variables

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

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D ILLO N E T A L
Table 1: Reliability and Validity of Study Variables (Continued)
Variable Definition
Personal and community resources
Organizational Perception of
support support from
the nurse prac-
titioner/physi-
cian mentor
and family/
friends
Abbreviations: ACNP, acute care nurse practitioner; NA, not applicable.
significant with comfort/confidence (r = 0.68;
P < .01), patient safety (r = 0.62; P < .01), pro-
fessional satisfaction (r = 0.44; P < .05), and
job satisfaction (r = 0.57; P < .01). There was a
significant negative correlation between com-
munication/leadership and job retention
(r = -0.35; P < .05; Table 3).
No significant differences were found
between nurses with 0 to 4 years and nurses
with more than 4 years of ICU/ED experience
in the measures of personal and community
resources, successful transition, and retention
(Table 4). Of the 30 identified skills/procedures
adopted from the survey results of Kleinpell
et al,31 only 15 were selected by the respond-
ents. The top 3 skills that were deemed most
difficult to perform were cricothyrotomies,
dictation or electronic medical record docu-
mentation of a history and physical, and bill-
ing and coding. Table 5 identifies the top 7
skills/procedures the participants found diffi-
cult to perform.
Discussion
The majority of the sample was more than
40 years old and had more than 4 years of
nursing experience in the ICU/ED before
becoming an ACNP. We found no differences
between nurses with 0 to 4 years and nurses
with more than 4 years of ICU/ED experience
in relation to successful transition and reten-
tion. Contrary to the results of our study, Hart
and Macnee7 identified that nurse practitioners
with more prior experience as a nurse (mean,
11 years) felt more prepared in practice than
those with little nursing experience. Consist-
ent with our study, Barnes20 reported no
W W W.A ACNACCONLINE .ORG
No. of
Sample Items Items Cronbach
I felt supported by my nurse practitioner/physician 10 0.87
preceptor
I had opportunities to practice skills more than
once in simulation
I had opportunities to practice skills more than
once in real life
My preceptor helped me to develop confidence
in my diagnostic skills
I felt that the nurse practitioner/physician provided
feedback about my work
relationship between prior nursing experience
(mean, 13.8 years) and the transition to the
nurse practitioner role. Previous nursing
experience is important, considering that
most ACNP programs require between 1 and
2 years of ICU/ED experience before accept-
ance, and this requirement may be related to
our finding that only 8 ACNPs had less than
4 years of ICU/ED nursing experience. The
low number of ACNPs with less than 4 years
of ICU/ED nursing experience may have been
responsible for the lack of a relationship
between these variables.
The findings in our study are consistent
with the Meleis model. Overall, the commu-
nity resources of organizational support and
communication/leadership were related to
successful transition (comfort/confidence,
patient safety, and professional and job satis-
faction) for ACNPs during their first 6 months
of practice. Support from the nurse practitioner/
physician mentor and their availability for new
situations and procedures was deemed impor-
tant by the new ACNPs. Feedback about their
work was important and helped the ACNPs
to develop confidence in their assessment and
diagnostic skills. Support from families and
friends during this time frame was also impor-
tant, consistent with findings identified by
Heitz et al15 in their study of nurses’ transition
into practice. New ACNPs felt supported in
their position by their mentors, in contrast to
new nurses, who voiced concerns about peer
and preceptor relations and communication
with physicians.21 This difference in relation-
ships may be related to the ACNP being per-
ceived on more of a peer level as well as the
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Table 2: Description of Demographic and difference between a preceptor and a mentor.

Study Variables (N = 34) Consistent with the Casey-Fink Graduate Nurse
Experience Survey, nurse practitioners also iden-
Characteristic No. (%)a tified the importance of organizational support.21
Sex No relationships were found between
Female 26 (79) personal resources and successful transition.
Male 7 (21) This may be representative of the high per-
Ethnicity centage of prior nursing experience in the
White 31 (91) ICU/ED in this sample. Although stressors
Black 1 (3) (eg, job performance and finance) were iden-
Hispanic 1 (3) tified, they did not seem to affect successful
Asian 1 (3) transition and job retention. This finding was
Area of working specialty consistent with the findings of Barnes20 that
Intensive care unit/emergency department 13 (39) organizational factors were more important
Not in intensive care unit 20 (61) than personal factors in the successful transi-
tion of nurse practitioners.
Highest level of education
Master of science in nursing
Responses to the skills/procedures items
32 (94)
Doctorate in nursing practice 0 (0)
revealed a lack of comfort in performing cri-
cothyrotomies, dictation or electronic medical
Nurse practitioner certification record documentation of a history and physi-
American Nurses Credentialing Center 29 (88) cal, and billing and coding. Cricothyrotomy
American Academy of Nurse Practitioners 4 (12)
American Association of Critical-Care Nurses 0
is not a commonly performed procedure,
which would correlate with a lack of comfort
Retention in performing. The ACNP skills survey31 lists
Time worked in first position after cricothyrotomy as a required skill, so includ-
graduation as a nurse practitioner
ing cricothyrotomy in a simulation portion
Still ongoing 14 (41)
0-6 months
of an ACNP program would improve comfort
5 (15)
7-12 months 2 (6)
for a new ACNP. Although the new ACNPs felt
13-18 months 6 (18) comfortable collecting a medical history and
19-24 months 7 (21) physical examination and doing so in a timely
manner (< 45 minutes), they were less comfort-
Feelings of leaving your job within the
first 6 months of employment
able in their ability to translate or organize
Never 15 (45)
this information into the required documen-
< Once per month 6 (18) tation. Continued exposure to the skill of
Once per month 12 (36) organizing history and findings on physical
examination and dictating/documenting in
Age, years
20-30
electronic medical records during the student
5 (15)
31-40 11 (32)
ACNPs’ clinical practicums would improve
41-50 14 (41) this skill. Billing and coding were also identi-
51-60 3 (9) fied as difficult skills. This information is
≥ 61 1 (3) similar to that found by Hart and Macnee7
Length of orientation
in their study of predominantly family nurse
Still ongoing 1 (3)
practitioners. The inclusion of billing and
0 or < 8 weeks 15 (44) coding skills in ACNP programs is unknown;
9-12 weeks 5 (15) however, including billing and coding in the
13-16 weeks 2 (6) classroom training as well as incorporating
> 24 weeks 1 (6) it into the clinical practicum would most
Did not have one 10 (29) likely increase new ACNPs’ comfort with
Prior experience in intensive care billing and coding.
unit/emergency department, years Other findings of interest were that the
0-4 8 (24) mean duration of orientation was 8 weeks
5-9 13 (38) or less and that 29% of the respondents
10-14 7 (21) reported not having any orientation. It is
15-20 6 (18) not surprising that limited orientation would
a
Percentages may not total 100 because of rounding. impact the transition process. This finding is

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D ILLO N E T A L W W W.A ACNACCONLINE .ORG

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

Transition and Retention

Successful Transition and Retention

Comfort/ Patient Professional Job Felt Like

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

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

a
Transition and Retention

Nurses’ Experience in Intensive Care Unit/

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

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

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VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Future Research
Expanding the data collection method to
include more settings may provide a more
representative and larger sample of ACNPs
as they transition to practice. Performing a
comparative design study evaluating ACNPs
at 6 and 12 months of practice would enable
evaluation of changes over time in the stud-
ied variables. Future research to evaluate
strategies to enhance successful transition and
retention is important as the demand for
ACNPs in hospital settings increases. Facili-
tating the transition of the new ACNPs into
competent health care providers by providing
them with support and assistance in their
practice environment is an important compo-
nent of these strategies.
Conclusion
Successful role transition is determined by
the extent to which individuals demonstrate
mastery of the skills and behaviors needed to
manage their new situations or environment.5
A successful transition of an ACNP into prac-
tice depends on an understanding of the com-
munity resources that are important for ACNP
transition. The importance of organizational
support, communication, and leadership during
the transition was supported by the Modified
Casey-Fink Graduate NP Experience Survey.
Hospitals that perform poorly in reten-
tion spend a mean of $3.6 million more than
those with higher retention rates.32 Highly
trained and specialized health care profession-
als are difficult and expensive to replace in
any health care setting.4,33 Nurse practitioners’
turnover is costly and disruptive to continuity
of patient care.33
It is vital that ACNPs working in acute
care settings be supported as they transition
into their new roles. Recommendations have
been made to facilitate the transition of new
ACNPs into competent health care providers
by providing them with support and assistance
in their practice environment.7 Bush stated that
nurse executives have the opportu-
nity to champion postgraduate NP
training programs. Designing pro-
grams for recent NP graduates can
help ensure adequate retention
and job satisfaction of a rapidly
growing and important segment
of the clinical workforce.34(p626)
Postgraduate and fellowship training pro-
grams provide community resources such as
181
ACNP T RA NSIT ION TO P RACT ICE
organizational support, communication, and
leadership, which the results of this study
indicate are related to successful transition.
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 AACN
A d v a n c e d
Cr i t i c a l Ca r e
SYMPOSIUM APRIL-JUNE 2016

Patient and Family Post–Intensive

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

Maurene A. Harvey, MPH

Educational Consultant
Lake Tahoe, Nevada

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

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

Patient and Family Post–Intensive Care

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

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

Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California
San Diego Health, Mail Code 8929, 200 W Arbor Drive, San Diego CA 92103 (jdavidson@ucsd.edu)
Maurene A. Harvey is an Educational Consultant, Lake Tahoe, Nevada.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016132

184
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
The Birth of Post–Intensive
Care Syndrome and
Post–Intensive Care
Syndrome-Family
In 2010, the Society of Critical Care Medi-
cine (SCCM) convened a task force to exam-
ine the long-term consequences of critical
illness. This group of scientists and clinical
experts gathered for a summit.2 The state of
the science was reviewed for outcomes asso-
ciated with critical illness for both patients
and patients’ families. Participants agreed to
refer to the new or worsening mental health,
physical, and cognitive outcomes that linger
past the ICU stay as post–intensive care syn-
drome or PICS. When those outcomes affect
patients’ family members, an “F” is added
and the term becomes PICS-F.
Raising Awareness
One of the major goals of the stakeholder
conference was to identify and promote strat-
egies to increase awareness of PICS and PICS-
F outside the critical care health care
community and among ICU survivors and
their families. Attendees have given presenta-
tions to their peers, published in their jour-
nals, and begun initiatives toward this end.
It became clear to us that a transfer out of
the ICU should include a functional reconcili-
ation to assess distance from baseline condi-
tion before hospitalization.7 This checklist
would follow the patient’s progress through
their postdischarge care and serve to inform
caregivers of potential often-missed issues.
The SCCM THRIVE Initiative is a grant-
funded project to test a program of peer-to-peer
support to treat PICS and PICS-F. Demonstra-
tion projects are in progress.13 SCCM’s ICU
Liberation Task Force is developing standard
slide sets and work tools to inform clinicians
about the efforts to reduce PICS through
appropriate and minimal sedation, mobility
programs, and delirium prevention and assess-
ment.14 During a second summit, the ABCDE
bundle, which addresses the PICS risk factors
of delirium, immobility, sedation, and dura-
tion of mechanical ventilation,14-16 was endorsed
as a method of minimizing PICS. The letters in
ABCDE stand for airway (A), spontaneous
breathing trials (B), care coordination and
communication between disciplines (C), delir-
ium assessment (D), and early mobility (E).
An FGH was added to the ABCDE mnemonic
to address issues with the family and transitions
185
Symposium
of care: family follow-up referrals and func-
tional reconciliation (F), good handoff com-
munication (G), and handout educational
materials on PICS and PICS-F (H).17,18
To promote awareness in patients and
families, YouTube videos have been created
by patients and their families to describe their
experiences.19 We established a definition of
PICS on Wikipedia20 and created a new PICS
brochure for patients and their families that
is available through the SCCM website
(www.sccm.org).19
This Issue: A PICS and PICS-F
Primer
Even though the problem of PICS and PICS-F
is clearly recognized, much more can be learned
about effective interventions to minimize
symptoms and conditions experienced by ICU
survivors and their families. In this issue, we
have invited authors to describe strategies they
are exploring to improve outcomes. It should
be recognized that the science supporting these
strategies is young. However, in the absence
of strong evidence, we have a duty to take
action in the best interest of the health of our
community given what is known today. To
that end, this issue is designed as a primer to
promote new ideas and programs targeted at
improving care in and out of the ICU to pre-
vent, recognize, and treat PICS and PICS-F.
We have asked each team of authors to
provide replicable steps for starting new initia-
tives in care. They have also invited a survivor
and/or family informant as coauthor to keep
the focus on the real issues and values at the
forefront of why practice needs to change.
We learn most when we listen, and we hope
that the guidance offered in these articles will
provide a compelling impetus for change.
The details of implementing an early mobil-
ity program in the ICU are described by Ramona
Hopkins and her team from Intermountain
Medical Center in Utah. Mary McCarthy and
her nursing colleagues from Madigan Army
Base in Tacoma, Washington, describe their
fledging diary program and the steps needed
to implement diaries in the ICU. Diaries have
been used in the Netherlands and Europe for
more than 20 years with some promising
results for both survivors and their fami-
lies.21-25 Use of diary programs in the United
States has not been reported before. Moving
outside of the ICU, Huggins and colleagues
discuss how to establish a post-ICU clinic to
Symposium
help patients and families who are dealing
with PICS and PICS-F. Finally, Mark Mik-
kelsen, a leader from the SCCM THRIVE
Initiative, describes one of the demonstration
projects in progress to establish peer-to-peer
support programs to help survivors and fami-
lies after an ICU stay.
In addition to the articles in the symposium
series, 2 of the regular columns in this issue
also address the topic of PICS and PICS-F.
In the Drug Update column, Joanna Stollings
and colleagues discuss medication manage-
ment options to ameliorate PICS. The ethics
of PICS and PICS-F are explored through a
historical case study in the Ethics column.
It was originally planned that Jessica, an ICU
survivor whose story is publicly available on
video and in print,17,26 would coauthor that
manuscript. However, with much regret, we
report that she died this year, presumably of
complications of her ICU stay many years
ago. We dedicate this issue to Jessica and all
those who share their ICU experiences with
us so that we can learn from them.
These articles will provide practical guid-
ance on how to start programs like these in
your own organization, measures of success
for quality monitoring, and a list of potential
research questions related to addressing the
gap in evidence.
In conclusion, it is our goal through this
issue not only to raise awareness surrounding
PICS and PICS-F, but to stimulate adoption
of strategies to enhance family-centered care,
to decrease the modifiable risk factors of PICS
(immobility, oversedation, duration of mechani-
cal ventilation, and delirium), and to study
the effects of these strategies on outcomes.
This is an important time for critical care
nurses and nurse scientists. Interventions are
being tested to address PICS and PICS-F, and
further research is needed in all areas related
to these potentially devastating syndromes.
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1. Desai SV, Law TJ, Needham DM. Long-term complica-
tions of critical care. Crit Care Med. 2011;39(2):371-379.
2. Needham DM, Davidson J, Cohen H, et al. Improving
long-term outcomes after discharge from intensive
care unit: report from a stakeholders’ conference. Crit
Care Med. 2012;40(2):502-509.
3. Brummel NE, Balas MC, Morandi A, Ferrante LE, Gill TM,
Ely EW. Understanding and reducing disability in older
adults following critical illness. Crit Care Med. 2015;
43(6):1265-1275.
4. Briegel I, Dolch M, Irlbeck M, Hauer D, Kaufmann I,
Schelling G. Quality of results of therapy of acute res-
piratory failure: changes over a period of two decades
[in German]. Anaesthesist. 2013;62(4):261-270.
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5. Wintermann GB, Brunkhorst FM, Petrowski K, et al. Stress
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of severe sepsis. Crit Care Med. 2015;43(6):1213-1222.
6. Parker AM, Sricharoenchai T, Raparla S, Schneck KW,
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7. Elliott D, Davidson JE, Harvey MA, et al. Exploring the
scope of post-intensive care syndrome therapy and
care: engagement of non-critical care providers and
survivors in a second stakeholders meeting. Crit Care
Med. 2014;42(12):2518-2526.
8. Davidson JE, Jones C, Bienvenu OJ. Family response to
critical illness: postintensive care syndrome-family. Crit
Care Med. 2012;40(2):618-624.
9. Netzer G, Sullivan DR. Recognizing, naming, and measur-
ing a family intensive care unit syndrome. Ann Am
Thorac Soc. 2014;11(3):435-441.
10. Jezierska N. Psychological reactions in family members of
patients hospitalised in intensive care units. Anaesthesiol
Intensive Ther. 2014;46(1):42-45.
11. Sullivan DR, Liu X, Corwin DS, et al. Learned helplessness
among families and surrogate decision-makers of patients
admitted to medical, surgical, and trauma ICUs. Chest.
2012;142(6):1440-1446.
12. Kentish-Barnes N, Chaize M, Seegers V, et al. Complicated
grief after death of a relative in the intensive care unit. Eur
Respir J. 2015;45(5):1341-1352.
13. Society of Critical Care Medicine. Thrive. 2016. http://www
.sccm.org/research/quality/thrive/Pages/default.aspx.
Accessed January 29, 2016.
14. Society of Critical Care Medicine. ICU liberation. 2016.
http://www.sccm.org/Research/Quality/Pages/ICU-Liberation
.aspx. Accessed January 29, 2016.
15. AACN. Implementing the ABCDE bundle at the bedside.
http://www.aacn.org/wd/practice/content/actionpak/withlinks
-ABCDE-ToolKit.content?menu=practice. Accessed Feb-
ruary 2, 2016.
16. Pun BT, Balas MC, Davidson J. Implementing the 2013
PAD guidelines: top ten points to consider. Semin Respir
Crit Care Med. 2013;34(2):223-235.
17. Davidson JE, Harvey MA, Schuller J, Black G. Post-intensive
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Nurse Today. 2013;8:32-38.
18. Davidson JE, Harvey MA, Bemis-Dougherty A, Smith JM,
Hopkins RO. Implementation of the Pain, Agitation, Delir-
ium Clinical Practice Guidelines and promoting patient
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Crit Care Med. 2013;41(9 suppl 1):S136-S145.
19. Society of Critical Care Medicine. New resources high-
light post-intensive care syndrome. http://www.sccm.org
/News/Pages/New-Resources-Highlight-Post-Intensive
-Care-Syndrome.aspx. 2016. Accessed January 29, 2016.
20. Post-intensive care syndrome. Wikipedia page. https://en
.wikipedia.org/wiki/Post-intensive_care_syndrome.
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21. Egerod I, Bagger C. Patients’ experiences of intensive care
diaries: a focus group study. Intensive Crit Care Nurs.
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The extent and application of patient diaries in Danish
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23. Jones C, Backman C, Capuzzo M, et al. Intensive care dia-
ries reduce new onset post traumatic stress disorder fol-
lowing critical illness: a randomised, controlled trial. Crit
Care. 2010;14(5):R168.
24. Jones C, Backman C, Griffiths RD. Intensive care diaries and
relatives’ symptoms of posttraumatic stress disorder after
critical illness: a pilot study. Am J Crit Care. 2012;21(3):172-176.
25. Garrouste-Orgeas M, Coquet I, Perier A, et al. Impact of an
intensive care unit diary on psychological distress in
patients and relatives. Crit Care Med. 2012;40(7):2033-2040.
26. Davidson JE, Hopkins RO, Louis D, Iwashyna TJ. Post-inten-
sive care syndrome. 2013. http://www.myicucare.org/Adult
-Support/Pages/Post-intensive-Care-Syndrome.aspx.
Accessed January 29, 2016.

