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

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1 Journal Club Feature AMERICAN ASSOCIATION OF CRITICAL-CARE NURSES NATIONAL SURVEY OF FACILITIES AND UNITS PROVIDING CRITICAL CARE By Karin T. Kirchhoff, RN, PhD, and Nancy Dahl. From School of Nursing, University of Wisconsin-Madison, Madison, Wis (KTK), and Research Dimensions, Toronto, Ontario (ND). BACKGROUND Little information is available nationally about critical units and nurses. What is known about nurses in hospitals is generally not broken down among all the specialties. OBJECTIVES To describe issues of workforce, compensation, and specific to critical units and nurses who work in them. METHODS The American Association of Critical-Care Nurses conducted a survey of randomly selected facilities with critical units in the United States. Facilities were solicited via to respond to a survey on the World Wide Web and provide information on operations, evaluations, nursing staff reimbursement and incentives, staffing, and quality indicators. Responding facilities also provided contact information for units in the facilities. Those units were surveyed about operations, acuity systems, staffing, policies on visitation and end-of-life, administrative structure, documentation, certification, professional advancement, vacancy/floating, staff satisfaction, orientation, association membership, wages, advanced practice nursing, and quality indicators. RESULTS The initial response rate ( of 8 eligible facilities) was 8.%, and of solicited units nominated by the facilities responded, yielding a.% response rate for the second phase. CONCLUSIONS These survey data define the scope and intensity of services offered and provide more specific figures about staffing issues and unit practices than has been accessible before. Health providers may use this information for benchmarking purposes, especially for instances in which the tables provide data for each particular type of critical unit. (American Journal of Critical Care. ;:-8) The American Association of Critical-Care Nurses (AACN) developed its national critical survey to collect vital information and to assess important US benchmarks against which hospitals can compare their institutions and critical units. The information collected is expected not only to inform participating institutions and the AACN about the unmet needs in critical units but also to provide critical nurses and other involved parties with information they require to bring about the changes needed in the workplace, in clinical practice, To purchase electronic or print reprints, contact The InnoVision Group, Columbia, Aliso Viejo, CA. Phone, (8) 8- or () - (ext ); fax, () -; , reprints@aacn.org. and in the regulations that affect these health providers and the of patients. This AACN survey provides benchmarks against which hospitals and critical units can compare. The types of data collected in this survey are not available elsewhere. Only recently have data from regional or national studies specific to critical begun to be published. Halpern et al provided information on the numbers of beds in intensive units AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

2 (ICUs) in the United States and the costs of intensive relative to national health expenses and the gross domestic product. Information is not available, however, about the severity of the shortage of nurses in critical units, statistics related to quality of in critical units, or other important factors that may vary from one type of unit to another. A search of the Cumulative Index to Nursing and Allied Health Literature with the terms nurse, critical, and statistics and limited to the years to yielded only articles from other countries, about a single state, or articles about nurses and clinical issues. When the search was limited to US journals, only references were found. Although many groups gather and publish comprehensive statistics on hospitals and nurses in the aggregate, few separate out the data for critical units and critical nurses. Reports of hospital statistics that include nursing issues and patient information tend to include only data combined across all units. Rarely are the data presented according to the specific characteristics of critical units. It is therefore difficult to ascertain if the issues and events reported are similar in frequency in all types of units. For example, staffing statistics have not been analyzed by type of unit; no one has compared data from ICUs versus data from telemetry units versus data from postanesthesia units (PACUs). Until now, these data have not been available on a national basis only within individual hospitals. Among the many variables included in the AACN national critical survey were hospital characteristics, unit and staff demographics, certification, formal and continuing education, leadership, decision making, patients outcomes, and staffing. In addition to traditional ICUs, the study included other areas within the hospital where acutely and critically ill patients are d for, such as progressive, telemetry, and step-down units. Data on these types of units, their nurses, and their patients are even scarcer because these units are still relatively new developments. PACUs were also included in the survey because they are an important part of the critical continuum. Planning for this survey began in the summer of. Data were collected from facilities in the fall of and from units in the spring of. In this article, we present part of a more comprehensive report available at or by calling The goal of this initial article is to present the profile of the facilities and units surveyed. Specific areas of the findings will be covered in more depth in future articles. A profile of facilities and units surveyed is presented here. A more complete report is available at Method Sample In addition to collecting data related to the characteristics of critical units and the nurses and patients who fill the units, the survey team also sought to learn about the facilities in which the units are housed. Because many of the variables of interest were hospital-wide rather than specific to a unit, the survey was divided and administered in phases: the facility phase and the unit phase. Contact information for collecting data in the unit-specific phase of the study was obtained during the facility phase. Facility Phase. The survey team purchased a list of hospitals that met the survey criteria from a nationally recognized health organization. Criteria for invitation to participate in the survey included the presence of one or more of the following types of units: ICUs (of any type), step-down units, progressive units, telemetry units, PACUs, and other units where nursing is provided for acutely and critically ill patients. Hospitals with fewer than licensed beds were omitted from the sample. Although these facilities may be listed as having an ICU, many have only or beds designated for stabilization of critically ill patients, and those beds are not always available. Eligible hospitals were then divided up into strata by number of beds (-; -; -; -, and ) and were randomly sampled across the strata. Specifically, quotas were placed on the number of hospitals contacted within various strata; that is, quotas were placed on hospitals with to operating beds, to operating beds, and so on. This process allowed the inclusion of more large hospitals and fewer smaller hospitals than would have been included if proportional sampling had been used; in proportional sampling, small hospitals would have predominated, preventing analyses of differences in hospitals with different numbers of beds. A total of facilities were included in the sample and invited to participate. During the course of the invitation and follow-up process, facilities were deemed ineligible, resulting in a final eligible sample of 8 facilities. Of those eligible facilities, (8.%) participated. When the data were tabulated, they were AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

3 weighted to ensure that the range of facility sizes reflected the range of sizes of US hospitals in general. Both the unweighted and weighted profiles of the facilities are listed in Table. Unit Phase. Responding facilities were asked to submit lists of their critical units, including progressive units, telemetry units, step-down units, and PACUs, and to provide contact information for the unit managers. The responding hospitals listed critical units, and the managers of those units were subsequently sent the unit phase of the survey. Of the units invited to participate, (.%) responded to the questionnaire. Unit data were left unweighted because the numbers of different types of units in US hospitals are unknown. Table Profile of facilities surveyed Feature Organizational control Nongovernment, not for profit Investor-owned, for profit Government, nonfederal hospital Government, federal hospital Facility type General medical and surgical hospital Academic medical center Setting Urban Rural Suburban Facility size * (No. of operating beds) > Percentage of facilities Unweighted Weighted Instrument Two instruments were used: one questionnaire for the facility data and another for the unit data. Respondents to both the facility and unit questionnaires were instructed to report data for a full -month period, preferably from their most recently completed fiscal year. Several steps were taken to improve the reliability and validity of the instruments. Experts in questionnaire design and in critical nursing and critical management designed and tested the instruments. After development of the questionnaires, experts in nursing management reviewed them for correct use of terms and generalizability across settings. Because the questionnaires were converted to pages on the World Wide Web, AACN staff and volunteers tested flow, handling of potential responses, and ease of use. Facility Survey. The facility questionnaire was administered online, and representatives for the invited facilities were ed an invitation with a link to the survey instrument. The questions were presented in a Web format, preprogrammed to allow respondent-selected options, when appropriate, or free text, when necessary. Facility representatives who did not have or who preferred a paper form were provided with a questionnaire on paper. The survey included questions on the following topics: demographics about operations ( questions), evaluations ( questions), nursing staff reimbursement and incentives ( questions), staffing ( questions), quality indicators ( questions), and information on critical units and contact information for critical unit managers to solicit responses to the unit survey. Unit Survey. Also administered online (with a paper option available upon request), the unit survey contained questions on a wide array of topics: operations ( questions), acuity systems ( questions), staffing (8 questions), policies on visitation and endof-life ( questions), administrative structure ( questions), documentation ( questions), certification ( questions), professional advancement ( questions), vacancy/floating ( questions), staff satisfaction ( questions), orientation (8 questions), association membership ( questions), wages or registered nurses (RNs; question), advanced practice nursing (8 questions), and quality indicators ( questions). Procedure After the facilities were randomly selected, a contact person equivalent to the critical director was determined for each facility, and contact information was collected. invitations were sent to these individuals to encourage them to go to the Web site where the facility questionnaire was available. As facility questionnaires were completed and critical units and managers were specified, invitations were sent to the unit contacts to ask them to complete the second phase, the unit questionnaire. Follow-up was implemented by using a number of options. A full-time AACN employee was dedicated to follow up with nonrespondents in both phases of the survey. Special was taken to follow up by e- mail and telephone to encourage participation or to *Mean number of operating beds was 8 unweighted and weighted. Percentages total less than because of rounding. AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