Implementing a Mobility Program to
Minimize Post–Intensive Care Syndrome
Ramona O. Hopkins, RN, PhD
Lorie Mitchell, RN, MSN
George E. Thomsen, MD
Michele Schafer
Maggie Link, PT
Samuel M. Brown, MD, MS
ABSTRACT
Immobility in the intensive care unit (ICU)
is associated with neuromuscular weakness,
post–intensive care syndrome, functional
limitations, and high costs. Early mobility–
based rehabilitation in the ICU is feasible
and safe. Mobility-based rehabilitation var-
ied widely across 5 ICUs in 1 health care
system, suggesting a need for continuous
training and evaluation to maintain a strong
mobility-based rehabilitation program. Early
mobility–based rehabilitation shortens ICU
and hospital stays, reduces delirium, and
increases muscle strength and the ability
to ambulate. Long-term effects include
T he old notion that the treatment of critical
illness ends at discharge from the intensive
care unit (ICU) is no longer sufficient. The large
majority of adults treated in the ICU survive
their critical illness, producing an expanding
group of survivors. These survivors may have
serious morbidities that are the aftereffects of
both the critical illness and its treatment. These
morbidities are associated with a substantial
burden for patients, their families, and society.1,2
Specifically, post–intensive care syndrome
(PICS),3,4 which includes physical, psycho-
logical, and cognitive impairments, develops
in many ICU survivors.5-11 PICS can persist for
years after a patient leaves the ICU, adversely
affecting patients and their families.5,6 Many
individuals do not return to work because of
functional or cognitive impairments, have sub-
stantial ongoing medical problems that require
187
AACN Advanced Critical Care
Volume 27, Number 2, pp. 187-203
© 2016 AACN
increased ability for self-care, faster return
to independent functioning, improved physi-
cal function, and reduced hospital readmis-
sion and death. Factors that influence early
mobility–based rehabilitation include having
an interdisciplinary team; strong unit leader-
ship; access to physical, occupational, and
respiratory therapists; a culture focused on
patient safety and quality improvement; a
champion of early mobility; and a focus on
measuring performance and outcomes.
Keywords: early mobility, rehabilitation, inten-
sive care unit, critical illness, post–intensive
care syndrome
Ramona O. Hopkins is Professor, Department of Psychology
and Neuroscience Center, Brigham Young University, Provo,
Utah, and Clinical Research Investigator, Center for Human-
izing Critical Care, and Department of Medicine, Pulmonary
and Critical Care Division, Intermountain Healthcare, 5121 South
Cottonwood St, Murray, UT 84107 (mona.hopkins@imail.org).
Lorie Mitchell is Nurse Manager, Shock Trauma Intensive Care
Unit, Department of Medicine, Intermountain Medical Center.
George E. Thomsen is Medical Director, Coronary Intensive Care
Unit, Department of Medicine, Intermountain Medical Center.
Michele Schafer is Member, Intensive Care Unit Patient-Family
Advisory Council, Intermountain Medical Center.
Maggie Link is Physical Therapist, Shock Trauma Intensive
Care Unit, Intermountain Medical Center.
Samuel M. Brown is Director, Center for Humanizing Critical
Care, Assistant Professor of Pulmonary and Critical Care
Medicine, Department of Medicine, Intermountain Healthcare,
and University of Utah School of Medicine, Salt Lake City, Utah.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016244
H O P K INS E T A L
expensive treatment, and often have substan-
tial reductions in quality of life.12-14 Although
most survivors are glad to be alive and grate-
ful for the care of ICU clinicians, they are often
eager for ways to improve their symptoms
and disabilities.
A growing area of research is focused on
patient-centered outcomes among survivors of
critical illness.15 Preventing or treating PICS
has become a substantial priority.16 Early
mobility–based rehabilitation—a therapy
that depends on ICU nurses, physical and
respiratory therapists, and physicians for its
success—has been a promising focus for efforts
to improve PICS.17-22 The effect of critical ill-
ness on an individual’s overall function, qual-
ity of life, and reintegration into the home
and work setting provides a strong justifica-
tion for early mobility/acute rehabilitation
and preventive measures, if they prove effec-
tive. Immobility in the ICU is associated with
the need for extended nursing care or treat-
ment in a rehabilitation facility and an inabil-
ity to walk and complete activities of daily
living.23,24 To date, exercise or mobility-based
rehabilitation in the hospital has been reported
to improve physical function for critically ill
patients.18 As the evidence continues to accu-
mulate, key questions arise regarding how to
implement early mobility, how it is experienced
by patients and their families, and what bar-
riers must be overcome to create and sustain
early mobility programs. Centrally, to what
extent can early mobility programs developed
in one clinical environment transfer success-
fully to another?
Evidence-Based Practice
Project Plan
In this article, we review the effects of early
mobility–based rehabilitation on ICU outcomes.
We describe the experience in a respiratory
ICU (RICU), where a care practice model for
early mobility was developed and implemented.
We then describe the experience with early
mobility programs in 4 other ICUs in our
corporation, exploring relevant similarities
and differences regarding patient mobility
among these ICUs. The experience of early
mobility is described from the perspective
of a patient (M.S.) who is a member of our
ICU Patient-Family Advisory Council. Finally,
we review the effect of early mobility–based
rehabilitation on long-term outcomes and
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W W W.A ACNACCONLINE .ORG
discuss factors that may affect early mobility–
based rehabilitation.
Project Team
The project team included 2 intensivists
involved in early mobility–based rehabilitation
in the ICUs described, a nurse psychologist who
studies ICU outcomes, the nurse manager of 1
of the ICUs, a physical therapist who works
in one of the ICUs, and a patient who under-
went early mobility during her critical illness.
Early Mobility and ICU
Outcomes
Neuromuscular complications including
ICU-acquired weakness are due, at least in
part, to immobility in critically ill patients.7,25-28
The etiology of ICU-acquired weakness is
unclear; risk factors include immobility, long
duration of mechanical ventilation, high ill-
ness severity, hyperglycemia, and medications
such as corticosteroids.29-31 Recent research has
begun to establish an evidence base for early
interventions to improve patients’ outcomes,
including early mobility–based rehabilitation.
In adult ICU populations, early mobility–based
rehabilitation is safe and feasible17,19 and may
improve PICS.3,4 Researchers in a number of
studies have documented improvements in
physical function with early mobility. Table 1
shows the effects of early mobility–based reha-
bilitation on important outcomes for patients:
increased ability to stand, pivot, and bear
weight,34 improved lower extremity muscle
strength,40 and getting out of bed sooner.41,42
Although the studies mostly include small num-
bers of patients, a consistent trend is apparent
in decreasing hospital length of stay (LOS),
days of mechanical ventilation, and time to first
out of bed with an increase in activity/ambula-
tion. Early mobility increased the number of
ventilator-free days24,32 and reduced hospital
readmissions.38 Early mobility increases the
number of people who ambulate, and not only
do they ambulate, they ambulate sooner than
other ICU patients and ambulate greater dis-
tances than do patients who do not participate
in mobility-based rehabilitation.17,19,32-34,37
Studies33,34,37,38 have demonstrated that ambu-
lation shortens both ICU and hospital LOS.
Winkelman et al35 reported that use of an
activity protocol reduced ICU LOS, suggest-
ing that even brief episodes of low-intensity
exercise may be sufficient to improve outcomes.
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Table 1: Effects of Early Mobility or Rehabilitation on Outcomes in Critically Ill Patients

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

Continued

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

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

Continued

190
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Table 1: Effects of Early Mobility or Rehabilitation on Outcomes in Critically Ill Patients

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

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

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

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

191
H O P K INS E T A L
Implementation of Early
Mobility in the ICU
Early Mobility Program in the
Respiratory ICU
The RICU—where our early mobility
protocol was first developed—was initially
designed to provide protocol-driven care for
patients with respiratory failure, with the
intent to provide outstanding clinical care
and to optimize post-ICU outcomes. A team
approach was used to identify areas for qual-
ity improvement, which resulted in develop-
ment and implementation of care process
models including minimizing sedation and
delirium reduction, daily spontaneous breath-
ing trials coupled with explicit mechanical
ventilation protocols, and early mobility–
based rehabilitation.46 The team included
bedside nurses, nurse practitioners, a physi-
cian, critical care technicians, physical thera-
pists, and respiratory therapists. Pioneering
early mobility–based rehabilitation and related
interventions often requires a change in ICU
culture. The fact that these care processes
were developed in the RICU by a multidisci-
plinary team17,22,46 appeared central to our
early success. This process for culture change
included the following steps: (1) identification
of the problem, (2) development of goals to
address the problem, (3) identification of the
steps to reach the goals, and (4) measurement
of whether the goals were met. This approach
engaged the entire clinical team, provided
immediate and direct feedback on progress
toward the goals, and allowed rapid changes
in patient care processes.46
The RICU early mobility protocol was devel-
oped and implemented in 2001 and 2002.
The mobility protocol47 goal was to ambulate
more than 100 feet (30 m) before ICU dis-
charge. For patients not able to ambulate,
activity consisted of standing at the bedside,
sitting in a chair, sitting on the edge of the bed,
or exercising in bed. Data from the RICU
showed that early mobility–based rehabilitation
was feasible and safe and improved patient-
centered outcomes: on the last full day in the
RICU, 69.4% of patients ambulated more
than 100 feet and 8.2% of patients ambu-
lated less than 100 feet (30 m). Disposition
of patients was as follows: 63.5% discharged
home or to a rehabilitation facility, 33.4%
admitted to a skilled nursing facility or long-
term acute care hospital, and 18% died
before hospital discharge.17,22,48-51
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In a subsequent study,22 we found that the
strongest single predictor of early mobility
was the ICU environment that emphasized
early mobility, more so than improvement in
the patients’ physiology, as measured by scores
on the Acute Physiology and Chronic Health
Evaluation (APACHE) II or other indices.22
Further, when patients were discharged from
the ICU and transferred to a medical/surgical
unit, we observed a substantial decrease in
mobility on the first day on the medical/sur-
gical unit: 55% of patients who ambulated
in the ICU did not ambulate the first day
after transfer, even though they had a provid-
er’s order for ambulation. This significant
decrease in mobility while in the general care
area was unexpected and suggested that a
culture of mobility-based rehabilitation simi-
lar to that in the RICU was essential in ensur-
ing that mobility was carried out every day.48
This finding is supported by a recent study
that showed a decrease in ambulation after
transfer to a general inpatient care area.52
Early mobility–based rehabilitation in criti-
cally ill patients is intrinsically linked with
the unique culture of each ICU, the beliefs of
the clinicians,19,22,46 available financial resources,
and formal institutional support. Even in
several ICUs within 2 institutions in 1 health
care system, there are profound differences
in unit culture and the approach to early
mobility–based rehabilitation.
Early Mobility–Based Rehabilitation
in Other ICUs
Organizational changes allowed us to
evaluate to a certain extent the influence of
institutional culture in ICUs on early mobility
in our institution. The hospital that housed
the original RICU, a medical ICU (MICU),
and the shock trauma ICU (STICU) became
a secondary care facility when the corporation
opened a new flagship hospital in a neighbor-
ing city in 2007. The RICU, thoracic ICU
(TICU), and STICU at the original hospital
moved to the new hospital, and only the
mixed-profile general MICU remained at
the original hospital.
With the move to the new hospital, the
RICU became a mixed-profile acute ICU with
a focus on patients with respiratory failure,
and the STICU doubled in size with a focus
on postoperative patients, septic shock, liver
failure, and acute trauma. In parallel, the
medical director of the RICU moved to the
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Table 2: Rehabilitation Practices in the Intensive Care Units at 2 Hospitals in 1 Health

Care System

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

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

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

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

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

195
H O P K INS E T A L W W W.A ACNACCONLINE .ORG

Activity for Y N Activity for

the extubated Is the pt the intubated
patient extubated? patient

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

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

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

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

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

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

C Continued

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

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

196
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B C

Has Do not ambulate pt, Has

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

Y Y

RN, ET, PT Ambulate pt at Ambulate as pt

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

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

Y Y

Continue progressive Continue progressive

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

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

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

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H O P K INS E T A L W W W.A ACNACCONLINE .ORG

100
Percentage of patients

80

60

40

20

0
2009 2010 2011 2012 2013 2014
Year

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

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

reflected both in a task of physical function

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

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clinical populations.56 Additional research is
needed to understand fully the effects of early
mobility–based rehabilitation on the cogni-
tive and psychological morbidities associated
with PICS.
Partnering With Families for
Early Mobility
Having a loved one in the ICU is difficult
at best, as the ICU environment can be a
threatening and disorienting place. Both the
severity of illness and the invasive therapies
can contribute to dehumanization and isola-
tion for both patients and their families.57
Engagement of both patients and their fami-
lies is increasingly recognized as a priority
in contemporary critical care.58 Families can
participate as members of the clinical team
in representing the patient’s values and prior-
ities and in direct participation in bedside
care.59,60 Early mobility–based rehabilitation
provides opportunities for family to partici-
pate in education about the need for and the
benefits of mobilizing their loved one.61 When
invited, family members are often happy to
participate in care of their loved one.62,63
Family members could participate in early
mobility–based rehabilitation in various ways,
including providing information about their
family member, supporting their family mem-
ber, walking alongside, providing encourage-
ment, communicating the importance of early
mobility, assisting with passive and active range
of motion exercises, and coaching their fam-
ily members.61 Rukstele and Gagnon61 used
the following steps to engage patients’ fami-
lies in early mobility: inviting them to par-
ticipate in early mobility, education (about
PICS morbidities, showing them how to do
mobility, and about the importance of the
task), and supporting the families. Staff in
The University of Michigan Health System’s
surgical ICU used these 3 steps and reported
that compliance with mobility increased from
64% to 99% during a 6-month period, sug-
gesting the importance of including patients’
families.60 Our experience has been that
patients’ families are excited to participate
in early mobility, feeling like their loved one
is making progress and that they are able to
participate. Such participation, where fami-
lies desire it, has become routine in all Inter-
mountain ICUs.
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IM P LE M E NT ING A M OBILIT Y P ROGRA M
Patient’s Perspective
One of the authors (M.S.) had a long stay
for acute respiratory distress syndrome in
the RICU and is now a member of the STICU
Patient and Family Advisory Council. We
report here her memories of the experience
of early mobility in the recovery phase, which
extended from several months in the RICU
to 1 month in a long-term acute care hospi-
tal to a readmission to the TICU for a post-
acute complication.
When you are in the ICU you
lose all your dignity, and you are
at the mercy of the hospital staff. I
don’t remember most of the early
months, as I was in a coma and
intubated. By the time I was out of
the coma, physical therapy was
ordered. My hands and feet were
so swollen that I basically had no
feeling in them, making it difficult
to stand. The physical therapist
would come by once or twice a
day. At first it was just dangling
my legs on the side of the bed.
When they would try to stand me
up, I would sometimes lose con-
trol of my bowels, which fright-
ened me. In addition, my oxygen
levels would drop so low they
would have to lay me down most
of the time. Eventually they were
able to get me into a chair, which
was so uncomfortable. I couldn’t
even sit upright in the chair. I just
wasn’t strong enough. I was finally
able to take a few steps, and the
nurses and respiratory therapists
would take me to the shower in a
wheelchair. I walked a few steps
and they would have the chair
right behind me. The doctors on
their visit would tell the staff to
get me up today. I was glad to
hear that the doctor wanted me to
get up. The therapist’s approach
really matters. One of the physical
therapists was kind and would
coach me and explain each step in
getting up and walking. Another
was more brusque and didn’t help
me to feel motivated, so our treat-
ments together didn’t really work
H O P K INS E T A L
well. The nurses would come by
twice a day to try to help me get
up and walk. It is so important to
work as hard as you can and try
to stand as soon as you can. Get-
ting up in the RICU helped me
be ready for rehabilitation at the
long-term acute care hospital.
Once I was in the long-term acute
care hospital, I was totally com-
mitted to getting stronger again.
I would even sign up for extra
PT appointments if other patients
couldn’t do them. I am so very
grateful for all the staff in the
RICU as well as the staff at the
long-term acute care hospital.
Overcoming Obstacles:
Barriers to Early Mobilization
Changes in clinical care should be evidence
based. Minimizing sedation, facilitating spon-
taneous breathing, delirium screening, and
early mobility–based rehabilitation are safe
and feasible, improve important patient-
centered outcomes, and are practice priorities
in adult ICUs.49-51 Data to date suggest that
early mobility–based rehabilitation is associated
with positive short- and long-term outcomes,
supporting incorporation of early mobility–
based rehabilitation as a standard of care in
the ICU.
Consistent implementation of early mobil-
ity is influenced by a variety of factors such
as low census with flex staffing (PTs have to
cover more units, fewer nurses, etc), unit-level
knowledge of early mobility, implementation
of a mobility protocol, administrative support,
and funding. Some of these issues can be
addressed at the unit level (eg, education),
whereas others will be outside the direct con-
trol of the unit (eg, funding for rehabilitation
staff). A recent review of early rehabilitation
in ICU survivors revealed that barriers to suc-
cessful mobility-based rehabilitation included
insufficient or lack of availability of physical
and occupational therapy, physiological or
neurological instability, and an ICU culture
that did not support early mobility.64 For
example, researchers in one study40 found
that early mobility–based rehabilitation was
not provided to critically ill patients more
than 50% of the time because of a shortage
of rehabilitation staff. Implementation of
mandatory mobility orders and a mobility
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W W W.A ACNACCONLINE .ORG
protocol increased mobilization from 22%
before implementation to 82% after imple-
mentation (P < .05).65 Further, numerous
studies17,24,40,46,66 support the important role
that ICU culture plays in early mobility–
based rehabilitation in critically ill patients.
Factors Associated With
Successful Practice Change
Care bundles and professional society
endorsements may help with the culture
change required to support early mobility.4,67,68
Programs such as the Society of Critical Care
Medicine’s ABCDE bundle were designed to
improve modifiable risk factors of adverse
outcomes. The ABCDE bundle includes daily
sedation awakening trials, breathing coordi-
nation, assessment, preventing delirium and
implementing early mobility–based exercise/
rehabilitation.69 As Clemmer70 noted, manage-
ment of sedation, delirium, and sleep are
interdependently necessary in order to mobi-
lize patients. Implementing new practices,
especially ones (eg, early mobility) that are
diametrically opposed to old ones (eg, seda-
tion and bed rest) can be a monumental task.
Important and dramatic changes in clinical
practice are exactly what the ABCDE bundle
is designed to address.
A report of the ICU Clinical Impact Interest
Group, who participated in implementation
of the ABCDE bundle, stated that a multidis-
ciplinary team was required to implement
the ABCDE bundle.19,21,25 Factors that were
associated with better implementation of the
ABCDE bundle included (1) ICUs that had
good organizational characteristics, including
strong and stable ICU leadership and consist-
ent staff for physical and respiratory therapy;
(2) an ICU culture focused on patient safety
and quality improvement; (3) ICUs that had
a clinical champion focused on implementing
early mobility; and (4) ICUs that used multi-
modal training for clinical staff during imple-
mentation of the ABCDE bundle.69
A recent article71 listed 7 guiding principles
for implementing new evidence-based practices,
such as the ABCDE bundle. The principles
include the following: (1) PICS-associated
morbidities are modifiable, and modifiable
causes and risk factors should be the focus
of interventions; (2) invested interdisciplinary
teams who use evidence and a team approach
to improve care delivery are needed; (3) inter-
disciplinary teams should use bidirectional
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
feedback and good communication for success-
ful change; (4) the evidence-based ABCDE
bundle should become standard clinical
care; (5) patients will wake up, breathe on
their own, and participate in early mobility–
based rehabilitation with implementation of
the appropriate care processes; (6) measure-
ment of goals and outcomes is necessary to
track progress and identify areas in need of
improvement or change; and (7) processes
should be put in place to monitor sedation,
delirium, breathing, and mobility-based
rehabilitation. Without such practices, there
is no way to assess improvement in mobility-
based rehabilitation.71
Limitations and Questions for
Further Research
Although research on mobility and exercise-
based rehabilitation in ICU populations is
increasing, a number of important questions
remain. The optimal timing of, protocol for,
and dose of mobility-based rehabilitation is
unknown. Research is needed to better under-
stand barriers to implementation of mobility-
based rehabilitation, including patient-related,
environmental, and cultural barriers. Education
of patients’ families regarding the benefits of
early mobility–based rehabilitation is needed,
as are efforts to ensure that mobility-based
rehabilitation continues when patients are
transferred to the general inpatient unit.
Research is also needed to understand the
long-term benefits of early mobility as well
as mechanisms of such benefits.
Conclusions
Multiple studies have shown that early
mobility–based rehabilitation in the ICU is
feasible and safe, and data are accumulating
regarding improving outcomes in critically ill
patients. Mobility-based rehabilitation varied
markedly across 5 ICUs in 1 health care sys-
tem, suggesting a need for continuous train-
ing and evaluation to maintain even a strong
mobility-based rehabilitation program. Early
mobility–based rehabilitation is associated
with shorter ICU and hospital stays, reduced
duration of delirium, increased muscle strength,
and both the ability to ambulate and greater
distance ambulated. Effects of early mobility
on long-term outcomes include increased abil-
ity to do self-care, return to independent func-
tioning, higher Physical Functioning scores,
and reduced 1-year hospital readmission and
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IM P LE M E NT ING A M OBILIT Y P ROGRA M
death. Factors that influence early mobility–
based rehabilitation include an interdiscipli-
nary team, a strong and stable ICU leadership,
access to physical, occupational, and respira-
tory therapy, an ICU culture focused on patient
safety and quality improvement, a champion
of early mobility, and a focus on measuring
performance and outcomes.
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45. Treggiari MM, Romand JA, Yanez ND, et al. Randomized
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46. Hopkins RO, Spuhler VJ, Thomsen GE. Transforming
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47. Hopkins RO, Spuhler VJ. Strategies for promoting early
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48. Hopkins RO, Miller RR 3rd, Rodriguez L, Spuhler V,
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50. Adler J, Malone D. Early Mobilization in the intensive
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systematic review. Chest. 2013;144(3):825-847.
52. Pandullo SM, Spilman SK, Smith JA, et al. Time for criti-
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53. Society of Thoracic Surgeons. Quality performance
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54. Harrold ME, Salisbury LG, Webb SA, Allison GT, Aus-
tralia, Scotland ICUPC. Early mobilisation in intensive
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55. Brummel NE, Jackson JC, Girard TD, et al. A combined
early cognitive and physical rehabilitation program for
people who are critically ill: the activity and cognitive
therapy in the intensive care unit (ACT-ICU) trial. Phys
Ther. 2012;92(12):1580-1592.
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59. Davidson JE. Facilitated sensemaking: a strategy and
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Facilitated sensemaking: a feasibility study for the
provision of a family support program in the intensive
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61. Rukstele CD, Gagnon MM. Making strides in preventing
ICU-acquired weakness: involving family in early pro-
gressive mobility. Crit Care Nurs Q. 2013;36(1):141-147.
62. Garrouste-Orgeas M, Willems V, Timsit JF, et al. Opin-
ions of families, staff, and patients about family partici-
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65. Hildreth AN, Enniss T, Martin RS, et al. Surgical inten-
sive care unit mobility is increased after institution of a
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sons PE, Critical Care Societies Collaborative USCIITG
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69. Carrothers KM, Barr J, Spurlock B, Ridgely MS,
Damberg CL, Ely EW. Contextual issues influencing
implementation and outcomes associated with an
integrated approach to managing pain, agitation, and
delirium in adult ICUs. Crit Care Med. 2013;41(9 suppl 1):
S128-S135.
70. Clemmer TP. Why the reluctance to meaningfully mobi-
lize ventilated patients? “The answer my friend is blowin’
in the wind.” Crit Care Med. 2014;42(5):1308-1309.
71. Vasilevskis EE, Ely EW, Speroff T, Pun BT, Boehm L,
Dittus RS. Reducing iatrogenic risks: ICU-acquired
delirium and weakness—crossing the quality chasm.
Chest. 2010;138(5):1224-1233.

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1. Describe 2 components of implementation of early mobility–based rehabilitation.
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3. List 3 barriers to early mobility–based rehabilitation.
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203

A Clinic Model: Post–Intensive Care
Syndrome and Post–Intensive Care
Syndrome-Family
Elizabeth L. Huggins, AG-ACNP
Sarah L. Bloom, AG-ACNP
Joanna L. Stollings, PharmD, BCPS
Mildred Camp
Carla M. Sevin, MD
James C. Jackson, PsyD
ABSTRACT
The number of patients surviving critical ill-
ness in the United States has increased with
advancements in medicine. Post–intensive
care syndrome and post–intensive care syn-
drome–family are terms developed by the
Society of Critical Care Medicine in order to
address the cognitive, psychological, and
physical sequelae emerging in patients and
their families after discharge from the inten-
sive care unit. In the United Kingdom and
Europe, intensive care unit follow-up clinics
T he number of patients surviving critical
illness in the United States has increased
with advancements in medicine. The long-term
consequences of critical care survivorship have
become evident. The implications of critical
illness on patients’ short- and long-term health
are vast and include consequences not only
for patients, but also for their loved ones.1
Evidence suggests that one-third of intensive
care unit (ICU) survivors have depression,2
one-half have cognitive impairment,3 and
physical disability is common.4 Mental health
outcomes have been reported among disease-
specific groups of critical illness survivors, such
as those with acute respiratory distress syn-
drome and sepsis.5 At 3 months after discharge,
cognitive testing performed on survivors of
critical illness has shown that an astonishing
one-third of patients experience cognitive
deficits similar to those seen in Alzheimer’s
204
AACN Advanced Critical Care
Volume 27, Number 2, pp. 204-211
© 2016 AACN
have been used to address the complications
of post–intensive care syndrome for some
time. However, the interprofessional clinic at
Vanderbilt University Medical Center is among
the first in the United States to address the
wide variety of problems experienced by inten-
sive care survivors and to provide patients
and their families with care after discharge
from the intensive care unit.
Keywords: critical care, post–intensive care
syndrome, follow-up clinic, rehabilitation
Elizabeth L. Huggins and Sarah L. Bloom are Adult-Gerontology
Acute Care Nurse Practitioners, Department of Medicine,
Vanderbilt University Medical Center (VUMC), 1161 21st Ave S,
Suite AA-1214, Nashville, TN 37232-2102 (elizabeth.huggins
@vanderbilt.edu, sarah.l.bloom@vanderbilt.edu).
Joanna L. Stollings is Clinical Pharmacy Specialist in the Med-
ical Intensive Care Unit (MICU) and Pharmacist in the ICU
Recovery Center, Dept of Pharmaceutical Services, VUMC.
Mildred Camp was a patient in the MICU at VUMC.
Carla M. Sevin is Assistant Professor, Director of the ICU
Recovery Center, Department of Medicine, Division of Allergy,
Pulmonary and Critical Care, VUMC.
James C. Jackson is Neuropsychologist and Assistant
Director of the ICU Recovery Center, Center for Health
Services Research, Departments of Medicine and Psychiatry,
VUMC, and Geriatric Research, Education and Clinical
Center (GRECC) Service, Department of Veterans Affairs,
Tennessee Valley Healthcare System, Nashville, Tennessee.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016611
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
disease and an additional third have cogni-
tive impairment similar to that seen after a
traumatic brain injury. Delirium was indepen-
dently associated with a spectrum of cognitive
impairments affecting patients after hospitali-
zation for critical illness.3 Older adults who
survive critical illness have a significantly higher
mortality rate in the 1-year period following
discharge when compared with other hospital-
ized patients and the difference is even greater
when compared with the general population.
The mortality rate in patients discharged to
a skilled nursing facility remains greater, at
24.1%, than the rate in patients discharged
to home, which is 7.5%.6 These statistics may
reflect a cohort of patients with a higher
severity of illness and may highlight the need
for improved care delivery to all survivors
of critical illness owing to the unique prob-
lems afflicting this population.
Post–intensive care syndrome (PICS) is a
term recently coined by the Society of Critical
Care Medicine to encompass the cognitive,
psychological, and physical issues that patients
face after an ICU admission. The term post–
intensive care syndrome-family (PICS-F) refers
to the response to critical illness by families
and describes the development of a cluster of
physiological outcomes such as posttraumatic
stress, depression, complicated grief, and anxi-
ety, among others.7 Post-ICU clinics have been
proposed as a strategy for improving long-
term care and outcomes for ICU survivors.8
In the United Kingdom, post-ICU clinics have
been in existence for more than 20 years; the
first clinic opened there was in Reading in
1993. In the United Kingdom, a national sur-
vey reported that of the 288 ICUs nationally,
80 of them had an associated post-ICU clinic.9
Despite the wide use of these clinics in Europe,
few data are available to demonstrate efficacy
and guide further practice. Therefore, no con-
sensus on the ideal model of care delivery has
been established. Within the United States,
clinics remain a novel way to improve the
health of ICU survivors. Clinics at Indiana
University and Vanderbilt University are
among the first in the United States with the
goal of improving post-ICU quality of life
and reducing hospital readmission rates
among medical and surgical ICU survivors.10
The Post-ICU Clinic
Since 2011, 2 ICU follow-up clinics have
been developed in the United States.11 The
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IM P LE M E NT ING A P OST- ICU CLINIC
Critical Care Recovery Center (CCRC) at the
Indiana University School of Medicine was
the first post-ICU clinic to open in the United
States in 2011. The CCRC targets geriatric
patients with depression and psychological
disorders and aims to improve the long-term
health of ICU survivors, reduce readmissions,
and provide care to optimize psychological
wellness.10 Patients qualify for the CCRC if
they were receiving mechanical ventilation
or experienced delirium that lasted more than
48 hours. The clinic is operated by an inter-
professional group that includes physicians,
registered nurses, and social workers.10
The ICU Recovery Center at Vanderbilt
opened in 2012 with the objective of improving
the long-term health and outcomes of patients
who have survived critical illness through an
interprofessional team approach. The Vander-
bilt Model employs providers with expertise
in critical care in an outpatient setting, a unique
approach to deliver care that addresses the
sequelae of critical illness and its associated
increased mortality. Teaching caregivers about
their loved ones’ recovery and supporting them
through this often-difficult transition are
integral parts of the model. In addition, the
clinic is designed to gain subjective and objec-
tive information about the lives of patients after
critical illness to guide research that will affect
treatment guidelines in the ICU. The inter-
professional team works together to recruit
and screen patients on the basis of established
criteria and to provide comprehensive follow-
up care in an outpatient setting. Patients’
family members are invited to attend the clinic
appointment at the discretion of the patient.
At this time, the Vanderbilt ICU Recovery
Center does not screen or treat these family
members for PICS-F. As the outreach of
the center grows, resources to address PICS-F
will be a priority.
The ICU Recovery Center Team
The Vanderbilt ICU Recovery Center team
consists of a medical ICU (MICU) nurse prac-
titioner, a pharmacist, a pulmonary intensivist,
a case manager, and a neurocognitive psychol-
ogist. The team is modeled after the interpro-
fessional team composition used within the
MICU. Each individual clinician is responsi-
ble for a component of the patient’s visit, and
information is shared among team members
during the clinic appointment for the purpose
of forming a collaborative treatment plan.
H U G G IN S E T A L W W W.A ACNACCONLINE .ORG

• Discusses work status and supports persons involved in care

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

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

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

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

• Accesses medications and durable medical equipment as indicated

Case Manager • Follows up with home health services if needed

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

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

206
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table: Inclusion and Exclusion Criteria for Recruitment and Attendance for the Post–
Intensive Care Syndrome Clinic
Inclusion Criteria
Primary
Adult (> 18 years old) with critical illness
(adult respiratory distress syndrome or sepsis)
Secondary (1 or more of the following):
Delirium > 48 hours
Received neuromuscular blockade, high-dose
steroids, and/or bed rest > 3 days
Prolonged course (> 7 days) in intensive care unit
Multiple new deficits anticipated at discharge
Shock (> 6 hours)
New organ dysfunction(s) with prolonged recovery
Ideally, the clinic’s aim has been to arrange
for outpatient follow-up before the patient’s
discharge, so that the visit is listed on the
patient’s discharge letter. Again, the referral
and scheduling process described has been
reformed on the basis of the clinic team’s
experience and may not reflect the ideal
strategy for other institutions.
A secure database that can be accessed
online can assist in storing data and gaining
insight into features of a patient’s hospitaliza-
tion, including when the patient moves out
of the ICU and the anticipated discharge dis-
position. As previously mentioned, patients
and their families are often unfamiliar with
the purpose of the PICS clinic and thus are
unwilling to schedule in the face of multiple
appointments. Frequently patients are fearful
of returning to the hospital, or lack the social
support, finances, or transportation to return
for multiple appointments. Tracking the
reason(s) that patients/families cite for declin-
ing to schedule an appointment can provide
insight into improving the scheduling process.
Using a data collection tool during the
creation of a PICS clinic is necessary to gain
valuable insight into trends associated with
referrals of patients, appointment scheduling,
and reasons observed for why patients do not
attend the clinic. The model for referrals and
recruitment of patients that is most successful
will vary by institution, and internal review
for quality improvement should be considered.
Initial Clinic Visit
At the initial ICU Recovery Center visit,
each patient is asked to complete spirometry
testing and a 6-minute walk test (if able). The
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IM P LE M E NT ING A P OST- ICU CLINIC
Exclusion Criteria
Preexisting dementia or cognitive deficit
Life-limiting illness with anticipated life expectancy
< 6 months
Managed primarily by different subspecialty service
(eg, liver/renal transplant)
Primary diagnosis in intensive care unit with specialty
resources in place after hospitalization (eg, stroke
or cardiac rehabilitation)
Long-term resident of skilled nursing facility or
long-term acute care facility
results of these performance metrics are used
to determine the patient’s physical capacity
in comparison to the predicted ability. Each
allows an objective measure of the patient’s
physical capacity and can be used to track
improvement throughout the patient’s
recovery.
The MICU nurse practitioner completes a
detailed history and physical examination as
it pertains to the patient’s resolving critical
illness. Special attention is focused on trache-
ostomy care, persistent respiratory insufficiency,
indwelling vascular catheters, neuromuscular
weakness, and skin breakdown. Key features
of a patient’s hospital course are reviewed.
A comprehensive health interview involving
the patient and family (if present) details nutri-
tional intake, activity tolerance, independ-
ence in daily living, and return to work status.
Patients are asked to explain how their post-
ICU life is different from their lives before
hospitalization. The nurse practitioner then
tailors the interview to investigate specific
complaints further depending on the patient’s
response. Complications, new deficits, and
support systems are evaluated in every patient
and then discussed with the clinic team. A
clinical pharmacist completes a full medication
review and provides medication education and
reconciliation. Additionally, indications and
eligibility for an annual flu shot and pneumo-
coccal vaccine are reviewed and offered to
the patient at this time.
A neuropsychologist meets with the patient
to evaluate and screen for cognitive impair-
ment, posttraumatic stress disorder (PTSD),
anxiety, and depression. Validated tools are
used in the psychological assessment portion
H U G G IN S E T A L
of each visit, per recommendations from
experts in PICS.12 These tools include global
measures of cognition, such as the Montreal
Cognitive Assessment13 and Trail Making Tests
A and B.14 These tools are augmented by tests
of psychological functioning such as the Beck
Depression Inventory II15 or the Hospital
Anxiety and Depression Scale16 and the PTSD
Checklist.17 Results from the cognition and
psychological functioning tests are quickly
interpreted by the neuropsychologist adminis-
tering them and then used in both therapeutic
conversations with patients and their families
and for purposes of treatment planning.
Additionally, smoking status is reviewed,
and cessation education and resources are
discussed. A case manager is available should
a patient need additional resources like home
medical care, durable medical equipment,
medications, primary care access, and afford-
able community health resources. We have
found that many of the items that are addressed
during the first clinic visit (eg, physical ther-
apy, medication reconciliation, health, nutri-
tion) were in place before discharge, but for
various reasons are not appropriately in
place weeks after discharge. We not only
verify these support services and equipment,
but also often set them up, reorder what is
appropriate, and assist patients and caregiv-
ers with communication with social services.
Treatment Plan
The clinic team completes the visit with a
collaborative review of pertinent findings and
the proposed assessment and plan. The treat-
ment plan often includes referrals to support
services such as physical therapy, occupational
therapy, or specialty providers. Survivors of
critical illness have a variety of special needs
following ICU discharge, all of which cannot
be mentioned here. Health promotion and
education on topics like immunization,
smoking cessation, and weight management
can help reduce further complications and
readmissions to the hospital in these vulnera-
ble patients. A pulmonary critical care attend-
ing physician meets with the patient and the
patient’s family to conclude each visit. Perti-
nent findings are summarized and plans for
future health care resources are agreed upon.
A summary of the patient’s hospitalization
and clinic appointment is sent to the patient’s
primary care provider in an effort to improve
communication and ensure that the patient
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will have access to ongoing follow-up. The
clinic’s goal is not to replace a patient’s pri-
mary care provider. Rather, the clinic strives
to bridge the gap between the ICU and out-
patient care as a patient makes the transition
from critical illness to home.
Measuring Success and
Future Research
Data on the effect of Vanderbilt’s ICU
Recovery Center remain anecdotal to date.
Currently this clinic is unable to report on the
outcomes of interest with quantitative findings.
Future projects designed to grow the limited
body of research are in the early stages. The
value of the aforementioned model and the
interprofessional team composition have not
been established as the standard of care for
PICS clinics. Additional specialties, not pre-
viously mentioned here, may also provide
value for both patients and their families.
For example, palliative care and primary care
providers may play an important role (Figure
2 conceptualizes the many disciplines that
can improve patient care through involvement
in a PICS clinic). The feasibility of any team
must be considered when developing a group
of providers for a PICS clinic.
The specific research questions the ICU
Recovery Center is focused on are evaluating
the effectiveness of this post-ICU clinic on
reducing hospital readmissions and improving
long-term health. The interventions employed
are screening for and treating psychological
ailments associated with critical illness, reduc-
ing the number of adverse medication effects,
and promoting health and safety. Currently
the ICU Recovery Center has received approval
from the institutional review board for data
collection that focuses on readmission rates
for ICU survivors who attend the clinic versus
ICU survivors who do not, as well as approval
for medication review and adverse outcomes,
long-term psychological ailments from critical
illness, and data that help to evaluate factors
that contribute to clinic attendance.
The following are steps to initiate and apply
the research process to determine the value
of PICS clinics. The first will be establishing
a clinic model that efficiently screens, tracks,
and recruits patients to be seen in the clinic.
The next step is to systematically evaluate and
study a large group of PICS patients, identify
major issues, and gather resources to treat
them. Third, important research questions
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Advance Practice Nurse/Physician Assistant
Critical Care Nurse
Physical Therapist
Occupational Therapist
Primary Care Provider(s)
Speech Language Pathologist
Patient &
Caregiver
Rehabilitation Medicine Specialist
Figure 2: Stakeholders in a multidisciplinary team approach to outpatient post–intensive care syndrome
clinics. All team members work in the medical intensive care unit at Vanderbilt University Medical Center
and in the clinic.
will focus on the efficacy, the value and the
impact that the PICS clinics have on long-term
outcomes, allowing development of the ideal
model. Finally, the knowledge gained through
research of PICS can be used to establish
PICS clinics and to prevent the development
of PICS while patients and their families are
in the ICU.
Overcoming Obstacles
Despite continued efforts, barriers to
effective post-ICU care are still evident. Two
of the most prominent obstacles experienced
at Vanderbilt University Medical Center are
the logistical challenge of recruiting and
screening patients and the availability of
adequate resources.
Patients who meet inclusion criteria for the
ICU Recovery Center often have long and com-
plicated hospital admissions. Tracking their
transition from the ICU to a step-down unit
and then to discharge is time-consuming and
requires personnel who have access to the
electronic medical record and can interpret
the chart to estimate when discharge is likely.
Therefore, a strong foundation of knowledge
about critical care and illness trajectory is
needed. Anecdotally, the clinic team has
observed face-to-face recruitment for appoint-
ments to be effective. However, patients may
feel overwhelmed when their anticipated long
recovery process is described. Patients frequently
cite a high number of providers or inability to
return to the hospital as a reason for not sched-
uling an appointment. Barriers such as trans-
portation, portable oxygen, family support,
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IM P LE M E NT ING A P OST- ICU CLINIC
Dietitian
Neuropsychologist
Clinical Pharmacist
Palliative Care Specialist
Social Work/Case Manager
Pulmonary Critical Care Physician
and financial constraints must be considered
when offering a follow-up appointment.
Once patients do return, basic resources
needed for specialists to identify and treat
the problems associated with critical illness,
such as a physical clinic location and labora-
tory capabilities, are necessary. Additional
resources such as access to pulmonary func-
tion testing, radiography, and further subspe-
cialty care are desirable.
Most of these barriers can be addressed with
additional resources, personnel, and funds.
The process of recruiting and tracking patients
can be streamlined with a dedicated staff mem-
ber who is able to recruit and track patients on
a daily basis. In addition, a physician champion
who is willing to advocate for patients and
their participation in the clinic is key. As
technologies advance and the electronic med-
ical record is consistently used, the tracking,
ordering and scheduling process for patients
will become more efficient. Additional educa-
tion and time spent with patients and their
families describing the sequelae of critical
illness tend to improve participation of patients
and their families. Once the range of difficul-
ties that survivors of critical illness may encoun-
ter is reviewed, patients and family members
can better understand the potential importance
of attending a PICS clinic.
Patient’s Perspective:
Millie Camp
In 2013, Mildred Camp, a previously
healthy woman in her 60s, was admitted to
Vanderbilt University Medical Center with a
H U G G IN S E T A L
new diagnosis of thrombotic thrombocytopenic
purpura. Her initial treatment plan included
high-dose steroids and rituximab. Although
she was discharged after 2 weeks, the treat-
ment of the disease left her body weakened
and susceptible to opportunistic complications.
Soon after, Mrs Camp was readmitted to the
hospital and transferred to the MICU with
acute respiratory distress syndrome. She
received mechanical ventilation for 17 days
and was in the ICU for a month. Mrs Camp
has little recollection of her time in the ICU,
but recalls feeling frightened and helpless as
she lay in bed unable to communicate her
needs. The memory of looking out of the
window into the hallway to see her nurse
working at a computer sticks out in her mind.
She recalls feeling powerless and vulnerable
to her caregivers’ ability to remain aware of
her needs. Mrs Camp’s family was by her
side and has helped her to grasp the pro-
found experience she endured. They clung to
updates from the nurses and doctors, watched
her monitor with intent, and prayed faith-
fully in the waiting areas when her condition
became critical. She tells us,
I was so swollen that my wedding
rings would not come off. So my
husband of 41 years (longer than
most of my caregivers had been
alive) began the arduous hour-long
process of cutting off my rings. You
can imagine his pain and sorrow
with this difficult task. ICU illness
impacts the whole family.
Mrs Camp left the ICU and spent months
in long-term acute care and rehabilitation,
where she worked tirelessly to rebuild her
strength. The magnitude of her weakness was
difficult to grasp; her physical capacity was
so severely diminished upon leaving the ICU
that she lacked the strength to sit up or roll
over in bed without assistance. Mrs Camp
was discharged after 3 months in hospitals,
with portable oxygen and outpatient physical
therapy scheduled for another 3 months. She
was also scheduled in the ICU Recovery Clinic.
She was committed to regaining her strength
both mentally and physically but was plagued
by “brain fog” and inattention. Three months
after discharge, she was able to be weaned
off of supplemental oxygen and had regained
much of her physical strength with intense
physical therapy, hiring a trainer after her
outpatient therapy was complete.
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W W W.A ACNACCONLINE .ORG
Of the ICU Recovery Clinic, she says,
The ICU Recovery Center was a
great resource—answering every
question, helping me recognize my
progress, validating my efforts,
and checking for post-ICU decline
in physical, cognitive, and psycho-
logical realms. The clinic provided
much-needed information, direc-
tion, and encouragement. I wanted
to sing again but lacked the breath
and vocal range. [I was referred
to] The Vanderbilt Voice Center,
[which] gave me vocal and breath-
ing exercises, which benefited my
overall breathing capacity. [A year
after I fell ill] I returned to my bar-
bershop chorus to sing, a major
goal in my recovery.
Today, it has been more than 3 years since
Mrs Camp was admitted to the MICU. She
reminds us that recovery is a long process,
one that requires not only physical endurance
but mental and emotional endurance. She
urges fellow survivors not to succumb to the
moments of pain, fear, weakness, fatigue, con-
fusion, doubt, hopelessness, and depression.
However, she adds, “I was very lucky to not
struggle with pain, depression, or anxiety
after my critical illness as I recognize these
ailments do suspend progress.” In closing, she
says, “I battle to moderate my expectations
as I continue my journey to optimal health
and delight in each new day.”
Conclusion
With an aging population and a growing
number of patients surviving critical illness,
the implications of post-ICU deficits are pro-
found. The ICU Recovery Clinic at Vanderbilt
University Medical Center is one example of
how critical care providers can use a PICS
clinic to improve the care of patients. Patients
and families benefit from the support of criti-
cal care clinicians outside of the ICU as a
way to manage the transition of their care to
a general practitioner. Future research is
needed to determine the ideal model for PICS
clinics in the United States and to quantify
the effects such clinics have on quality of life
after discharge and readmission rates.
REFERENCES
1. Desai SV, Law TJ, Needham DM. Long-term complica-
tions of critical care. Crit Care Med. 2011;39(2):371-379.
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2. Jackson JC, Pandharipande PP, Girard TD, et al. Depression,
post-traumatic stress disorder, and functional disability in
survivors of critical illness in the BRAIN-ICU study: a lon-
gitudinal cohort study. Lancet Resp Med. 2014;2(5):369-379.
3. Pandharipande PG, Girard TD, Jackson, JC, et al. Long-
term cognitive impairment after critical illness. N Engl J
Med. 2013;369(14):1306-1316.
4. Herridge MS, Tansey CM, Matté A, et al. Functional
disability 5 years after acute respiratory distress syn-
drome. N Engl J Med. 2011;364(14):1293-1304.
5. Davydow DS, Desai SV, Needham DM, Bienvenu OJ.
Psychiatric morbidity in survivors of the acute respira-
tory distress syndrome: a systematic review. Psycho-
som Med. 2008;70(4):512-519.
6. Wunsch H, Guerra C, Barnato AE, et al. Three-year out-
comes for Medicare beneficiaries who survive intensive
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7. Davidson JE, Jones C, Bienvenu OJ. Family response
to critical illness: postintensive care syndrome–family.
Crit Care Med. 2012;40(2):618-624.
8. Stollings JL, Caylor MM. Postintensive care syndrome
and the role of a follow-up clinic. Am J Health Syst
Pharm. 2015;72(15):1315-1323.
9. Griffiths J, Barber V, Cuthbertson B, Young J. A
national survey of intensive care follow-up clinics.
Anaesthesia. 2006;61:950-955.
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10. Khan BA, Lasiter S, Boustani MA. Critical care recovery
center: an innovative collaborative care model for ICU
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12. Needham DM, Davidson J, Cohen H, et al. Improving
long-term outcomes after discharge from intensive
care unit: report from a stakeholders’ conference. Crit
Care Med. 2012;40(2):502-509.
13. Nasreddine ZS, Phillips NA, Bédirian V, et al. The Mon-
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14. Reitan RM. Validity of the Trail Making Test as an indi-
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16. Zigmond AS, Snaith RP. The hospital anxiety and
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17. Blanchard EB, Jones-Alexander J, Buckley TC, Forneris
CA. Psychometric properties of the PTSD Checklist
(PCL). Behav Res Ther. 1996;34(8):669-673.