4 determine the reason for nonresponse. Nonresponse was a bigger factor in the facility phase of the survey than in the unit phase. Ultimately, the sample of facility responders was compared with the group of nonresponders to ensure that the sample of responders was representative of the randomized pool of hospitals. The research team validated that the responder facilities did not differ significantly from the nonresponder facilities in terms of available data such as number of beds or geographic distribution. Output from the completed questionnaires was reviewed for consistency with expected responses, and clarification was sought for outliers. Extreme outliers in individual item responses that could not be verified were removed so as not to alter reported means. Results Participating Facilities In total, respondents participated in the facility survey. All participating facilities had or more licensed beds; facilities with fewer beds had been excluded from the study. The actual (unweighted) and weighted profiles of facilities that participated in the study are shown in Table. US hospitals in general and the weighted data include fewer large hospitals than actually participated in the study. Academic and urban hospitals tend to be larger than other facilities. Therefore, their proportions were reduced accordingly when the number of large hospitals in the weighted sample was reduced. The weighted profile of facilities is the profile that should be considered when the facility findings are examined, because the findings reflect this breakdown. According to this profile, the majority of facilities represented in the data are general medical and surgical hospitals (%), nongovernment, not-for-profit organizations (%), from a variety of settings, with a mean of operating beds and 8 licensed beds. Where sample sizes allowed, differences between the various facility types and sizes are indicated. Operations. Not all respondents provided information on inpatient admissions, excluding newborns but including neonatal and swing admissions and readmissions (swing beds are those that can be used to provide either acute or long-term depending on the needs of the community or patients). Participating institutions had a mean of almost admissions per year (Table ). More than two thirds of respondents did not have data available on cost per patient day or were unable to answer the question. Of those responding, the mean cost per patient day was $88 (Table ). The mean cost per adjusted discharge was $. Evaluations. Most hospitals surveyed (8%) were accredited by the Joint Commission on Accreditation Table Descriptive statistics of facilities (N = ) with critical units Facility information Inpatient admissions, excluding newborns, including neonatal and swing admissions (n = 8) Inpatient readmissions, within days (n = ) Inpatient days, excluding newborns, including neonatal and swing admissions (n = 8) Discharges (n = ) Costs, US$* Per patient day (n = 8) Per adjusted discharge (n = ) Mean 8 88 Median 8 8 *More than two thirds of respondents did not answer this question. of Health Organizations (JCAHO). Four percent were not accredited (% did not provide that information). Facilities that were accredited had scored a mean of on their most recent JCAHO survey. At the time of the survey, only % of responding hospitals had been designated Magnet nursing services through the American Nurses Credentialing Center s Magnet program. Seventy-nine percent of facilities did not have Magnet-designated services, but almost half of these (%) said that they planned to apply for such status in the next years. Mainly larger hospitals planned to apply (Table ). Five percent of responding hospitals had Magnet-designated nursing services, although almost half planned to apply. Incentives. Most hospitals offered tuition reimbursement both to RNs for academic programs (8%) and to students in educational programs to become RNs (8%). Almost half of the facilities surveyed (%) had implemented professional development and advancement programs for bedside nurses, primarily clinical ladder systems. A further % had programs in development. Almost half had nursing development programs such as a clinical ladder. Staffing. About half of the responding institutions (%) provided information on numbers of budgeted RN full-time equivalent (FTE) positions. Among those, AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

5 Table Facilities plans for Magnet-designated nursing services Percentage of responding facilities Facility size, No. of beds Facility type Setting Status of facility < (n = ) > (n = ) Academic (n = ) General medical/surgical hospital (n = ) Urban (n = ) Suburban/ rural (n = ) Facility has Magnetdesignated service Facility plans to apply for Magnet designation 8 Percentage of facilities 8 Data not available/no answer* Among those answering (n = ) < days - days - days -8 days - days > days Figure Number of days required to fill a vacant position for a registered nurse. *Questionnaire included a data not available response option that was combined with no answer responses in the data. the numbers of total budgeted RN FTEs ranged up to or more; most facilities (%) had fewer than positions. The median number of budgeted RN FTE positions was, and the mean was. The total number of unfilled budgeted RN FTE positions was up to or more; most hospitals (%) had fewer than unfilled positions. The median and mean numbers of unfilled positions were and, respectively. The means for total and unfilled budgeted positions were slightly higher than the medians because some hospitals had many positions. The mean vacancy rate, calculated by dividing the mean number of unfilled positions () by the mean number of budgeted RN positions (), was.8%. Among the facilities that provided information, the total number of RN staff who had terminated employment during a -month period (including voluntary and involuntary termination) was up to or more. The median number of terminations was, and the mean number was (the mean is higher because a few hospitals had high termination levels). Respondent hospitals reported a mean turnover rate of.8%. The mean turnover rate was calculated by dividing the mean number of terminations () by the mean number of RNs on the payroll (). Almost two thirds of respondents did not have data available on the number of days needed to fill a Hospitals reported a nursing vacancy rate of.8% and a turnover rate of.8%. vacant RN position or were unable to answer the question. Answers varied among those who responded, but it took a mean of days (median days) to fill a vacancy (Figure ). Most hospitals (%) did not have a collective bargaining unit representing their nursing staff. Most facilities surveyed (%) did not have a collective bargaining unit representing their nursing staff. AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

6 Table Critical units represented in this report Type of critical unit Intensive units Medical-surgical Combined intensive/coronary Cardiovascular/surgical Coronary Neonatal Pediatric Medical Surgical Neuro-neurosurgical Trauma Burn Postanesthesia units/recovery rooms Progressive units Telemetry Step-down Intermediate Progressive Other types of critical units Percentage of total sample (N = units) 8 8 Twenty-two percent of hospitals did have collective bargaining units, half with mandatory (closed-shop) membership. Table Percentages of each unit type among small, medium, and large units* Type of unit Intensive units Medical-surgical Combined intensive/ coronary Neonatal Progressive units Telemetry Step-down Unit size, No. of beds Small < (n = 8) 8 Medium - (n = ) Large > (n = ) Participating Units Critical units were defined as any unit in which acute and critically ill patients received. In this survey, the prevalent types of critical units, ICUs, PACUs, and progressive units, were studied (Table ). From the responding facilities, critical units participated in the survey. A little more than half of the units in this study were traditional ICUs. The unit results were not weighted to reflect hospitals nationwide, because the proportions of critical units across US hospitals in general are not well known. Therefore, we caution that the total results for each question are skewed to the activities of the more dominant units in the sample. (For example, the total results are somewhat more representative of the activities of recovery room/pacus, medical-surgical ICUs, and combined intensive/coronary units and less representative of the activities of trauma units and burn ICUs). Differences between ICUs (total) and progressive units (total) and PACUs specifically are discussed throughout this section, because their sample sizes were large enough for categorical analysis. The sample sizes for the other individual units were too small for such analysis. The unit findings also often varied, depending on the size of the unit or the size or location of the hospital the unit was in (eg, urban, suburban, or rural hospitals). Significant differences are noted. Table shows relationships between the types of units in a hospital and the unit s size. Of note, in this table, smaller units (- operating beds) are predominantly ICUs. The larger units with beds or more were mainly progressive units. For this reason, smaller units and ICUs often had common patterns throughout the findings. The same was true of larger units and progressive units. Operations. Almost half (%) of the critical units in the study had fewer than operating beds; the largest concentration of units (% of units) had to beds. Overall, the mean unit size was operating beds (median beds; Figure ). Almost two thirds of the units provided information on their admissions. Overall, the number of critical admissions varied widely from less than to or more. Critical units had a mean of about admissions during a -month period, but, half of the units had fewer than admissions annually. More than three quarters of units did not provide information on readmissions, an important indicator of quality of. Perhaps the respondent did not have access to the information or that information was not collected in the unit. Of the units for which information was provided, 8% had had no readmissions within 8 hours during the preceding -month period. Among the few remaining respondents, the number of readmissions within 8 hours varied widely from to or more during a -month period. The median number of readmissions was, and the mean was 8 *Numbers in table are percentages of each type of unit in each unit size range. For example, 8% of small (< bed) units are intensive units. Percentages do not total. All other units represented in this study and listed in Table are equally prevalent among smaller and larger units. A bold number within a category (eg, within Unit size) is significantly higher than nonbold numbers within the same category. An italic number is significantly higher than nonitalic numbers, but significantly lower than bold numbers. 8 AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