Developing a Diary Program to
Minimize Patient and Family
Post–Intensive Care Syndrome
Meaghan Locke, RN-BC, BSN, CCRN
Sarah Eccleston, RN, MSN, ACCNS-AG, WCC
Claire N. Ryan, RN, BSN
Tiffany J. Byrnes, RN, BSN
Cristin Mount, MD
Mary S. McCarthy, RN, PhD, CNSC
ABSTRACT
A series of evidence-based interventions
beginning with an intensive care unit diary
and a patient/family educational pamphlet
were implemented to address the long-
term consequences of critical illness after
discharge from the intensive care unit, bun-
dled as post–intensive care syndrome and
post–intensive care syndrome–family. An
extensive literature review and nursing
observations of the phenomenon high-
lighted the potential for this project to have
a favorable impact on patients, their fami-
lies, and the health care team. The goal of
P ost–intensive care syndrome (PICS) is an
increasingly confronted phenomenon
that encompasses physical, neurological, cog-
nitive, and emotional issues affecting patients
long after their stay in the intensive care unit
(ICU). The prevalence of this syndrome is
variable but can be high, occurring in 15% to
more than 50% of ICU survivors.1-3 In addi-
tion, patients’ family members experience
psychological and emotional trauma at a high
rate, so the PICS definition has been broad-
ened to include family members (PICS-F).2
Patients may have survived their critical
illness, yet they face considerable challenges
to reach a full recovery. These challenges
include ICU-associated posttraumatic stress
disorder and anxiety disorders, neurocogni-
tive deficits that are new or worse than they
212
AACN Advanced Critical Care
Volume 27, Number 2, pp. 212-220
© 2016 AACN
this article is to explain the education of all
stakeholders; the introduction of the diary,
video, and educational pamphlet; and the
evaluation of the acceptance of these inter-
ventions. This process began with an infor-
mal evaluation of the educational products
and overall perception of the usefulness of
the diary by patients, family members, and
staff. The efforts described contribute to the
evidence base supporting diaries as an adjunct
to intensive care.
Keywords: intensive care, diary, post–intensive
care syndrome
Meaghan Locke is a Consultant, Critical Care Nursing Section,
Madigan Army Medical Center.
Sarah Eccleston is Critical Care Clinical Nurse Specialist,
Center for Nursing Science & Clinical Inquiry, Madigan
Army Medical Center.
Claire N. Ryan is Intensive Care Unit (ICU) Staff Nurse, Critical
Care Nursing Section, Madigan Army Medical Center.
Tiffany J. Byrnes is ICU Staff Nurse, Critical Care Nursing
Section, Madigan Army Medical Center.
Cristin Mount is Chief, Department of Medicine, Madigan
Army Medical Center.
Mary S. McCarthy is Senior Nurse Scientist, Center for
Nursing Science & Clinical Inquiry, Madigan Army Medical
Center, 9040 Jackson Ave, Tacoma, WA 98431
(mary.s.mccarthy1.civ@mail.mil).
The authors declare no conflicts of interest. The ICU Diary
Program received a small grant award from the Army Surgeon
General’s System for Health Initiative.
DOI: http://dx.doi.org/10.4037/aacnacc2016467
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
were at baseline, extreme muscle weakness that
limits activities of daily living, decreased pulmo-
nary reserve that also limits activity, chronic
pain syndromes, and any lingering effects of
the disease process that initially required ICU
admission.1 Unfortunately, patients and their
families are often not educated about what
to expect upon surviving a critical illness or
injury because transitions from the ICU to
the general care area and from there to home
or another facility are usually focused on the
acute care needs of the patient.
Additionally, the phenomenon of PICS has
only recently been recognized by the critical
care community, and many non-ICU provid-
ers are unaware of the impact that PICS and
PICS-F may have on patients and their family
members after discharge from the hospital.3
Patients are unsure of whether or not these
symptoms are expected, and non-ICU provid-
ers may not recognize that a focused evalua-
tion is needed. If health care providers could
address the gap in PICS/PICS-F care by first
educating patients and their families about
what to expect after surviving an ICU stay,
accompanied by an ICU diary to help patients
remember what occurred and trigger follow-up
discussions with primary care providers, they
could potentially increase satisfaction of patients
and patients’ families and improve transitions
of care from the ICU to acute care teams.
Literature Review
Each year, millions of patients are admit-
ted to the ICU, and one-third of them require
mechanical ventilation.2 These patients are
also often unconscious or sedated. ICU sur-
vivors have a high incidence of a variety of
mental health symptoms that may affect their
recovery, including nightmares, unwanted
thoughts and memories, anxiety or depres-
sion, and posttraumatic stress syndrome.4
These memories contain actual events that
occurred during the ICU stay, as well as delu-
sions. ICU survivors describe memories and
dreams that they are often unable to compre-
hend and that often lead to a reduction in
their quality of life.5 Affected patients and
their family members may benefit from a
written document to reflect on their experi-
ence of critical illness. This record of events
may allow them to move slowly past the
delusional memories and misconceptions
that formed in the disoriented mind during
the ICU stay.
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D E VE LOP ING A N ICU D IA RY P ROGRA M
According to Garrouste-Orgeas et al,6
various studies have elucidated the following
strategies designed to help family members
actively provide support to themselves and the
patient: flexible visitation policies, involvement
in nursing care, and participation in maintain-
ing a diary during the ICU stay. ICU diaries
have been widely used in European countries
as a low-cost technology to improve the qual-
ity of life after critical illness.7,8 Qualitative
studies reveal that the diary enables patients
to evaluate their recovery and improves com-
munication with their families about their
experiences, thus sustaining family-centered
care.6,7,9-13 Diaries may also enable patients
to make sense of their intensive care encoun-
ter, which they previously may have failed
to understand.7
Critically ill patients can have both negative
and positive experiences during their time in
an ICU. These experiences are due to a variety
of factors, but one that stands out is the loss
of time for patients who have been sedated
or otherwise confined in the ICU. Critically
ill patients also often suffer from disorienta-
tion and delirium, thus creating a “void” of
what transpired during their stay. These “voids”
are then filled in by what the patient thinks
might have happened; by what they were told
happened by staff, family, and friends; or by
past experiences.13 Nurses can assist patients
by addressing the risk for PICS/PICS-F upon
admission and throughout the ICU stay,
using the diary to help promote a more posi-
tive reflection on their illness episode. Nurses
can also help manage expectations regarding
the future plan of care goals with sensitive
and meaningful communication via the diary.
The critical care community is aware of
evidence suggesting that the struggles faced
upon discharge from the hospital are often
complicated by insufficient recovery and
rehabilitation resources for both patients
and family members, including a lack of spe-
cific knowledge on the part of primary care
providers who interact with and follow up
with survivors and close family members
after the hospitalization.14 Specific inpatient
interventions to address individual elements
of PICS and PICS-F include delirium screen-
ing and prevention protocols, early mobility
protocols, detailed management of sedation
regimens, and ICU diaries.1,14,15 Our evidence-
based practice (EBP) project team proposed
that a combined ICU diary and patient/family
LO C K E E T A L
educational pamphlet might reduce symptoms
of PICS/PICS-F and improve satisfaction of
patients and their families with respect to prep-
aration for discharge from the ICU and even-
tual discharge from the hospital. The team was
optimistic that this project would also benefit
the health care team by encouraging them
to be more engaged with the patient and the
patient’s family, demonstrating their commit-
ment to the best possible outcomes for the
patient along his or her illness trajectory.
EBP Program Plan
Guiding Questions
The ICU diary program was implemented
as an EBP project using the Iowa Model of
Evidence-Based Practice to Promote Quality
Care.16 The setting for this program is a 20-
bed mixed medical-surgical ICU in a 198-bed
level II trauma center. It is the second largest
military medical center and serves 25 000
active duty service members on the fourth
largest military base, with an additional 110 000
beneficiaries in the surrounding Pacific
Northwest community. Efforts at this time
are focused on evaluating the processes and
outcomes of the project in terms of feasibility,
sustainability, and staff and patient/family
satisfaction within the facility. The background
questions for this EBP change project were
1. Given the complex care environment
of the ICU and the highly mobile status of
military nurses, is it feasible to implement a
program designed to prevent PICS and PICS-F
for select patients and their families in our
level II medical center?
2. Given the frequent turnover of medical
and nursing staff in a military ICU environ-
ment in a teaching hospital, can we achieve
sufficient staff and patient/family engagement
to support adoption of an ICU diary program?
3. Can we achieve a high level of patient
and family satisfaction with the educational
products (pamphlet, video, and diary) and
staff interactions surrounding implementation
to sustain an ICU diary program?
4. What tools and interventions will be
needed to formally evaluate the impact of the
ICU diary on long-term biopsychosocial out-
comes once adoption of the practice has occurred?
(Research question for future protocol)
Preparation
Before implementation of the ICU diary
program, ICU nurses, clinical nurse specialists,
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W W W.A ACNACCONLINE .ORG
and a nurse researcher with an interest in this
project met every 2 weeks for 2 months to
discuss the EBP model selection, review the
literature, and develop a strategy for intro-
ducing the new program. Once those tasks
were accomplished, the group set a “kick-off”
date and arranged a nursing grand rounds
presentation to introduce the program to
potential stakeholders throughout the hospital.
The team invited Dr Judy Davidson, a nation-
ally recognized nurse and subject matter expert
on PICS and PICS-F, to speak. The focus of the
presentation was the biopsychosocial implica-
tions of PICS and PICS-F and EBPs that pre-
vent or diminish the long-term effects, such
as judicious sedation, early mobility, and use
of an ICU diary. The audience included medi-
cal and nursing staff as well as ancillary sup-
port staff, such as the chaplain. This discussion
provided the motivation needed to move for-
ward with the ICU diary program.
Project Team
After determining that the EBP project was
a priority for the organization, the next criti-
cal step was assembling a team.16 Selecting a
dedicated group of professionals to lead the
EBP project was viewed as crucial to its suc-
cessful implementation. The team leader hired
was an ICU nurse previously on staff at the
hospital who had developed an excellent
rapport with coworkers and interdisciplinary
team members. Her credibility and advocacy
for patients were undeniable, and she easily
garnered widespread support from staff and
leaders. She immediately set about building
the team and identifying champions. Devel-
oping the educational tools and the curriculum
for in-service training followed. The final team
included a team leader, 2 ICU nurse managers,
a critical care clinical nurse specialist, 2 ICU
staff nurse champions, 2 ICU physician direc-
tors, 2 staff nurse champions from the step-
down unit and 6 from the medical-surgical
unit, and a nurse researcher. The chaplain
and the palliative care team were also strong
advocates and actively engaged in the pro-
gram. The team could not have developed or
purchased the educational tools and other
materials without the support of the ICU
supply specialist, the information manage-
ment/visual information teams, logistics staff,
the administrative officer from the Center for
Nursing Science and Clinical Inquiry, and
staff from the Public Affairs office.
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Project Tools
The diary is an 18-page packet contained
in a clear covered binder. Using a clip binder
allowed the nursing staff to easily add pages,
if necessary. The diary began with “Get to
Know Me” pages dedicated to the patient’s
personal information such as name, nickname,
birth date, and general preferences, with space
for other relevant details or patient and family
photographs. The next section defined PICS,
talked about the transition to other nursing
units, the discharge process, and posthospital-
ization follow-up.
The team, with coordinated efforts from
hospital support services and constructive
feedback from the nursing staff, developed
several educational tools to augment imple-
mentation of the ICU diary program. The
packet also contained a section describing
what to expect regarding the ICU stay and the
purpose of devices and equipment in a typical
ICU suite. Along with the diary, families were
provided an educational brochure entitled
“PICS & The ICU Diary: A Guide for Families
and Patients.” The primary nurse initiating
the diary also arranged for the family to view
a short video on PICS/PICS-F that had been
filmed in the ICU, featuring unit champions
and choreographed by marketing experts from
our Public Affairs office. The video was availa-
ble on the patient education channel or on a
portable DVD player. The new channel was
projected for programming on in-room televi-
sions and will eventually offer around-the-clock
access hospital wide. The video was also made
available on the hospital’s Facebook page for
viewing by any military beneficiary/health care
consumer interested in knowing more about
PICS or PICS-F. This multimodal approach
served to educate current and future patients
and their family members.
In addition to the program tools, families
were provided with an opportunity to use a
Polaroid camera to take pictures of visitors, the
patient, or the patient’s room, if they wanted to
include photos in the diary. Health Insurance
Portability and Accountability Act (HIPAA)
concerns were addressed and cleared by the
hospital’s legal office before the cameras were
purchased. Photos taken by family members
did not include details beyond the individual
patient’s room. The intent was for the patient
and family to keep this diary upon transfer
from the ICU and encourage them to review
it at their convenience, either on the acute
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D E VE LOP ING A N ICU D IA RY P ROGRA M
care unit or once they returned home. While
on the acute care unit, patients and loved
ones continued to document the patient’s
illness and recovery journey, if desired.
Implementation
The ICU diary program procedures adopted
from the literature suggested that nurses typ-
ically initiated diaries on patients who were
intubated for longer than 24 hours, and/or
rated positive for delirium on the Confusion
Assessment Method for the ICU (CAM-ICU)
tool. For this program, the primary nurse
was responsible for completing the initial diary
entry, which included a brief explanation of
why the patient was admitted to the ICU.
Subsequent entries were written throughout
the shift by the patient’s nurse, physician
team, and/or ancillary services (eg, respira-
tory therapists, social workers, and chaplains).
Participation in the ICU diary program was
voluntary. Nurses were encouraged to contrib-
ute at least 1 entry per shift. Patients’ families
and friends were invited to complete entries
as well; the team believed that their participa-
tion in the diary would help patients better
appreciate the support they provided through-
out the illness experience. (For examples of
diary entries, see Table.) The diary remained
with the patient when the patient was trans-
ferred to an acute care unit or discharged to
a skilled nursing facility or home.
A tracking tool was maintained by the team;
unit champions rotated the task of checking
in with nurses, patients, and family members
to assess diary utilization, provide feedback
on diary entries to the nurses, and answer
any questions. This tool listed the patient’s
initials, the date of admission, the date that
the diary was initiated and by whom, the date
when the patient was transferred from the
ICU, the unit to which the patient was trans-
ferred, the name of team member following
up with the patient/family and unit champion,
and the date when the patient was discharged
from the hospital. All nurses were informed
of the tool and its secure central location in
the ICU in order to enroll new patients and
update the tool upon transfer from the ICU
and discharge from the hospital. When patients
were transferred to one of the acute care units,
an ICU diary program champion attempted
to follow up with them at least once before
discharge from the hospital. Nurses identified
as unit champions on the medical-surgical
LO C K E E T A L W W W.A ACNACCONLINE .ORG