7 Percentage of units 8 < beds - beds - beds - beds - beds > beds Percentage of units* Adult Recovery/ intensive Progressive postanesthesia No. of beds (n = 8) (n = ) (n = ) < 8-8 > Mean Figure Total number of operating beds in the unit. * A bold number within a category (eg, within intensive ) is significantly higher than nonbold numbers in other units (eg, progressive ). Numbers of units do not total because of no answer responses, units unspecified, and exclusion of atypical units (eg, neonatal and pediatric intensive units). (the mean was skewed high because a few critical units had high numbers of readmissions). Among the % of respondents who provided information, numbers of inpatient days for their units were as high as or more in a -month period. The median number of inpatient days was 8, and the mean was 88 (the mean was skewed slightly higher than the median because some units had very large numbers of inpatient days). Seventy percent of respondents provided information on the mean length of stay in their units. In most critical units (%), the length of stay was between and days. The longest stays were in larger critical units (% of patients in the largest units stayed for days versus % in the smaller units) and in urban hospitals (which are more likely to have the larger critical units; Table ). Table also shows how numbers of operating beds, admissions, and inpatient days varied depending on unit size and hospital setting. Naturally, larger units had more operating beds, admissions, and inpatient days; mean values among smaller and larger units are shown in the table. Hospital size had little relation to the number of beds in a unit, except in the smallest hospitals. Small hospitals (- operating beds) had a mean of beds per critical unit. Larger hospitals had a mean of or beds per critical unit, regardless of whether the facility had to beds, to beds, or more than beds. Acuity Systems. Forty-two percent of critical units in the study used a formal acuity system. Formal acuity systems were more prevalent in the largest hospitals (> beds) and urban hospitals (which tended to be the larger ones). A wide variety of systems were in place. In about in critical units surveyed, respondents had seen an increase in patients acuity in the preceding year or had perceived that acuity at the time of patients transfer or discharge was higher than it had been year earlier. Respondents from the larger units ( or more operating beds) and urban/suburban hospitals were most likely to have noticed these changes in acuity (although urban facilities were less likely than suburban facilities to have experienced higher-acuity transfers/discharges). Increases in patients acuity were reported equally in ICUs, progressive units, and PACUs. But, progressive units (and ICUs, directionally) were more likely than PACUs to see patients being transferred or discharged with higher acuity (Table ). The same trend was evident in terms of chronic critical patients. Almost half of units (%) had seen an increase in the percentage of longer-term chronic critical patients who could not be placed elsewhere (eg, patients receiving long-term mechanical ventilation, patients with complex wound management, and patients in stable condition who were receiving intravenous vasoactive medications). Again, this increase had occurred more in urban and suburban hospitals than in rural facilities. Respondents from units in smaller hospitals (up to operating beds) and the largest hospitals (> beds) were more likely to have noticed an increase than were respondents from mid-sized facilities (- beds; Figure ). Staffing. In most of the critical units surveyed (%), the nurse manager or assistant nurse manager coordinated staffing. A few facilities coordinated staffing either through a staff-run scheduling committee or a staff nurse coordinator; these methods of coordinating AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

8 Table Unit statistics by type of facility and unit* Unit size, No. of beds Setting Unit statistic < - > Urban Suburban Rural No. of operating beds < - - > Mean (n = 8) 8 (n = ) 8 (n = ) (n = 8) 8 (n = ) (n = ) 8 No. of admissions, mean (n = ) (n = ) (n = 8) (n = ) (n = ) (n = ) No. of inpatient days, mean (n = ) (n = ) (n = ) (n = ) 8 (n = ) 8 (n = ) Length of stay, days < - > Mean (n = ) 8 (n = 8). (n = ) (n = ) (n = ) 8 (n = ) * This table includes results from questions. The total numbers of respondents for each question are shown in parentheses. Most numbers in the body of the table are percentages of respondents reporting that statistic. The rows of mean values are actual numbers of that statistic rather than percentages of respondents. A bold number within a category (eg, within Unit size, Setting) is significantly higher than nonbold numbers within the same category. An italic number is significantly higher than nonitalic numbers, but significantly lower than bold numbers. Table Perceived changes in patients acuity in the preceding year by type of facility Unit type Percentage of all units or facilities responding* Change Patients acuity had Increased Stayed the same Decreased Adult intensive (n = 8) Progressive (n = ) 8 Recovery/ postanesthesia (n = ) 8 Unit size, No. of beds < (n = 8) - (n = ) > (n = ) Urban (n = 8) Setting Suburban (n = ) 8 Rural (n = ) Were patients being transferred or discharged with higher acuity? Yes No * A bold number within a category (eg, within Unit type, Unit size, Setting) is significantly higher than nonbold numbers within the same category. were more prevalent among smaller or rural hospitals or government nonfederal hospitals (as opposed to nongovernment, not-for-profit centers). Respondents were asked which factors they considered in determining the number of nurses needed for their basic staffing plans. Of the factors listed in the survey, the most commonly considered factor (by 88% of respondents) was the expected patient census. The need for specialized skills (eg, balloon pumps, dialysis) and the skill mix of the staff ranked next in importance. A formal acuity system had the lowest priority. The few PACUs were less inclined than ICUs and progressive units to select any of the factors. Smaller units (up to operating beds) were more AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

9 Stayed the same Decreased Increased Feature of Percentage of facility respondents* Size, No. of beds > Setting Urban 8 Suburban Rural Figure Percentage of respondents who had perceived changes in the number of long-term chronic critical patients in the preceding year. * Bold numbers within a category (eg, facility size, setting) are significantly higher than nonbold numbers in the same category. likely than large units to take into account the need for specialized skills. Formal acuity systems were more of a priority to urban hospitals, where these systems were more established, than to suburban/rural facilities. Still, acuity systems had the lowest priority even among urban hospitals (Table 8). The majority of respondents thought that the staffing had not been optimal up to % of the time in terms of the match between patients acuity and the nurses skill level or mix. Most respondents thought that the staffing had not been optimal up to % of the time in terms of the match between patients acuity and the nurses skill level or mix. Nine percent of critical units participating in the study had recently been required to close beds for more than days because of insufficient numbers of RNs. This finding was consistent among all types and sizes of units. Overall, most critical units (%) had a policy that patients being transported out of the unit must be accompanied by a unit nurse. The number of transports of patients out of the unit for tests or procedures varied considerably and depended on the unit. Respondents were asked what they used when they needed to adjust staffing to manage sudden or emergency admissions or sudden increases in patients acuity. Of the options given in the survey, the most commonly used strategies (used by % of units or more) were calling in regular staff RNs on their days off, calling in regular staff RNs early, and juggling current RN staff to make do. Borrowing ( floating ) RNs from other critical areas was the next-mostused alternative (by just more than half of the units). Floating RNs from other noncritical areas was the least favored option. The predominant way that units in the study managed floating among their staff was via cluster unit floating; staff were required to float, but in a designated unit only (% of units). Among the remaining units, practices were equally prevalent: in open units (%), staff were required to float to any unit within the facility; in closed units (%), staff were not required to float outside of their unit. The strategies used to manage sudden or emergency situations or to manage floating varied considerably by type of unit and hospital. Progressive units were less likely than ICUs and PACUs to use on-call systems and were more likely to float RNs from non critical areas. ICUs and progressive units were more likely than PACUs to use several different approaches for managing sudden admissions or increases in patients acuity. They were more likely than PACUs to call in regular staff RNs on their days off, to float RNs from other critical areas, or to use agency nurses. The reasons were not addressed in the survey. This finding may be linked to the fact that the few PACU nurses in the study used other strategies that were not listed among the options for that item. Or, perhaps PACUs did not adjust staffing for sudden situations to the same degree that ICUs and progressive units did. Similarly, rural hospitals were less likely than urban or suburban hospitals to use many of the strategies listed. Again, the reasons for this finding were not addressed in the survey. Perhaps fewer rural hospitals AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

10 Table 8 Factors considered in determining the number of nurses needed for basic staffing plan by type of facility and unit Unit type Percentage of units or facilities responding* Factor considered Expected patient census Specialized skills needed Skill mix of nurses Formal acuity system Other Adult intensive (n = 8) Progressive (n = ) 8 Recovery/ postanesthesia (n = ) 8 Unit size, No. of beds < (n = 8) - (n = ) > (n = ) Urban (n = 8) 8 Setting Suburban (n = ) Rural (n = ) * A bold number within a category (eg, within Unit type, Unit size, Setting) is significantly higher than nonbold numbers within the same category. than urban/suburban hospitals had increases in the acuity of patients or in the number of patients requiring long-term chronic critical. Or, perhaps rural hospitals used other approaches that were not listed in the questionnaire. Or, perhaps they did not need to make staffing adjustments to the same degree as urban and suburban hospitals did. Visitation Policies. In the survey, respondents were asked what their unit s family visitation policy was and were given alternatives to select from, with an option to write in another response (these other responses were quite diverse). The family visitation policies given were as follows: open on a scheduled basis only, open except for rounds and/or changes in shift reports, and open at all times. Family visitation policies varied considerably by unit type and size. Units that were open on a scheduled basis only (eg, hourly, every hours for a specified time, or some other schedule) were almost always ICUs or progressive