Table: Diary entries by various roles

Date Role Diary Entry

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

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

216
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Measuring Success and
Future Research
For the pilot phase of the program, assess-
ing the knowledge and support of ICU staff
(registered nurses, licensed practical nurses,
physicians) for the ICU diary initiative was
the primary interest. In order to solicit feed-
back on the educational efforts to date, the
resources created, and the introduction of
the ICU diary, we interviewed individual
nurses and physicians and simultaneously
distributed a 10-item staff perspective survey
during a 2-week period. The survey used a
Likert-type scale for 7 statements, as well as
3 open-ended questions to address the pro-
gram’s biggest barriers, greatest benefits, and
aspects needing improvement. We placed sur-
veys in staff mailboxes and provided an opaque
ballot box for the return of anonymous sur-
veys. The low response rate was disappointing,
and the team resorted to 12 informal individ-
ual interviews of nurses and physicians. Over-
all, feedback from nurses and physicians was
very positive. Noticeable improvements in
nurses’ initiating diary entries were seen each
week as knowledge and comfort level increased.
In the past 3 months, 17 diaries were initiated,
compared with 3 in the preceding 2 months.
More diaries were implemented without
prompting from the unit champions, and
more nurses and physicians were contribut-
ing entries on a regular basis. The diaries had
a mean of 10 to 15 entries each, with 3 or 4
entries per day. A recent briefing to department
chiefs in the surgical services line resulted in
an invitation for a surgery grand rounds
presentation about the program in order to
engage more surgeons and surgical residents
in the diary process for their ICU patients.
Acute care units have welcomed the ICU diary
program’s team leader for unit in-service train-
ing sessions, and the number of volunteers
willing to be a part of the ICU outreach plan
exceeded all expectations.
Team discussions have focused on next steps
for the program, which would involve meas-
uring the psychological impact of diaries on
outcomes for patients and patients’ families
at intervals recommended in the literature,
possibly testing different methods and timing
of diary debriefing after discharge to see
which lead to the best outcomes, and explor-
ing responses of patients and patients’ fami-
lies to the diary program in the ICU with
formal qualitative or experimental methods.
217
D E VE LOP ING A N ICU D IA RY P ROGRA M
Overcoming Obstacles
The first obstacle in implementing a hospital-
wide, multidisciplinary project was the need
for widespread education about a new pro-
cess. Having identified program champions
early in the pilot phase, staff awareness chal-
lenges were overcome with one-on-one or small
group in-service training sessions. Knowing
what to write in the diary was one of the
greatest struggles for the ICU nurses. Using
examples from the literature or developed by
the team, nurses gained confidence in writing
about day-to-day events, messages of caring,
and progress notes without describing clini-
cal details typical of the medical record. As
mentioned previously, educating the nurses
on the acute care units was vital to ensuring
follow-through after the patient left the ICU
and ultimately to achieving project goals.
These unit champions became responsible for
engaging and educating their coworkers about
the project as it moved forward. On the acute
care units, we encouraged the nurses, during
hand-off or change of shift, to write “ICU
diary” on the white communication board
posted in each room detailing daily goals.
Logistics hurdles occurred frequently, and
the project team met to decide on sustainable
solutions. One hurdle faced was identifying a
specific location for all the program supplies
and devices, as well as the diary itself. In some
instances, the family seemed protective of the
diary, keeping it with their personal belongings.
Other times, the diary was hidden among all
the other supplies in the ICU suite. The team
developed a simple solution and had plastic
file holders mounted on the outside of each
patient’s ICU room. This provided a stand-
ardized location, as well as a visual cue, for
nurses and other staff to be mindful of con-
tributing to the patient’s diary. Family mem-
bers could easily retrieve it from that spot as
well. Project supplies such as additional dia-
ries, pens, and the cameras and DVD players
were maintained on a mobile cart secured in
the ICU supply area.
Implementing a project of this magnitude
does require institutional resources and funds.
The team had the support of nursing leaders
at all levels and a small grant to cover project
expenses including team leader salary, the new
education channel, DVD players, cameras,
and a color printer. The team also purchased
customized pens with the hospital logo and a
window to display 1 of 6 reminder messages
LO C K E E T A L
reflecting what to include in diary entries. These
were provided to staff and family members.
Examples of the messages include What noises
are in your room?, Who visited you today?,
and What happened in the world today? As
mentioned previously, an experienced team
leader was paramount to ensure adherence
to program objectives, achievement of goals,
and program adoption. We found the best
way to deal with obstacles was to anticipate
them and use the team’s energy to develop
innovative solutions.
Perspective of Staff, Patient,
and Patients’ Families
Staff Perspective
Attaining staff buy-in is an inherent prob-
lem of any EBP initiative on a busy clinical
unit. A multitude of tasks already must be
completed in a 12-hour shift, so adding another
project that required education, training, and
follow-up to ensure that it was implemented
effectively was a challenge. Staff members
provided insightful comments during differ-
ent phases of the project rollout. Although
these comments (listed in the following para-
graphs) highlight feedback specific to imple-
mentation of this ICU diary program, they
may serve to inform implementation processes
at other health care facilities considering
adoption of a similar program.
Even after initial training was provided,
staff members voiced that they did not have
enough knowledge about the ICU diary pro-
gram to start a diary on a patient. Nurses
expressed that they did not know what to
write in the diary and requested that sample
entries be provided during the initial educa-
tion process, rather than later as had been
done in this project. However, if a diary was
already started and entries were already
written in it, they felt it was easier for them
to contribute. The nurses who contributed
reported that the time required to write in
the diary was minimal and was not perceived
as a burden on their day. Several months after
the project was underway, some staff nurses
remained apprehensive. Other nurses consid-
ered diary entries to be one of their last pri-
orities, especially when staffing was low or
the patient load was increased. “If a nurse is
busy and trying to catch up with charting
[and it’s shift change], the last thing I want to
do is stay after to write a journal entry” (L.B.,
oral communication, November 2015). One
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W W W.A ACNACCONLINE .ORG
nurse said it was “tedious, like the updating
of care plans,” and commented that “some
nurses participated while others did not”
(J.L., oral communication, November 2015).
A few staff members felt that writing in a
diary posed a potential legal threat and that
it might be used against them if a lawsuit
occurred. Despite reeducation emphasizing
that this was not a part of the patient’s medi-
cal record, they still felt that it could be used
against them and were reluctant to participate.
These feelings were amplified after a camera
was offered to family members to take pic-
tures of their loved ones while in the ICU,
specifically for posting in the diary. It did
not seem to matter that this idea was derived
from published reports and was vetted through
the hospital’s legal department with approval
granted to proceed as long as photos included
only the immediate ICU suite and patients
and their family members.
Despite the aforementioned issues, the
majority of nurses interviewed for feedback
felt that the ICU diary program was a good
idea overall. As far as its effect on the nursing
staff, some felt that writing diary entries was
a helpful way of sharing their support and
feelings. Other comments included, “I can see
if someone passes away, it could be a closure
thing for family members and they can recount
just how sick they were” (J.L., oral communi-
cation, November 2015). She added, “and
the diary provided the family members some-
thing to do and focus on rather than staring
at the monitors for 24 hours” (J.L., oral com-
munication, November 2015). Another regis-
tered nurse stated, “It also provides the family
and patient a means of helping them remem-
ber or reflect on events that occurred while
in the ICU” (J.K., oral communication, Novem-
ber 2015). The nurses who participated felt
that the patients’ families responded favora-
bly to the project. One nurse stated, “I think
it gives the family a job to help in their loved
ones’ recovery. [It] kind of gives them a bit of
control or input in [their] care” (B.W., oral
communication, November 2015).
The diary also provided a level of emotional
support as family members read entries from
the staff and other friends and relatives. One
staff nurse commented that it was nice to see
the interest and enthusiasm of family members
when they heard about the diary. She contin-
ued, “It gives me hope that both patients and
family will benefit from simply keeping a daily
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
journal for them” (T.B., oral communication,
November 2015). Another nurse summed up
his thoughts like this, “If I had any family or
friends in the ICU, I would hope someone
would start an ICU diary for them” (J. S., oral
communication, November 2015).
Patient/Family Perspective
One positive experience relayed to an ICU
diary champion came from a 20-year-old
woman who had a baby via cesarean section
at 26 weeks’ gestation. Her child was imme-
diately taken to the neonatal ICU (NICU) for
care. A few days after the birth of her child,
she was admitted to the ICU and intubated
for sepsis from a postoperative infection. She
remained intubated for 4 days. During this
time, an ICU diary was started. The husband
was oriented to the ICU diary, as he went
back and forth from our ICU to the NICU
to spend time with his wife and also his new-
born child. During her intubation, the ICU
patient remained lightly sedated and aware
of her surroundings. She was able to write
her care needs on a clipboard and frequently
asked about her child. After getting written
approval from the father and explaining the
mother’s current situation in the ICU to the
NICU nurse manager, a unit champion was
able to educate and include the NICU nurse,
who began writing entries in the ICU diary
in order for the mom to have updates. Her
nurse also obtained pictures of her child, with
permission, that were placed in her ICU diary
so she could see her child. This was met with
great appreciation and approval.
After speaking with the patient, her hus-
band, and her mother after extubation, it
was evident that the ICU diary was going to
help tremendously in her recovery. Her mother
arrived from out of town and was able to
read the entries to her; the patient felt that
this helped her understand what had happened
while she was intubated. The patient stated
that she remembered some of the nurses, but
after reading the entries she felt she remem-
bered exactly who took care of her. She was
also happy to find out that the diary was hers
to keep and stated she was thankful she would
be able to go back and read about what hap-
pened during her ICU admission. After read-
ing the diary entries, she said they answered
a lot of her questions that she was not able
to ask while she had a breathing tube and
was under the influence of medications. The
219
D E VE LOP ING A N ICU D IA RY P ROGRA M
patient’s mother was especially thankful that
the diary was started for her and stated she
learned a lot about her daughter’s care before
her arrival by reading the diary. Both the
patient and mother loved the added pictures
taken of her child in the NICU. Overall, they
were extremely appreciative of the accounts
of her illness written in the ICU diary (S.M.,
oral communication, November 2015).
Other comments received from patients
and/or their family members support the idea
that knowing who visited and that they were
not alone was very comforting:
it is good to just tell about your
day, and what their day was like.
They might think no one came to
visit them, but then realize that
they did come to visit because it is
written down. It helps him to
know that he had support while he
was here (R.Z., oral communica-
tion, November 2015).
In another instance where the family was
dealing with a sudden and devastating condi-
tion involving their young adult daughter, the
mother stated,
Me, personally, I find it very diffi-
cult to write in the book. I am
still very emotional and it’s hard
to write in it, but other family
members have used it and I think
it will be very helpful later down
the road for both myself and for
her. We have been reading the
diary to her at the bedside, and it
is a nice resource for us (S.M.,
oral communication, November
2015).
Conclusion
For more than a decade, the Institute of
Medicine has advocated for the inclusion of
patient- and family-centered care in the defi-
nition of health care quality because we now
have evidence that this care is associated with
better outcomes and greater patient satisfac-
tion.17 In a recent publication, Auriemma et al18
describe their efforts to develop a framework
for patient- and family-centered care outcomes
for critical care. The most salient themes for
both patients and family members included the
following: sick, caring, suffering, comments
about medical staff, description of emotional
states, and physical qualities of the ICU (eg,
environment, medical equipment, and noise).
LO C K E E T A L
These researchers, and others who performed
similar research, agree that the expressed
themes are most likely related to satisfaction
of patients and their family members with
the ICU experience and care.14,18,19 Because of
the similarities found in the perceptions and
experiences of patients and their family
members, it is important to include both in
any initiative that addresses the phenomenon
of critical illness.17-19
Although this ICU diary program was devel-
oped to help mitigate the negative effects of
PICS/PICS-F, a secondary effect was that it
was a source of inspiration to the patient,
the patient’s family, and staff members. Writ-
ing daily entries about the patient’s progress
in the ICU was viewed as therapeutic, espe-
cially when what was written included the
eventual removal of the ventilator and, ulti-
mately, transfer from the unit. The program
was, and continues to be, a means for patients’
families to cope with the circumstances of
their loved ones; it provided an outlet to deal
with the daily struggles surrounding clinical
progression or regression.
One of the great satisfactions in the critical
care nursing profession is saving the lives of
patients and seeing them leave the ICU, but
it is vital to understand that this is only one
step in the healing and recovery process. As
this program continues to expand and improve,
it will be crucial to create a mechanism to
get feedback from patients and their family
members so that we can understand how
the ICU diary assisted in their recovery and
return to everyday life. Numerous gaps remain
in our understanding of the strategies most
likely to favorably influence the adjustment
of patients and their family members to the
consequences of critical illness. More research
by interdisciplinary ICU teams is needed to
build an evidence repository for interventions,
such as an ICU diary, that will reduce physi-
cal, cognitive, and mental health comorbid
conditions and allow patients to regain their
quality of life.
ACKNOWLEDGMENTS
The authors wish to thank K. Taylor Blair,
BA, RN, for her critical review of this manu-
script, as well as writing, editing, and format-
ting assistance, without compensation.
The views expressed in the article are those
of the authors and do not reflect the official
220
W W W.A ACNACCONLINE .ORG
policy of the Department of the Army, the
Department of Defense or the US Government.
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Peer Support as a Novel Strategy to
Mitigate Post–Intensive Care Syndrome
Mark E. Mikkelsen, MD, MSCE
James C. Jackson, PhD
Ramona O. Hopkins, PhD
Carol Thompson, PhD, DNP, ACNP
Adair Andrews, RN, MATD
Giora Netzer, MD, MSCE
Dina M. Bates, MD
ABSTRACT
Post–intensive care syndrome, a condition
defined by new or worsening impairment
in cognition, mental health, and physical
function after critical illness, has emerged
in the past decade as a common and life-
altering consequence of critical illness. New
strategies are urgently needed to mitigate
the risk of neuropsychological and func-
tional impairment common after critical ill-
ness and to prepare and support survivors
on their road toward recovery. The present
Mark E. Mikkelsen is Assistant Professor, Department of
Medicine, Center for Clinical Epidemiology and Biostatistics,
Perelman School of Medicine at the University of Pennsyl-
vania, Gates 05042, 3400 Spruce Street, Philadelphia, PA
19104 (mark.mikkelsen@uphs.upenn.edu).
James C. Jackson and Carla M. Sevin are Assistant Professors,
Department of Medicine, Vanderbilt University School of
Medicine, Nashville, Tennessee.
Ramona O. Hopkins is Clinical Research Investigator,
Department of Medicine, Center for Humanizing Critical
Care, Intermountain Medical Center, Murray, Utah and
Professor, Psychology Department and Neuroscience
Center, Brigham Young University, Provo, Utah.
Carol Thompson is Professor, College of Nursing,
University of Kentucky, Lexington.
Adair Andrews is Quality Implementation Program
Manager, Society of Critical Care Medicine, Mount
Prospect, Illinois.
Giora Netzer is Associate Professor, Division of Pulmonary
and Critical Care Medicine and Department of Epidemiol-
ogy and Public Health, University of Maryland, Baltimore.
Dina M. Bates is Assistant Clinical Professor, Division of
Pulmonary, Critical Care, and Sleep Medicine, University
of California San Diego School of Medicine.
AACN Advanced Critical Care
Volume 27, Number 2, pp. 221-229
© 2016 AACN
Aaron E. Bunnell, MD
LeeAnn M. Christie, RN, MSN
Steven B. Greenberg, MD
Daniela J. Lamas, MD
Carla M. Sevin, MD
Gerald Weinhouse, MD
Theodore J. Iwashyna, MD, PhD
state of critical care survivorship is described,
and postdischarge care delivery in the
United States and the potential impact of
the present-day fragmented model of care
delivery are detailed. A novel strategy that
uses peer support groups could more
effectively meet the needs of survivors of
critical illness and mitigate post–intensive
care syndrome.
Keywords: critical illness; survivorship;
quality of life; resilience; peer support
Aaron E. Bunnell is Assistant Professor, Department of
Rehabilitation Medicine, University of Washington, Seattle.
LeeAnn M. Christie is Research Scientist, Dell Children’s
Medical Center of Central Texas, Austin.
Steven B. Greenberg is Clinical Associate Professor, North-
Shore University HealthSystem, Evanston, Illinois.
Daniela J. Lamas is Clinical/Research Fellow and Gerald
Weinhouse is Assistant Professor of Medicine, Division of
Pulmonary and Critical Care Medicine, Brigham and Women’s
Hospital, Boston, Massachusetts.
Theodore J. Iwashyna is Associate Professor, Department of
Internal Medicine, University of Michigan, Center for Clinical
Management Research, Department of Veterans Affairs, Ann
Arbor, Michigan, and Australian and New Zealand Intensive
Care Research Centre, Department of Epidemiology and Pre-
ventive Medicine, Monash University, Melbourne, Australia.
The work was supported in part by the National Institutes of
Health, National Heart, Lung and Blood Institute Loan Repay-
ment Program, Bethesda, MD (M.E.M.) and the Health Ser-
vices Research and Delivery Service of the Department of
Veterans Affairs (T.J.I., IIR 11-109). The 6 inaugural Society of
Critical Care Medicine Peer Support Collaborative sites were
awarded seed grants.
DOI: http://dx.doi.org/10.4037/aacnacc2016667
221
MIK K E L S E N E T A L
P ost–intensive care syndrome (PICS), a
condition defined by new or worsening
impairment in cognition, mental health, and
physical function after critical illness,1,2 has
emerged as a common and life-altering conse-
quence of critical illness.3-6 Unfortunately, PICS
is also resistant to change, with several rand-
omized controlled trials showing no benefit
of various promising strategies.7-12 New strat-
egies are urgently needed to mitigate the risk
of neuropsychological and functional decline
after critical illness and to prepare and sup-
port survivors on their road toward recovery.
In this article, we outline the present state
of critical care survivorship. We focus on the
impairments and vulnerabilities of this popu-
lation of patients. We then detail postdischarge
care delivery in the United States and the poten-
tial impact of the present-day fragmented
model of care delivery. To bridge the gap
between what survivors currently experience
and what is needed, we offer a novel strategy
that uses peer support groups and may more
effectively meet the needs of survivors of
critical illness.
Critical Care Survivorship
In the United States alone, approximately
5.7 million adult patients are cared for
annually in an intensive care unit (ICU),13
and nearly 1 million of these patients will
require mechanical ventilation.14 Advances
in care have improved survival, resulting in
millions of critical care survivors being dis-
charged back into the community each year.
Many survivors experience new or worsening
functional impairments, leading some experts
to herald these developments as a “hidden
public health disaster”15 even as they praise
the remarkable success of critical care medi-
cine in reducing short-term mortality.
PICS Sequelae
At the time of hospital discharge, 46%
to 80% of survivors experience cognitive
impairment.16,17 At 3 and 12 months after
discharge, 40% and 34%, respectively, of
previously healthy survivors remain impaired
to a degree that would be consistent with mod-
erate traumatic brain injury.3 At 12 months,
clinically significant symptoms of anxiety,
depression, and posttraumatic stress disorder
are present in 20% to 30% of survivors.4,18,19
Functional impairment, defined as impairment
in activities of daily living and instrumental
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W W W.A ACNACCONLINE .ORG
activities of daily living (ie, activities that
allow a person to live independently such
as finances and medication management),
afflicts 27% of survivors at 12 months.5 The
result is that the majority of survivors of
critical illness appear to suffer from PICS.1-6
In addition to cognitive, mental health, and
physical impairments, critical care survivor-
ship frequently encompasses chronic pain,20,21
sexual dysfunction,22 disability, financial
loss,23 and inability to return to work,9,23-25
all of which culminate in reduced health-
related quality of life in survivors.23,26
Qualitative studies of patients with severe
sepsis and acute respiratory distress syndrome
and their caregivers have illuminated the
present-day experience of critical care survi-
vorship.27-29 Survivors and their caregivers
crave information at each step of recovery,29
yet frequently lack the knowledge required
to understand what they have experienced
and what to expect. Survivors struggle with
the enduring impact of critical illness on their
own health and the impact on caregivers.
They lament the lack of support after discharge
to tend to or learn to cope with their ongoing
health needs and lack of independence.27,28
Although additional studies are necessary to
fully grasp the challenges experienced by sur-
vivors, and to identify strategies that facilitated
recovery, the available evidence provides a
blueprint for what survivors need.
Post-ICU Follow-up
Contemporary follow-up of ICU survivors
in the United States is fragmented and unco-
ordinated.30-32 The fragmentation is charac-
terized by poor communication between care
providers,29-31 a reality exacerbated by the
multitude of discharge destinations for survi-
vors and high rehospitalization rates.32-35
While strategies evolve to improve communi-
cation between acute care and primary care
providers,31 and integrated electronic health
records should facilitate this important pro-
cess improvement, PICS and other sequelae
of critical illness remain underrecognized,
understudied, and underfunded. A small
number of ICU follow-up clinics have been
established in the United States to combat
this fragmentation.36 These clinics draw on
2 decades of experience from the United King-
dom37 and incorporate into clinical practice
the identification of neuropsychological and
physical problems and timely referral to other
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
health care providers. Although conceptually
appealing, the effectiveness of nurse-led ICU
follow-up clinics in the United Kingdom was
not demonstrated when tested.38 More proxi-
mally, in a separate trial, increasing physical
and nutritional rehabilitation during the
post-ICU acute hospital stay did not result
in improved physical recovery or quality of
life as measured by the Short Form 36 Health
Survey.11 However, germane to the constructs
of preparation and support, the intervention
that was paired with informational content
delivery led to improved patient satisfaction
with physical and nutritional support, coordi-
nation of care, and preparation at discharge.11
Additional studies drawing on the lessons
learned from these seminal trials are needed.
Issues of survivorship are rarely addressed
during the period of critical illness.39 As knowl-
edge translation is notoriously slow, outpa-
tient providers are most likely unaware of
PICS and thus are even less likely to address
issues of survivorship. The result is that mil-
lions of survivors of critical illness are being
discharged into the community, unprepared
and uneducated about what to expect and
how best to cope, adjust, and recover. Impair-
ments will therefore frequently go unrecog-
nized and/or undermanaged. A substantial
burden will fall on their informal caregivers,23
many of whom may be struggling with their
own emotional sequelae from their ICU
experience. Family members and caregivers
are not immune to the psychological trauma
of the ICU; in fact, they are also vulnerable
to developing a form of PICS known as post–
intensive care syndrome–family (PICS-F),40-42
which includes mental health consequences
and may include physical symptoms and
social isolation.
Novel strategies to augment survivors’ social
support structure may be important to pro-
moting a culture of resilience.43,44 These strate-
gies would complement initiatives that aim
to improve survivors’ physical and neuropsy-
chological well-being. Additionally, these strat-
egies could also facilitate coordination between
inpatient and outpatient settings. Peer support
has the potential to fulfill these imperatives.
Peer Support
We propose that peer support for ICU
survivors may serve a crucial role in both
improving the recovery of current survivors
and in accelerating the progress of knowledge
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P E E R SUP P ORT FOR CRIT ICA L ILLNE SS SURVIVORS
about recovery. We define ICU survivors in
this context—in contrast to our technical use
above—as patients and their loved ones who
have emerged from critical illness. We believe
that the continuum of survivorship begins at
ICU admission and may continue for years or
decades afterward. We define peer support as
the process of providing empathy, offering
advice, and sharing stories between ICU sur-
vivors. Peer support is founded on the princi-
ples that both taking and giving support can
be healing if done with mutual respect. Peer
support is centered on the notion that survi-
vors can help each other through problems
and have the willingness to do so. Peer sup-
port is not a clinician-centered model; the role
of clinicians is to help provide the safe space
in which survivors can work together to dis-
cover what they share to help each other.45,46
The potential benefits of peer support
emanate from the establishment of a commu-
nity that promotes health and well-being
through the shared experience of illness and
recovery. The potential benefits, applied to
survivors of critical illness, are many: mental
reframing (hope, optimism), effective role
modeling, information sharing, and practical
advice that is not readily available to health
care professionals at present.45,46 Peer support
has proven effective in people with mental
health disorders and substance abuse issues,45,46
in the self-management of diabetes,47 and
among cancer survivors.48,49 It can lead to
empowerment, self-advocacy, and improved
outcomes. However, although “authentic
empathy,” “validation,” and “acceptance”
are important contributions offered by the
peer support model,45 programs that formally
integrate education into the program appear
to be the most valuable.50 In the near future,
sharing effective coping and compensation
strategies by health care providers and peers
may accelerate recovery further.51-53
As survivors and their caregivers have
first-hand experience of the challenges that
survivors face, these individuals are well suited
to educate and prepare peer survivors for
certain aspects of the recovery process. In
addition, because spirituality and religion
appear to be important in survivors’ support
networks,6 and given the reluctance of health
care providers to engage in the spiritual aspects
of illness and recovery,54 peer support groups
may be a vehicle through which these aspects of
recovery can be explored and acknowledged.
MIK K E L S E N E T A L W W W.A ACNACCONLINE .ORG