units; very few respondents from PACUs reported having this policy (Figure ). Most intensive units were open for family visitation on a scheduled basis only; larger units were more likely to be open all the time. Policies varied even within unit type. Most ICUs were open on a scheduled basis only (%). But, ICUs also commonly had a policy of being open except for rounds and/or changes in shift reports (%). The percentage of progressive units that were open at all times (%) did not differ significantly from the percentage that were open on a scheduled basis only (%). Not surprisingly, most (8%) of the few PACUs in this study used some other family visitation policy than the just listed (Figure ). Smaller units (< operating beds) were more likely than large units to have a policy of being open except for rounds and/or changes in shift reports. Larger units ( beds) were more likely than other units to be open at all times. End-of-Life Care. Respondents were also asked what policies they initiated for managing patients when the goals of changed from aggressive to comfort. Again, they were given alternatives to select from, with an option to write in another response (these other responses varied widely). The comfort policies that they were given were palliative standards, end-of-life standards, and hospice services in the unit. Comfort policies varied considerably by type of unit. Progressive units (8%) and ICUs (%) were most likely to have comfort policies. Among both progressive units and ICUs that did have policies, palliative standards and end-of-life standards were equally prevalent. Progressive units were more likely than ICUs to also implement hospice services in the units (Figure ). Most PACUs (%) did not have comfort standards or those policies were not applicable to their units. Those that did have policies tended to use policies that differed from the policies listed in the questionnaire. In terms of facility types, smaller hospitals (- operating beds) were more likely to use hospice services in the unit than were larger hospitals. Urban and rural facilities were most likely to initiate palliative standards, whereas suburban hospitals implemented a variety of approaches. Nongovernment, notfor-profit institutions were less likely than government, nonfederal facilities to have any comfort policies. Overall, about in critical units reported using some type of end-of-life protocol, and this find- AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

11 Percentage of units 8 Open on scheduled basis only Open except for rounds/shift changes Adult intensive (n = 8) Percentage of responding units* Unit type Progressive (n = ) 8 Recovery/ postanesthesia (n = ) Unit size, No. of beds - (n = ) < (n = 8) > (n = ) Open at all times 8 Other 8 Figure Family visitation policy. * A bold number within a category (eg, within Unit type, Unit size) is significantly higher than nonbold numbers within the same category. Numbers of units do not total because of no answer responses, units unspecified, and exclusion of atypical units (eg, neonatal and pediatric intensive units). Palliative standards End-of-life standards Hospice services in the unit Physician writes orders Transfer to appropriate unit Other None Not applicable Percentage of units 8 Figure Services initiated when goals changed to comfort. Percentage of units that initiated each service* Adult intensive (n = 8) Progressive (n = ) Totals exceed % because of multiple mentions. * A bold number within a unit (eg, within intensive ) is significantly higher than nonbold numbers in other units. An italic number is significantly higher than nonitalic numbers, but significantly lower than bold numbers. Numbers of units do not total because of no answer responses, units unspecified, and exclusion of atypical units (eg, neonatal and pediatric intensive units). Recovery/ postanesthesia (n = ) ing was consistent across most types of units and facilities studied. The one exception was among urban hospitals, where an end-of-life protocol was somewhat more prevalent than it was in suburban facilities. Administrative Structure. Slightly more than half of the units (%) surveyed had formalized shared governance through written bylaws and staff-directed committees, mostly at a facility-wide level. Units with a formalized structure were more likely to be PACUs (particularly when compared with progressive units), rural hospitals, and smaller units with fewer than operating beds. AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

12 Table Percentages of units responding in which nurses were recognized for activities* Recognition Public acknowledgment Bonus Plaque Letter Gift None Other Certification Association membership < 8 Research/ scholarly activities Volunteer activities Years of service at facility *Totals exceed % because of multiple mentions. Less than of %. Documentation. Overall, % of the critical units surveyed used an electronic documentation system. These units were more likely to be ICUs and progressive units, smaller hospitals (up to operating beds), suburban hospitals, and nongovernment, not-for-profit hospitals. The majority of critical nurses (8%) could access the Internet in their units as a resource for their nursing practice. Nurses in large hospitals (> operating beds), mid-sized hospitals (- beds), and mid-sized units (- beds) had even greater Internet access than did other nurses. Recognition. Nursing recognition awards were presented in 8% of the units in the study. The awards were often presented on multiple levels, usually including the facility level (% of respondents), but nurses were also commonly awarded at the nursing department (%) and unit levels (%). Nursing recognition awards had a variety of forms, depending on what nurses were being recognized for. Public acknowledgment was an