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

Support for Survivors of Critical Illness

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

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

224
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 P E E R SUP P ORT FOR CRIT ICA L ILLNE SS SURVIVORS

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

for Use in Peer Support Groups

Challenges Possible Mitigation Strategies References

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

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

225
MIK K E L S E N E T A L
alternative that warrants investigation; however,
its utility in other populations has not been
established.58 If centers of recovery emerge
as an effective and financially solvent model,
incorporating ICU staff and survivors into
peer support staff as full-time employees or
volunteers, as done successfully in mental
health clinic models,45 may be prudent.
Design and Development of a
Peer Support Collaborative
In 2015, the Society of Critical Care Medi-
cine (SCCM) initiated the Thrive Supporting
Survivors of Critical Illness initiative. Thrive
has 3 pillars: a peer-support collaborative,
expanding research into recovery, and edu-
cation within and outside the ICU around
PICS.59 The peer-support collaborative began
with an international call for applications,
the first action of the Thrive group. In the
fall of 2015, 6 inaugural sites were awarded
on the basis of their innovative and team-
oriented design to implement, collaborate,
and assess the effectiveness of peer-to-peer
support groups applied to survivors of critical
illness and their caregivers. The 6 sites include
5 adult hospitals and 1 pediatric hospital.
We expect to expand the collaborative by 5
new sites each year for at least 2016 and 2017,
balancing the needs of group cohesion with
tremendous interest in participation.
The aim of the collaborative is to catalyze
the development of a network of pioneer
in-person support groups, testing the feasibil-
ity of peer support and amassing a body of
proven experience and skills to grow and
support survivors of critical illness. The under-
lying model of the peer-support collaborative
is itself a form of collaborative peer support—
that the leaders of the 6 sites convene monthly
to share successes and challenges and to brain-
storm solutions. The site leaders are joined
on the monthly calls by SCCM staff and an
international group of experts to be available
as a resource for the sites. As the collaborative
matures, the aim is for formal monthly com-
munications to parallel frequent and informal
idea exchanges and mentoring between sites.
These efforts at group cohesion are facilitated
by annual site visits by SCCM staff and a mem-
ber of the Thrive initiative, and in-person
meetings at SCCM’s annual congress.
A basic principle of the peer-support collab-
orative is that no evidence base for providing
peer support to ICU survivors exists. We need
226
W W W.A ACNACCONLINE .ORG
to invent this future together. It is, by design,
improvisational. In some ways, the collabora-
tive is a support group for usually evidence-
based clinicians busy working in an area
without any evidence yet. The collaborative’s
start-up culture is balanced by reporting to
the broader SCCM Thrive initiative and to
SCCM’s executive committee. Each year, the
collaborative will share its current state of
the art at SCCM’s annual congress and work
to codify best practice in ways that can be
scaled up and shared broadly.
We expect that in several years the evidence
base will be sufficient to propose definitive
clinical trials to evaluate alternative models
of peer support. However, premature conduct
of such evaluative trials—before the techniques
of peer support have developed sufficiently
to warrant testing—is not part of the collabo-
rative’s mandate.
What to Expect
Based on the experience in the support
group context and otherwise at the Vander-
bilt Recovery Clinic, Intermountain Medical
Center,60 and Toronto General Hospital,29,30,61,62
several recurrent themes should be anticipated
when implementing a peer-support group.
Chief among these relates to identity—that
is, survivors grapple with questions related
to who they are after intensive care. Acutely
aware of new cognitive deficits, personality
changes, and physical limitations, survivors
frequently struggle in a quest to cope with
loss and to define and eventually embrace a
“new normal.” Even as they look ahead and
brace for an unfamiliar future, they are regu-
larly buffeted by feelings of frustration, guilt,
and regret—sometimes for poor health deci-
sions that led to critical illness and sometimes
for contributing to the distress of family mem-
bers. Regardless of prior health status, they
tend to be preoccupied with health concerns,
leading to vigilance, social disengagement, and
withdrawal. In many cases, they feel powerless
and victimized by circumstances, a dynamic
that can result in decreased self-efficacy and
a burgeoning sense of helplessness.
Facilitating support groups made up of
individuals struggling with the aforementioned
issues is both satisfying and challenging.
Although successful group facilitators share
certain characteristics regardless of the patient
population in question—traits such as the abil-
ity to forge close connections and to relate to
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
others in a nonjudgmental fashion—effective
leaders of post-ICU support groups should
possess specialized knowledge. In particular,
facilitators need to anticipate the natural his-
tory of PICS, as well as the impact of this
condition on diverse domains of functioning
so that they can expectantly manage and
engage the issues that will most likely emerge
and facilitate discussion. In addition, facilita-
tors need to understand the resistance that
patients often have to addressing important
parts of their history, as discussions of their
illnesses and in-hospital experiences are often
highly traumatic. The group must possess a
vision of what constitutes a “good” outcome.
This hard-to-define metric will involve accept-
ance of limitations for some, subtle improve-
ments or more for others, and ideally a richer
sense of community and a revitalized sense of
hope and purpose for all that attend. Coming
together to jointly build this shared vision
can be a rewarding part of the group process.
Finally, the group must be prepared for how
to handle and guide survivors who have med-
ical and psychosocial needs that require atten-
tion and extend beyond the scope of the
support group.
Conclusions
As the population of survivors of critical
illness has grown, so has our understanding
of the many challenges faced by survivors.
To meet the needs of survivors, innovative
strategies are urgently needed. Because so
little is presently known regarding how to
rehabilitate the functional disabilities that
develop after critical illness, a potentially
high-yield endeavor to complement hospital-
based initiatives is to turn to survivors
through the design and implementation of
peer-support groups.
ACKNOWLEDGMENTS
The authors are grateful for our partners in
the Society of Critical Care Medicine Thrive
Supporting Survivors of Critical Illness initia-
tive (Noel R. Baldwin, Sean Berenholtz, Linda
L. Chlan, Alison Clay, Christopher E. Cox,
Martha A.Q. Curley, Aluko Hope, Carol M.
Hodgson, Kimberly T. Joseph, John Marshall,
Cheryl Misak, James M. O’Brien, Neethi
Pinto, Hallie Prescott, Mary D. Still, Elizabeth
Wilcox, Hannah Wunsch).
227
P E E R SUP P ORT FOR CRIT ICA L ILLNE SS SURVIVORS
This work does not necessarily represent
the official views of the US Government or
the Department of Veterans Affairs.
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42. Davydow DS, Hough CL, Langa KM, Iwashyna TJ.
Depressive symptoms in spouses of older patients with
severe sepsis. Crit Care Med. 2012;40(8):2335-2341.
43. Maley JH, Mikkelsen ME. Sepsis survivorship: how
can we promote a culture of resilience? Crit Care Med.
2015;43(2):479-481.
44. Charney DS. Psychobiological mechanisms of resilience
and vulnerability: implications for successful adaptation
to extreme stress. Am J Psychiatry. 2004;161:195-216.
45. Mead S, MacNeil C. Peer support: what makes it
unique? Int J Psychosoc Rehabil. 2006;10(2):29-37.
46. Davidson L, Bellamy C, Guy K, Miller R. Peer support
among persons with severe mental illnesses: a review
of evidence and experience. World Psych. 2012;11(2):
123-128.
47. Fisher EB, Boothroyd RI, Coufal MM, et al. Peer support
for self-management of diabetes improved outcomes
in international settings. Health Aff. 2012;31(1):130-139.
48. Campbell HS, Phaneuf MR, Deane K. Cancer peer sup-
port programs: do they work? Patient Educ Couns.
2004;55(1):3-15.
49. Ussher J, Kirsten L, Butow P, Sandoval M. What do
cancer support groups provide which other supportive
relationships do not? The experience of peer support
groups for people with cancer. Soc Sci Med. 2006;62:
2565-2576.
50. Jacobs C, Ross RD, Walker IM, Stockdale FE. Behavior
of cancer patients: a randomized study of the effects of
education and peer support groups. Am J Clin Oncol.
1983;6:347-350.
51. Jackson JC, Ely EW, Morey MC, et al. Cognitive and
physical rehabilitation of intensive care unit survivors:
results of the RETURN randomized controlled pilot
investigation. Crit Care Med. 2012;40(4):1088-1097.
52. Brummel NE, Jackson JC, Girard TD, et al. A combined
early cognitive and physical rehabilitation program for
people w ho are critically ill: the activity and cognitive
therapy in the intensive care unit (ACT-ICU) trial. Phys
Ther. 2012;92(12):1580-1592.
53. Cox CE, Porter LS, Buck PJ, et al. Development and
preliminary evaluation of a telephone-based mindful-
ness training intervention for survivors of critical ill-
ness. Ann Am Thorac Soc. 2014;11(2):173-181.
54. Ernecoff NC, Curlin FA, Buddadhumaruk P, White DB.
Health care professionals’ responses to religious or
spiritual statements by surrogate decision makers dur-
ing goals-of-care discussions. JAMA Intern Med. 2015;
175(10):1662-1669.
55. Brinkman S, Bakhshi-Raiez F, Abu-Hanna A, de Jonge
E, de Keizer NF. Determinants of mortality after hospi-
tal discharge in ICU patients: literature review and
Dutch cohort study. Crit Care Med. 2013;41:1237-1251.
56. Brinkman S, de Jonge E, Abu-Hanna A, Arbous MS, de
Lange DW, de Keizer NF. Mortality after hospital dis-
charge in ICU patients. Crit Care Med. 2013;41:1229-1236.
57. Wunsch H, Guerra C, Barnato AE, Angus DC, Li G,
Linde-Zwirble WT. Three-year outcomes for Medicare
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
beneficiaries who survive intensive care. JAMA. 2010;
303(9):849-856.
58. Eysenbach G, Powell J, Englesakis M, Rizo C, Stern A.
Health related virtual communities and electronic sup-
port groups: systematic review of the effects of online
peer to peer interactions. BMJ. 2004;328(7449):1166.
59. Mikkelsen ME, Iwashyna TJ, Thompson C. Why ICU
clinicians need to care about post-intensive care syn-
drome. Crit Connect. 2015;14:4.
60. Brown SM, McBride G, Collingridge DS, et al. Validation
229
P E E R SUP P ORT FOR CRIT ICA L ILLNE SS SURVIVORS
of the Intermountain patient perception of quality
(PPQ) survey among survivors of an intensive care unit
admission: a retrospective validation study. BMC Health
Serv Res. 2015;15:155.
61. Herridge MS, Cheung AM, Tansey CM, et al. One-year
outcomes in survivors of the acute respiratory distress
syndrome. N Engl J Med. 2003;348:683-693.
62. Herridge MS, Tansey CM, Matté A, et al. Functional
disability 5 years after acute respiratory distress syn-
drome. N Engl J Med. 2011;364:1293-1304.
 AACN Advanced Critical Care
Volume 27, Number 2, pp. 230-235
© 2016 AACN

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

Overcoming Barriers to Using Patient-Reported

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

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

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

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

DOI: http://dx.doi.org/10.4037/aacnacc2016265

230
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Clinical Inquiry

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

Assessment

Opportunities for Integration of a Validated

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

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

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

231
Clinical Inquiry
time and sensitive to clinical changes as
they occur.1 As such, they provide opportuni-
ties for better data capture on the patient’s
perception of health care and well-being.
When used as a standard part of care
delivery, the time involved in obtaining PRO
data is time well spent because it allows the
patient to communicate measurable priori-
ties, concerns, and perceptions to the health
care team. Nurses and other care providers
can then integrate direct patient input into
the plan of care, the education plan, and plans
to prepare for discharge. For example, assess-
ing health literacy by using a standardized
PRO tool may highlight opportunities for
educational delivery method, such as the
use of pictures rather than words, or the
use of alternative medication information
rather than standard pamphlets from the
Food and Drug Administration.6 In addi-
tion, issues that are of particular concern to
the patient or the patient’s family can more
easily and systematically be identified and
addressed, including knowledge gaps about
the plan of care or gaps in the patient’s
understanding of self-management expecta-
tions after discharge.7
Despite more than a decade of encourage-
ment to improve the quality of patient care
by including PROs as a part of standard
clinical assessment and clinical practice,
these types of assessments of directly cap-
tured, PROs are still not routinely used.8
PROs are not typically integrated in usual
care delivery or standard assessments of
patients. In current clinical practice, we fail
to assess PROs as an integral component of
baseline information on patients, informa-
tion that could be used to drive care delivery
and develop a more patient-centered plan
of care.
What Is the Added Value for Nurses
and Providers?
The value of PROs for nurses and provid-
ers can be broken down into 4 opportunities:
(1) enabling better data capture on patients’
perceptions of care, (2) allowing the nurse or
provider to focus on the patient’s perceived
concerns without wasting time on issues about
which the patient may not be concerned, (3)
providing structure for the nursing assessment
to address and prioritize patient-centered con-
cerns, and (4) improving communication and
continuity of patients’ concerns and the plan
232
W W W .AACN ACCON LIN E .ORG
for resolving those concerns across settings
of care and over time.
Examples of these opportunities to use
PROs to elicit patient-reported outcome data
include assessment and care planning for
patient literacy, patient-perceived quality of
life, emotional impact of illness, medication-
taking skills, patient goals for care including
priorities, knowledge, skills, and ability to
self-manage health conditions, or the social
and psychosocial factors influencing patients’
self-management. Documentation of each of
these key components of the patient assessment
is required for high-quality care, and yet, the
use of valid and reliable PRO tools to collect
patients’ responses to these important assess-
ment questions is far from “standard.” As a
result, the patient’s response cannot be reliably
compared across patients’ experiences or even
within an individual patient’s experience, pre-
venting nurses from assessing improvement
at the individual level over time.9
Powerful incentives to increase awareness
of the value of PROs and encourage their use
in clinical settings are emerging. For example,
health care providers participating in account-
able care organizations are now expected to
provide evidence that the care they delivered
produced value for the patient, as determined
and reported by the patient.10 These new indi-
cations for use of PROs parallel suggestions
that The Joint Commission and National Qual-
ity Forum may require use of PROs in order
for organizations to be accredited.11 And yet,
thus far, real-time clinical applications of PROs
have been limited.
To date, the most commonly used and
recognized examples of PROs in standard
practice patterns include pain assessments
(eg, the postoperative pain assessment, chest
pain assessment, pediatric pain scales, and
others) and assessments of satisfaction with
care (eg, HCAHPS).12 Despite incentives for
these examples and other use cases, PROs in
clinical settings have major drawbacks, not the
least of which are that they take considerable
nursing time to administer to patients and
that they are not reportable and actionable
in real time. These drawbacks create a signifi-
cant disincentive for PRO use for hospital
nurses and a burden for ambulatory care
nurses, where it can be challenging to find the
results in the electronic health record (EHR)
and difficult to maintain continuity and
alignment with the plan of care.
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Overcoming Barriers to Using
PROs in Practice
Barriers in clinical practice settings present
challenges for nurses who seek to improve
practice quality and patients’ outcomes
through clinical inquiry projects that depend
on PROs. These barriers, though somewhat
unique across patient populations and clinical
sites, can be broadly grouped into 3 catego-
ries: (1) barriers to work-flow integration,
(2) lack of real-time reporting for actionable
metrics, and (3) technology-based barriers
that prevent interoperability. Next we
describe 3 brief solutions that highlight the
promise of how these PROs can be used more
effectively to contribute important data for
clinical inquiry projects.
Work-Flow Integration
Although the opportunity to obtain impor-
tant patient-centered clinical information
(not available via any other mechanism or
any other location in the EHR) is recognized
by the health care team, the opportunity to
obtain and use the information is not easily
integrated into a unit’s work flow. The first
step in addressing this challenge is through
a shared governance platform, a meeting with
a performance-services or Six Sigma process
engineering team, or through a unit clinical
practice council. Identify the decision-making
informal leadership team in place, and use
these leaders to evaluate work flow to accom-
modate PRO collection. The process of initi-
ating change in established unit work flow can
be difficult and is best addressed by partner-
ing with established leadership groups such
as these.13
The second step in ensuring that work
flow accommodates PROs is to map not
only the patient day, but also the entire
course or plan of care. For example, the
acute care nurse, discharging nurse, and
follow-up nurse each have unique responsi-
bilities that can be mapped across a shift as
well as across the entire course of care or
trajectory of illness. One example of a suc-
cessful approach is shown in Figure 1.
Reporting Trends
Reporting PRO scores and trends in real
time is another challenge that can stymie the
use of PROs for clinical inquiry. Although
the benefits of collecting and using these
data are many, at a local level the front-line
233
Clinical Inquiry
• Huddle with charge nurse: use PROs to
set priorities and acuity levels
• Handoff between nurses: use PROs in
7 AM
shift report
• Morning weights and vital signs
• Distribute morning medications
• Before serving meals, verbally reassess
key PROs:
Pain score, comfort
Noon Satisfaction with meal, environment
of care
Expectations for communication
regarding plan of care
• Before administering evening medica-
tions, taking evening vital signs, or
shift change, reassess key PROs for
7 PM
changes during shift
Figure 1: Work-flow integration of patient-reported
outcomes (PROs) on day shift.
staff does not usually receive scores and
trends on admission, during patient handoff,
or even before the patient is discharged. The
time delay makes using the survey responses
difficult. The immediate opportunity for
evaluation of the health care experience and
communication between patients and pro-
viders about that experience is lost. Without
the ability to obtain results of PROs in an
actionable, real-time format, the value of
the tools is diminished. One solution is to
hardwire reports of actionable PROs into
patient handoffs using an SBAR (situation,
background, assessment and recommenda-
tion) reporting process for communication.14
Using SBAR for communication of PROs
during patient report ensures that the results
and actionable trends will be integrated into
care planning and priority setting and will
maintain integrity and continuity across
shifts (Figure 2).
Although the opportunity exists to find
trends in scores over time, send these trends
to the clinic or referring provider, and print
out these trends for patients to take home,
scores are not always easy to find trends in
and translate. One solution is to adopt crite-
ria for selection of PROs to be used for a
Clinical Inquiry
SITUATION: At each handoff, the nurse optimizes
patient-centered priorities and addresses key
patient-specific PROs: (a) preexisting PROs,
(b) PROs specific to the current plan of care, and
(c) PROs in preparation for discharge
BACKGROUND: Patient’s presenting problem,
admission diagnosis, medical and social history
should each be evaluated from the patient’s per-
spective, using pertinent PROs specific to this
admission (eg, pain scales or preexisting PROs in
the electronic health record)
ASSESSMENT: Objective and subjective PRO
data are shared with oncoming nurse, including
relevant changes in PROs since previous shift
RECOMMENDATION: Using the PRO scores, or
changes in PROs, focus the care plan and tailor
daily care goals (including patient education) to
align with patient-reported goals and priorities;
base recommended plan of care and priorities for
postdischarge care planning on trends in PROs
Inpatient stay: Discharge: Complete
continue with plan of care using PROs
care plan, update to drive outpatient goal
plan of care and setting; document and
PRO report as print discharge instruc-
appropriate, and tions (after visit summary)
refer back to using PROs to educate
SBAR (situation, patients about home
background, medications, follow-up
assessment, office visits, activity
and recommen- progression, and priori-
dation) at each ties for lifestyle modifi-
shift change cation goals
Figure 2: The SBAR (situation, background, assess-
ment, and recommendation) algorithm for using
patient-reported outcome (PRO) data in patient-
centered handoff.
given population of patients. The PRO most
useful for clinical inquiry projects is one that
is (1) actionable, indicating that the results
have clinical meaning and drive or contrib-
ute significantly to the care plan; (2) inter-
pretable, meaning that the scoring is clear
234
W W W .AACN ACCON LIN E .ORG
immediately during use and does not require
extensive programming to get a score during
a given shift; (3) efficient to use, meaning
minimal time is required for the nurse to
administer the survey or tool; (4) patient-
friendly, so that it can be completed inde-
pendently, without the need for interpretation
or additional instructions; and (5) obligatory,
meaning the documentation of the measure
is a valuable data point in the patient care
process and is therefore an expectation of
leadership and/or quality regulatory boards
such as The Joint Commission or the National
Quality Forum.
Technology and Incentives
The third broad category of barriers to PRO
use in clinical practice includes technology-
based challenges. The goal for PRO data cap-
ture is to achieve fully integrated EHR
functionality, with interoperability across
settings of care and across devices, such as
electronic tablets, telephones, and other web-
based devices. Although the horizon is short-
ening, and examples of PROs on electronic
platforms are becoming more common,15
the state of “usual standard care” still does
not typically include ePROs. As shown in
Figure 3, electronic procurement of PROs
to support clinical inquiry would include
data sharing among providers across sites
of care, graphic depiction of trends that are
easy to interpret and share with patients,
and online access to surveys for patients to
complete at home or in the clinic waiting room
after hospital discharge. Specific strategies
for approaching technology-based barriers at
a given hospital or in a specific unit will vary
depending on the EHR system and the avail-
ability of information technology specialists;
however, the pace of systematic changes across
the country is rapidly moving forward in
support of electronic PRO systems.16,17
Conclusion
The assessment of patients’ perspectives
as key stakeholders in high-quality, high-value
health care is quickly becoming an important
and recognized opportunity for nurses. To
improve the ability to tailor and shape care
plans to the needs and goals of individual
patients, we must improve our skills and the
efficiency with which we select, interpret,
and use PROs in clinical practice. Using
strategies to address work-flow barriers,
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016 Clinical Inquiry

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

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

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

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

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

maximize reporting opportunities, and resolve
technology barriers will improve the clarity
of the patient’s voice in clinical inquiry projects.
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1. US Department of Health and Human Services FDA
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2. Doos L, Bradley E, Rushton CA, Satchithananda D,
Davies SJ, Kadam UT. Heart failure and chronic
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3. Reeve BB, Wyrwich KW, Wu AW, et al. ISOQOL
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22:1889-1905.
4. Eapen ZJ, Tang F, Jones PG, et al. Variation in perfor-
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5. Spertus J. Barriers to the use of patient-reported outcomes
in clinical care. Circ Cardiovasc Qual Outcomes. 2014;7:2-4.
6. Wolf MS, King J, Wilson EA, et al. Usability of
FDA-approved medication guides. J Gen Intern Med.
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7. Coleman EA, Mahoney E, Parry C. Assessing the quality
of preparation for posthospital care from the patient’s
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8. Rumsfeld JS. Health status and clinical practice: when
will they meet? Circulation. 2002;106:5-7.
9. Snyder CF, Blackford AL, Aaronson NK, et al. Can
patient-reported outcome measures identify cancer
patients’ most bothersome issues? J Clin Oncol. 2011;
29:1216-1220.
10. Burston S, Chaboyer W, Gillespie B. Nurse-sensitive
indicators suitable to reflect nursing care quality: a
review and discussion of issues. J Clin Nurs. 2014;23:
1785-1795.
11. Brown DS, Donaldson N, Burnes Bolton L, Aydin CE.
Nursing-sensitive benchmarks for hospitals to gauge
high-reliability performance. J Healthc Qual. 2010;32:9-17.
12. Wolosin R, Ayala L, Fulton BR. Nursing care, inpatient
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J Nurs Adm. 2012;42:321-325.
13. Weiner BJ. A theory of organizational readiness for
change. Implement Sci. 2009;4:67.
14. Compton J, Copeland K, Flanders S, et al. Implementing
SBAR across a large multihospital health system. Jt
Comm J Qual Patient Saf. 2012;38:261-268.
15. Sawyer T, Nelson M, McKee V, et al. Implementing
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Crit Care Nurse. 2016;36(1):60-70.
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 AACN Advanced Critical Care
Volume 27, Number 2, pp. 236-240
© 2016 AACN

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

in Critical Care Karen Stutzer, RN, PhD
Department Editors

The Ethics of Post–Intensive Care Syndrome

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

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

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

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

Judy E. Davidson is Evidence-Based Practice and Research Nurse Liaison, University of California
San Diego Health System, Mail Code 8929, 200 W Arbor Drive, San Diego CA 92103 (jdavidson@
ucsd.edu).
Karen Stutzer is Assistant Professor of Nursing, College of St Elizabeth, Morristown, New Jersey.
The authors declare no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016586

236
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
As she recounted her postinjury experience,
her strongest memory was of the fear caused
by loneliness and abandonment. Many of her
bones were broken, and in the beginning, she
could barely lift a finger to press the call but-
ton. She was heavily sedated and receiving
mechanical ventilation. The physicians would
come to round each day with her mother
present and declare, over her bed, that she
would most likely not survive. She described
their rounding dialogue in detail, remember-
ing every word as if it were yesterday. Jane
assumed that the team thought she was either
too critically ill or too sedated to remember,
so their discussion was frank and open in
regard to how seriously ill she was.
She recalls that following a day of hearing
about her poor prognosis, the night-shift staff
encouraged her mother to go home to rest
because they rationalized that her mother
would need her strength to manage her daugh-
ter’s rehabilitation or death. But her mother
did not want to leave her daughter’s bedside.
She had rented a motor home to be as close
to her daughter as she could be. She was
plagued by the thought that her daughter
might die alone without her family present.
When the nurses had encouraged her mother
to leave her beside, they told Jane that if she
pushed the call bell, they would call her mother
and she could come in to be with her. Jane
did push the call bell. The nurse came in and
said she would call her mother for a visit. The
clock was visible from the head of the bed.
Jane remembers watching the second hand
go around and around for hours. She prayed
for her mother’s return, but it did not happen.
The nurses, she assumed, felt she was too
sedated or ill to remember.
Jane describes other instances of asking
for her mother to be present at her bedside.
She recalled that when the nurse left to get
her mother, she overheard the nurses at the
nursing station laughing, jeering at the thought
that a grown young woman needed her mother
so badly. She could not fathom why the nurses
did not understand her need to have family
with her. Jane perceived those nurses as cold
and indifferent to her needs.
Jane’s mother, on the other hand couldn’t
cope with the imposed separation any longer.
To avoid being asked to leave, on some eve-
nings she hid under the bed. She would reach
her hand up through the rails to touch Jane’s
fingers. One night she even hid behind the
237
Ethics in Critical Care
curtains. She found a urinal and kept it with
her in case she needed to use it. It gave her
comfort to be able to still see her daughter.
She continually feared that her daughter
would die alone.
Jane shared that she and her mother both
received psychiatric care for many years to
treat the mental illness caused by their ICU
experience; both were diagnosed with post-
traumatic stress disorder (PTSD). PTSD has
been noted in both critical care patients and
family members of critically ill patients.3
Jane and her mother openly admitted their
admiration for those who saved Jane’s life;
but “the save” was not the end of the story.
It was the beginning of a long and arduous
journey of recovery. They remind us that how
the second chapter unfolds can be shaped by
the first chapter—the ICU stay. In PICS and
PICS-F, anxiety, depression, or symptoms of
PTSD related to the ICU stay may develop in
the patient or the patient’s family. For instance,
our best intentions at helping patients’ family
members get rest or respite can be counter-
productive to their strong desire for presence
and safeguarding their loved one’s life.
Ethics Analysis
The ethical issues that attend the preven-
tion or mitigation of PICS/PICS-F include
individual clinician and systems/organiza-
tional interventions. Nurses are moral agents;
institutions are moral communities. A straight-
forward ethical analysis of Jane and her moth-
er’s case might invoke the ethical principles
of nonmaleficence, beneficence, and respect
for persons. We should, at a minimum, not
harm our patients (or their families), and,
given informed consent, we are obligated to
provide them with empirically sound benefi-
cial treatment. We are also obligated, at a
minimum, to respect the dignity of patients
and their family members as persons.
Jane and her mother are grateful for Jane’s
lifesaving treatment—perceived benefits are
not at issue. Further exploration is needed to
understand the harms that resulted from the
behaviors, inattention, or disregard for what
Jane or her mother understood to be benefi-
cial to them and their well-being. Both women
report being emotionally traumatized by their
forced separation, and by the apparent indif-
ference, infidelity, and uncaring attitudes
demonstrated by nurses and other critical
care professionals.
Ethics in Critical Care
Critical care nurses’ conception of profes-
sional duty is not limited to ethical analysis
and ethical principles. Rather it is informed
by a notion of moral agency that is conso-
nant with the work of feminist philosopher
Margaret Urban Walker.4 Walker sees moral-
ity not as a theory or a set of rules or princi-
ples, but as a set of practices in our everyday
lives. Patients, in Walker’s words, are nurses’
business. She would see nursing practice as
morally situated in 3 things: role, responsibil-
ity, and accountability. The critical care nurse
is a professional: she (or he) has a body of
expert knowledge that she professes to use
for the good of others (her patients). In her
role as a nurse, she is responsible for and
accountable to her patients. The competent
critical care nurse (physician or other clini-
cian) presumes that an unconscious patient
can hear, can understand, and thus is mindful
to touch the patient, to reassure, to explain,
to give the unconscious or even dying patient
“the benefit of the doubt.”
The experiences of Jane and her mother
and their subsequent struggle with PICS and
PICS-F remind us of a key expectation of the
nurses’ code of ethics: “The nurse practices
with compassion and respect for the inherent
dignity, worth and unique attributes of every
person.”5 Treating vulnerable people with
compassion and honoring their dignity is a
rigorous, nonnegotiable standard for all nurses.
What might have interfered with the nurses’
ability to demonstrate empathy and under-
standing for this patient and her mother?
Although none of us were in this specific
situation, we may have witnessed similar
instances where members of the health care
team have demonstrated a lack of empathy
or caring. One possible explanation for the
behaviors described is compassion fatigue.
Compassion fatigue is described as nurses
losing their ability to nurture in their rela-
tionships with patients and patients’ families.6
An integral component of nursing is being
present with patients and patients’ families,
and as such, the nurse participates in both
the joy and suffering that transpire in those
interactions. Compassion fatigue is progres-
sive and occurs in nurses as a result of the
stress of prolonged, intense relationships with
patients in which the nurses’ compassionate
energy is expended and not restored.6,7 When
compassion fatigue is present, changes in
ethical and clinical values may occur,
238
W W W .AACN ACCON LIN E .ORG
including lack of identification of patients’
needs and lack of enthusiasm for patient
care.7 Compassion fatigue can also coexist
with other factors such as moral distress that
can further erode nurse’s abilities to engage
with empathy and compassion.
In order for nurses to fulfill their ethical
obligations, the code of ethics for nurses
rightly calls nurses to care for themselves
so that they can care for others. It states that
the nurse owes the same duties
to self as to others, including the
responsibility to promote health
and safety, preserve wholeness of
character and integrity, maintain
competence, and continue personal
and professional growth.5
It is vital that critical care nurses understand
that the tension of persistently monitoring
critically ill patients in order to ensure early
detection of deteriorating condition and the
witnessing of suffering and death take their
toll. Failure to self-acknowledge the impact
of this level of responsibility and subse-
quently engaging in self-care activities can
result in expending a level of energy that
exceeds the nurses’ ability to recover, and
compassion fatigue ensues.7
Call to Action
Providing care that minimizes the devel-
opment of PICS and PICS-F and the harms
associated with them is the ethical responsi-
bility of nurses. Understanding the factors
that contribute to PICS and PICS-F, a com-
mitment to live the ethical values reflected in
the code of ethics, awareness of the impact
of compassion fatigue on caring behaviors,
understanding patients’ experience, and
contributing to an environment that supports
humanistic care are elements of a multi-
pronged approach.
Understanding Patients’ Experience
Mitigating the impact of development of
PICS and PICS-F begins with a robust under-
standing of the experience of patients in the
ICU. The Society of Critical Care Medicine
has produced a number of videos available
on YouTube (https://www.youtube.com/watch
?v=mahm5WHxB7Q). Patients discuss their
experiences in their own words and identify
interventions that they believe would be sup-
portive of critically ill patients and their fami-
lies. In one video (https://www.youtube.com
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
/watch?v=TFHP7WbICro), the patient poi-
gnantly shares the most meaningful care she
received. She highlights that what might be
considered mundane, like talking about the
weather or some uplifting news, helped her to
feel human and connected. Readers should
consider viewing these videos with other
members of the health care team in order to
facilitate insight into the patient’s perspective
of the ICU stay. As a team, consider incorpo-
rating recommendations into practice on your
unit. Be cognizant of the right of patients and
their families to participate in their own care
by use of open visiting hours, participation in
rounds, and answering questions honestly. It
is also important to be aware of the words we
say and how we say them, so that caring is
evident with all interactions.
A variety of factors in the ICU have been
noted to exacerbate the high rates of anxiety,
depression, and PTSD noted in patients and
their families after an ICU stay.3,8 One prom-
ising approach to diminishing the emotional
aftermath of a stay in the ICU is the use of
diaries.8,9 The diary is maintained by the ICU
staff members and describes the patient’s
daily activities, visitors, and the patient’s
responses to those activities. Some diaries
include photographs of the patient’s jour-
ney.3,8 Patients have responded positively to
receiving the diaries. The diaries assured them
that there were people who cared about them
as they went through their illness.3 It has
been reported that the patients and families
who received diaries had lower levels of
PTSD than did those who did not receive a
diary.10-12
Environments That Support
Humanistic Care
Jenkins and Warren7 share the wisdom of
Native Americans, who say, “each time you
heal someone, you give a piece of yourself
away.” How can critical care nurses ensure
that they are able to give and restore in order
to be ready to give again? Certainly taking
care of themselves, learning stress manage-
ment strategies, developing self-awareness,
and being mindful of balance in one’s life is
a start.7 Beyond that, leaders in the environ-
ment where nurses practice need to be mind-
ful of the potential for compassion fatigue to
develop in their staff.
Nursing leaders and colleagues need to
monitor one another for signs of compassion
239
Ethics in Critical Care
fatigue, including chronic absenteeism, high
turnover, and interpersonal conflict among
the staff.7 Providing the staff with support
and education on compassion fatigue is a
start. Creating an environment that fosters
nurses supporting each other is vital.7 Pro-
grams aimed at enhancing nurses’ resiliency
are showing promising results in regard to
decreasing compassion fatigue and increasing
compassion satisfaction.13 The effects of these
programs have been sustained over time.13
Likewise, administrative supports that pro-
mote a healthy work environment for all cli-
nicians such as appreciative practice initiatives;
compassionate care programs for caregivers,
patients, and families; and institutional resources
to address clinical ethical issues and moral
distress are promising practices.
Conclusion
The lifesaving critical care environment
is fraught with hazards for patients, their
families, and the health care team. Under-
standing the nature of PICS and PICS-F as
well as interventions to potentially mitigate
the impact of an ICU stay is a key responsi-
bility of the health care team. Being alert to
the development of compassion fatigue and
acting preemptively to diminish its develop-
ment are key responsibilities of both leaders
and members of the health care team. Having
knowledge about our patients and caring for
self allow us to be optimal agents of care.
REFERENCES
1. Needham DM, Davidson J, Cohen H, et al. Improving
long-term outcomes after discharge from intensive
care unit: report from a stakeholders’ conference. Crit
Care Med. 2012;40(2):502-509.
2. Davidson JE, Harvey MA, Schuller J, Black G. Post-
intensive care syndrome: what to do and how to pre-
vent it. Am Nurse Today. 2013;8:32-38.
3. Jones C. Recovery post ICU. Intensive Crit Care Nurs.
2014;30:239-245.
4. Walker MU. Morality in practice: a response to Claudia
Card and Lorraine Code. Hypatia. 2002;17(1):174-182.
5. American Nurses Association. Code of Ethics for
Nurses With Interpretive Statements. Silver Spring,
MD: American Nurses Association; 2015.
6. Coetzee SN, Klopper HC. Compassion fatigue within
nursing practice: a concept analysis. Nurs Health Sci.
2010;12:235-243.
7. Jenkins B, Warren NA. Concept analysis: compassion
fatigue and effects upon critical care nurses. Crit Care
Nurs Q. 2012;35(4):388-395.
8. Akerman E, Ersson A, Fridlund B, Samuelson K. Pre-
ferred content and usefulness of a photodiary as
described by ICU patients: a mixed method analysis.
Aust Crit Care. 2013;26:29-35.
9. Ewens B, Chapman R, Tulloch A, Hendricks JM. ICU
survivors’ utilisation of diaries post discharge: a quali-
tative descriptive study. Aust Crit Care. 2014;27:28-35.
Ethics in Critical Care
10. Garrouste-Orgeas M, Coquet I, Perier A, et al. Impact
of an intensive care unit diary on psychological dis-
tress in patients and relatives. Crit Care Med. 2012;
40(7):2033-2040.
11. Jones C, Backman C, Capuzzo M, et al. Intensive care
diaries reduce new onset post traumatic stress disorder
following critical illness: a randomised, controlled trial.
Crit Care. 2010;14(5):R168.
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W W W .AACN ACCON LIN E .ORG
12. Jones C, Backman C, Griffiths RD. Intensive care dia-
ries and relatives’ symptoms of posttraumatic stress
disorder after critical illness: a pilot study. Am J Crit
Care. 2012;21(3):172-176.
13. Potter P, Deshields T, Berger JA, Clark, M, Olsen S,
Chen L. Evaluation of a compassion fatigue resiliency
program for oncology nurses. Oncol Nurs Forum. 2013;
40(2):180-187.
 AACN Advanced Critical Care
Volume 27, Number 2, pp. 241-247
© 2016 AACN

ECG Gerard B. Hannibal,

Challenges Department Editor
RN, MSN, CCRN

2015 Advanced Cardiac Life Support Updates

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

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

Gerard B. Hannibal is Staff Nurse, Progressive Care Unit, The Louis Stokes Cleveland Department of
Veterans Affairs Medical Center, 10701 East Boulevard, Cleveland, OH 44106 (jerry.hannibal@gmail.com).
The author declares no conflicts of interest.
DOI: http://dx.doi.org/10.4037/aacnacc2016955

241
ECG Challenges
Emergency Cardiac Care
Guidelines Update 2015
The authors of the emergency cardiac care
guidelines make it clear that the 2015 docu-
ment published in Circulation is an update—
not a revision. A revision is a change that
corrects or improves, whereas an update
reviews the most recent information about a
topic. For example, when the International
Liaison Committee on Resuscitation (ILCOR)
changed the emphasis of emergency care from
breathing and airway as the primary survey
to circulation as the primary focus (ABC
survey to CAB survey), that was a revision.
In the current document, an upper limit is,
for the first time, added to the rate of chest
compressions. This change is an update based
on research that indicates that overly rapid
chest compressions do not allow adequate
depth of compression.
The guidelines have been revised periodically
in the past 50 years. CPR came into use in
the early 1960s, and the National Academy
of Sciences published the first US guidelines
in 1966. The American Heart Association
published 7 guideline revisions in the next
50 years, starting in 1974 and resulting in
the current guidelines. This new iteration of
emergency cardiac care guidelines takes advan-
tage of current Internet technology and the
need to quickly translate science into action.
The complete searchable updates and current
guidelines are now available for immediate
review at https://eccguidelines.heart.org/index
.php/circulation/cpr-ecc-guidelines-2/.3
The method used for both gathering and
evaluating evidence for the current guidelines
and the update was also revised for 2015.
The committee used the PICO method (popu-
lation, intervention, comparator, and outcome)
to formulate questions based on clinical sig-
nificance and new evidence. One hundred
sixty-five PICO questions were reviewed, result-
ing in 315 updates for emergency cardiac
care. Levels of evidence and classifications
of recommendations were also revised; the
guidelines and updates are divided into 5
classes of recommendation, with 5 levels of
evidence. Note that class III recommendations
are newly divided into 2 subcategories: no
benefit to a procedure or treatment, and dan-
gerous treatments or procedures that should
not be performed.4 Table 1 summarizes the
total number of updates with their levels of
evidence. The high percentage of updates
242
W W W .AACN ACCON LIN E .ORG
Table 1: Numbers and Percentages of
Emergency Cardiac Care Updates in
2015 Classified by Level of Evidencea
Level of No. of % of
Evidence Description Updates Total
A Systematic reviews 3 1
B-R Randomized studies 50 15
B-NR Nonrandomized studies 46 15
C-LD Limited data 145 46
C-EO Consensus of expert 73 23
opinion
a
Note the low number of updates based on high-level evidence.
based on limited data or expert consensus as
opposed to the low number of updates based
on high-level evidence illustrates the paucity
of high-quality, pertinent research in the field
of resuscitation.
Basic Life Support Updates
The basic life support (BLS) updates (Table 2)
are focused on 2 areas: improving the quality
and performance of CPR and instituting “just
in time” bystander CPR by emergency medi-
cal response dispatchers.5 CPR quality issues
include adding an upper limit of 120 compres-
sions per minute to promote adequate depth
of compressions and complete chest recoil,
reducing pauses before and after a shock,
and adding the use of intramuscular or intra-
nasal naloxone by BLS health care providers
when opioid-related stupor is likely. The update
includes the addition of a new limit to com-
pression depth of 2.4 inches for adult victims,
along with a goal of increasing the chest
compression fraction to at least 60%. Chest
compression fraction is a measure of the per-
centage of time that chest compressions are
actually in progress. Additionally, CPR pro-
viders are urged not to lean on the chest so
that full recoil can be attained.5
The BLS section of the update also places
a heavy emphasis on improving the rate of
bystander CPR. EMS dispatchers are urged
to learn to identify cardiac arrest on the basis
of descriptions of bystanders. Dispatchers
should assume that the victim is in cardiac
arrest if the bystander describes gasping
(agonal breathing) or the absence of breath-
ing. Dispatchers should then either provide
support to a bystander who is trained in
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table 2: Selected Updates for 2015
Guidelines for Cardiopulmonary
Resuscitation Quality and Classification
of Recommendation
Emergency Cardiac Care Practice
Compression rate 100-120 (new upper limit)
Compression depth 2-2.4 inches (5-6 cm)
(new lower limit)
Reduce pauses before and after shock
Increase chest compression fraction
(goal at least 60%)a
Naloxone for opioid stupor (health care
providers)
OHCA, shockable rhythm—3 cycles 200
compressions with passive oxygen insufflation
(EMS only)
No routine passive ventilation for conventional
CPR
Routine passive ventilation okay for EMS
bundled services
EMS dispatchers—assess for consciousness
and abnormal breathing
Dispatcher to assume victim is in cardiac
arrest if no normal breathing
Educate dispatchers to identify cardiac
arrest through a range of clinical signs
and symptoms
Dispatchers provide “chest compression
only” instructions for OHCA
10 breaths per minute during CPR with
advanced airway
Artifact-filtering algorithms not recommended
except for research
Audiovisual feedback devices may be used
Lay rescuers not to use head-immobilization
devices
Abbreviations: COR, class of recommendation; CPR, cardiopulmonary
resuscitation; EMS, emergency medical services; OHCA, cardiac
arrests occurring outside of the hospital.
a
Chest compression fraction measures the percentage of time that
chest compressions are actually in progress.
CPR or teach the untrained bystander to do
“compressions-only CPR” until EMS providers
reach the scene.5
Advanced Cardiac Life Support
Updates
The advanced cardiac life support (ACLS)
updates were developed by addressing 37 PICO
ECG Challenges
questions related to oxygen use, advanced
airways, ventilation rate, carbon dioxide
detection, physiological monitoring, prog-
nostication, defibrillation, drugs, and extra-
corporeal CPR (Table 3).6 Providers should
COR continue to use the maximum feasible amount
IIa of oxygen during CPR. When feasible, the
update recommends physiological monitoring
I
such as quantitative waveform capnography
and arterial pressure monitoring during CPR.
I Use of a bag mask valve device and use of
IIb an advanced airway for oxygenation and
ventilation are considered equivalent from
an evidence standpoint in the update, and
IIa
either can be used depending on the skills of
the provider. When an endotracheal tube is
IIb used, a combination of continuous waveform
capnography and clinical assessment is the
most reliable method of confirming and mon-
IIb itoring tube placement.6
The rate of assisted breathing for all breath-
IIb less patients with an advanced airway is sim-
plified to 10 breaths per minute (one breath
every 6 seconds) to prevent excessive ventila-
I
tion. Biphasic defibrillation is preferred over
monophasic defibrillation, and the single-shock
I approach continues to be preferred over the
stacked-shock method. Vasopressin was
I removed from the general-use pulseless vic-
tim algorithms because its effect is equivalent
to that of epinephrine6; however, there remains
I a use for vasopressin in a bundled approach
to IHCA with intravenous steroids.7 Epi-
nephrine use in nonshockable rhythms was
IIb
upgraded; epinephrine should be used as soon
as feasible in cardiac arrest victims with
IIb nonshockable rhythms (asystole or pulseless
electrical activity). Extracorporeal CPR (extra-
IIb corporeal membrane oxygenation) is now
III
included in the ACLS algorithm for use in
special circumstances.6
The complete emergency cardiac care guide-
lines are available free from the website https://
eccguidelines.heart.org/index.php/circulation
/cpr-ecc-guidelines-2/, including a full-color PDF
version of the highlights of the 2015 guide-
lines update.3 Updates are clearly compared
with the 2010 guidelines, and the rationale
for each change is included for all categories
in the highlights of the PDF document. The
journal Circulation is also allowing free access
to the 2015 update via its website. For those
who have the Circulation iPad application,
both the ILCOR and AHA versions of the
update are available as free downloads.
243
ECG Challenges W W W .AACN ACCON LIN E .ORG

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

2015 Advanced Cardiac Life Support Updates

PICO Question Topic Recommendation COR

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

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

IOM Report on Improving research; delayed translation of research to

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

244
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
Table 4: Institute of Medicine Recommendations to Improve Cardiac Arrest Survivala
Recommendation
Establish a national cardiac arrest registry
Foster a culture of action through public awareness
training
Enhance the capabilities and performance of
emergency medical services
Set national accreditation standards related to
cardiac arrest for hospitals and health care systems
Adopt continuous quality improvement programs
related to cardiac resuscitation
Accelerate research on pathophysiology, new
therapies, and translation of science for cardiac arrest Association, and The US Department of Veterans
Accelerate research on the evaluation and adoption
of cardiac arrest therapies
Create a national cardiac arrest collaborative
a
Based on information from Graham et al.2
(already in place in some states) is one of the
tantalizing strategies suggested.2
The third recommendation is to enhance the
capabilities and performance of emergency
medical systems through the leadership of
the National Highway Traffic Safety Admin-
istration. The IOM charges this administra-
tion with coordination of the various
federal, state, and local agencies involved in
training first responders and paramedics. Goals
include standardized dispatcher-assisted CPR
protocols and development of a consistent
training curriculum across the country. The
fourth recommendation charges The Joint
Commission to collaborate with stakeholders
to develop accreditation standards for health
care facilities specific to care and treatment of
patients with cardiac arrest. The IOM report
notes that no accrediting agency requirements
for hospitals to report outcomes from cardiac
arrest are currently in place.2
With the fifth recommendation, the IOM
charges hospitals, health care systems, and
EMS systems to adopt continuous quality
improvement (CQI) programs. CQI activities
should include data collection, setting of
performance benchmarks, feedback, and
fine-tuning of cardiac arrest protocols to
promote improvement of outcomes. Most
hospitals use the principles of CQI for many
245
ECG Challenges
Responsible Agency
Centers for Disease Control and Prevention
State and local departments of health and education,
training organizations
National Highway Traffic Safety Administration
The Joint Commission
Hospitals, health care systems, and emergency
medical services systems
National Institutes of Health, The American Heart
Affairs
National Institutes of Health, Agency for Healthcare
Research and Quality, US Department of Veterans
Affairs, Patient-Centered Outcomes Research Institute
American Heart Association and American Red Cross
quality indicators, but its use for emergency
resuscitation in hospitals is not optimal.
Recommendation 6 calls for the acceleration
of research in pathophysiology, new therapies,
and translation of science through the leader-
ship of the National Institutes of Health (NIH),
the AHA, and the US Department of Veter-
ans Affairs. The IOM notes that traditional
research methods using multiphase trials may
not be appropriate for cardiac arrest research,
and adaptive trial designs are more likely to
lead to rapid translation of findings.2
Recommendation 7 calls for acceleration
of research related to evaluation and adop-
tion of cardiac arrest therapies through the
leadership of the NIH, the Agency for Health-
care Research and Quality, US Department
of Veterans Affairs, and the Patient-Centered
Outcomes Research Institute. New technolo-
gies and treatments should be applied in a
timely manner and evaluated for their effec-
tiveness in improving resuscitation outcomes.
The final recommendation, and perhaps the
most important one, is to create a national
collaborative for cardiac arrest led by the
AHA and American Red Cross. The collab-
orative will develop strategies, convene work-
ing groups for projects, meet on a regular
basis, and encourage the development of
new technologies.2
ECG Challenges
Role of Nurses in Improving
Cardiac Arrest Survival
The 2015 emergency cardiac care updates
call for a renewed effort to provide timely
and highly effective CPR both inside and out-
side the hospital. Nurses are the first respond-
ers in hospitals and are in the ideal position
to take the lead in ensuring high-quality CPR
for IHCA. As CPR providers, nurses can use
their skills to provide compressions at the
proper rate and depth to promote maximum
effectiveness. Nurses can use their leadership,
communication, and team-building skills to
ensure that other CPR providers use the
principles of high-quality CPR.
Even though most training centers rely on
a retraining schedule of every 2 years, the
emergency cardiac care guidelines note that
the optimal training interval needed to main-
tain BLS and ACLS skills is unknown.8 BLS
skills deteriorate rapidly after a training course,
and it is reasonable to provide more frequent
training for individuals who are likely to treat
victims of cardiac arrest. Nurses can have
an impact on skill maintenance by training
regularly with mock codes, providing the
skill reinforcement and self-efficacy needed
to maintain optimal CPR skills and team
process. Mini practice sessions on nursing
care units using high-fidelity mannequins
could provide opportunities for more frequent
practice and self-guided skill checks. Internet-
based simulation skill practice programs such
as those developed by the AHA could also
aid in skill maintenance.
Nurses are also hospital leaders in continu-
ous quality management and are in a good
position to influence leadership through data
collection, setting benchmarks, and feedback.
Nurses can provide support for CQI and out-
comes measurement related to cardiac arrest
care. Serving as busy direct care providers,
nurses may not feel that they have the time
to “stick around after a code” and review
what went well and what did not, but critical
debriefings are important and lessons learned
should be documented and shared. Nurses
can also promote appropriate use of targeted
temperature management after cardiac arrest
for victims of both OHCA and IHCA in emer-
gency departments and intensive care units.
Nurses are in a good position to support
thoughtful and realistic considerations of
advance directives and patients’ preferences
for resuscitation when appropriate. Most
246
W W W .AACN ACCON LIN E .ORG
in-hospital cardiac arrests (82%)6 are associ-
ated with nonshockable cardiac rhythms,
specifically pulseless electrical activity and
asystole. IHCA numbers are high in part
because of the serious nature of the illness of
hospitalized patients, and one way to decrease
the occurrence of IHCAs is to reduce futile
care. Supporting critically ill individuals’
wishes for peaceful last days and appropri-
ate, timely hospice care can have the second-
ary effect of decreasing the numbers of
in-hospital resuscitations.
Although nurses are ideally positioned in
their roles as bedside caregivers to improve
IHCA outcomes, they need to be creative in
order to have an impact on improving OHCA
survival. One potential area in which nurses
can influence OHCA is in teaching the basics
of CPR to family members of at-risk individ-
uals or providing CPR resources so that they
can learn on their own. The AHA has a con-
cise 1-minute video that teaches hands-only
CPR.9 Such a video is useful for patient and
family education both inside and outside of
the hospital. Nurses can also become politi-
cally active and influence state legislators to
pass legislation promoting citizen education
in CPR and proper use of the AED. Nurses
can participate in research related to knowl-
edge gaps identified in both the emergency
cardiac care updates and the 2015 IOM report.
Summary
Acute and critical care nurses endeavor to
ensure optimal outcomes for patients in all
of their interactions with critically ill persons.
The current deficiencies in outcomes related
to cardiac arrest and the lack of significant
progress in the past 30 years is a concern for
all of us. Nurses can make their optimal
contribution in this area by fully supporting
AHA and IOM initiatives to improve cardiac
arrest outcomes.
REFERENCES
1. Neumar RW, Shuster M, Callaway CW, et al. Part 1:
Executive summary: 2015 American Heart Association
guidelines update for cardiopulmonary resuscitation
and emergency cardiovascular care. Circulation. 2015;
132(18 suppl 2):S315-S367.
2. Graham R, McCoy M, Schultz A, eds; Institute of Medicine.
Strategies to Improve Cardiac Arrest Survival: A Time to
Act. Washington, DC: National Academies Press; 2015.
3. American Heart Association. CPR and first aid: emer-
gency cardiovascular care. Resuscitation Science
website. https://eccguidelines.heart.org/index.php
/circulation/cpr-ecc-guidelines-2/. Published 2015.
Updated 2015. Accessed February 18, 2016.
VOLU ME 27 • N U MB ER 2 • APRIL - JUNE 2016
4. Morrison LJ, Gent LM, Lang E, et al. Part 2: Evidence
evaluation and management of conflicts of interest: 2015
American Heart Association guidelines update for cardio-
pulmonary resuscitation and emergency cardiovascular
care. Circulation. 2015;132(18 suppl 2):S368-S382.
5. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5:
Adult basic life support and cardiopulmonary resusci-
tation quality: 2015 American Heart Association guide-
lines update for cardiopulmonary resuscitation and
emergency cardiovascular care. Circulation. 2015;
132(18 suppl 2):S414-S435.
6. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: Adult
advanced cardiovascular life support: 2015 American
Heart Association guidelines update for cardiopulmo-
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Circulation. 2015;132(18 suppl 2):S444-S464.
247
ECG Challenges
7. Mentzelopoulos SD, Malachias S, Chamos C, et al.
Vasopressin, steroids, and epinephrine and neuro-
logically favorable survival after in-hospital cardiac
arrest: a randomized clinical trial. JAMA. 2013;310(3):
270-279.
8. Bhanji F, Donoghue AJ, Wolff MS, et al. Part 14: Edu-
cation: 2015 American Heart Association guidelines
update for cardiopulmonary resuscitation and emer-
gency cardiovascular care. Circulation. 2015;132(18
suppl 2):S561-S573.
9. American Heart Association. CPR and first aid: emer-
gency cardiovascular care—two steps to staying alive
with hands-only CPR. American Heart Association
website. http://cpr.heart.org/AHAECC/CPRAndECC
/Programs/HandsOnlyCPR/UCM_473196_Hands-Only
-CPR.jsp. Updated 2015. Accessed February 18, 2016.
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