often-used reward across different activities. Many facilities rewarded a particular achievement in several ways. As indicated in Table, Almost all facilities rewarded nurses for years of service at the facility, usually via public acknowledgment or a gift (about two thirds of facilities) or often with a letter (%). About three quarters of facilities recognized nurses for certification, mostly through public acknowledgment (% of facilities) or bonuses (%). About half to two thirds of facilities rewarded nurses for volunteer and research/scholarly activities, respectively, again usually through public acknowledgment. About in facilities did not recognize association membership at all. (Smaller units and suburban/ rural hospitals were less likely to reward membership than were larger units with beds and urban hospitals.) Similarly, about 8 in facilities surveyed offered no financial support for association membership, and this finding was consistent across all types and sizes of facilities. Professional Advancement. Most of the hospitals in the study (8%) offered financial support to nurses for continuing education. This support most often was in the form of paid registration or paid time off for local or regional/national meetings (in about two thirds of units). Progressive nurses were less likely than ICU or PACU nurses to receive support for continuing education. The same was true for nurses in government nonfederal hospitals, compared with nurses in nongovernment not-for-profit facilities. Small to midsized units ( operating beds) were more likely than large units to offer paid time off for meetings. Filling Vacancies. The total number of budgeted RN FTE positions in the critical units in the recent months before the survey was up to or more (mean positions). The total number of open/unfilled budgeted RN FTE positions (excluding contract) was up to or more. But % of units had minimal numbers of unfilled positions. Specifically, % had no unfilled positions and % had or open positions. On average, units had open/unfilled positions. The mean vacancy rate was.8%. This rate was slightly higher than the.8% vacancy rate reported facility-wide. The vacancy rate was calculated by dividing the mean number of unfilled positions () by the mean total number of budgeted RN positions (). The actual total number of RNs (individuals) in the units was up to or more; about half of the units had between and RNs. The mean number of individuals working in the units was 8. Total numbers of RN FTEs working in the units seemed lower than the total number of RNs working there; this finding was not surprising because of the number of part- AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

13 Table Orientation to critical by unit type and facility size* Orientation Total (N = ) Adult intensive (n = 8) Unit type Progressive (n = ) Recovery/ postanesthesia (n = ) - (n = ) Facility size, No. of beds > (n = ) Not-yet-licensed students have a clinical rotation on unit Unit hires newly licensed registered nurses Newly licensed registered nurses A standardized program is used for all orientees Preceptors are assigned to each orientee Mean length of orientation, days < > New-hire experienced registered nurses A standard program is used for all orientees Components are individualized for each nurse Preceptors are assigned to each orientee Mean length of orientation, days < > * A bold number within a category (eg, within Unit type, Facility size) is significantly higher than nonbold numbers within the same category. time staff (fewer units had RN FTEs). But these numbers should be viewed with some discretion because % of the units did not provide information on RN FTEs. Thirty-four percent of units used RN FTEs that were contract staff (including travelers and local external agencies). Slightly more than half of the units surveyed (%) reported that their numbers of budgeted RN positions had not changed since the previous - month period. Twenty-seven percent of units, however, had experienced an increase in the number of budgeted positions; these were more likely in suburban facilities than in urban/rural ones. The number of budgeted RN positions had decreased among % of units, particularly units in larger hospitals (the number of positions in smaller hospitals was more likely to have remained unchanged). The turnover rates for ICUs, progressive units, and PACUs were.%,.%, and.%, respectively. Turnover rates were determined by dividing the mean number of terminations by the mean number of RNs on the unit s payroll. More than half of the respondents did not have data available on the number of days required to fill a vacant RN position in their units or were unable to answer the question. Among those who provided information, it took a mean of days to fill a vacant post, although some units required more than days. Progressive units (mean days), followed by ICUs (mean days), took the longest to fill vacancies. PACUs were able to fill vacant RN positions quickly in comparison (mean days). Orientation Programs. About 8 in units in the study reported having clinical rotations of not-yetlicensed students in their units and hiring newly licensed RNs (Table ). Respondents from more than 8% of units reported having standardized orientation programs for all AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

14 newly licensed RNs and for all newly hired experienced RNs. Almost all units assigned preceptors to all orientees. In most units, components of the orientation were individualized for each newly hired experienced RN. But, individualization was not quite as commonly practiced as were implementing standardized programs and assigning preceptors (Table ). ICUs and progressive units and larger hospitals (> beds) were more likely to have orientation programs in place for newly licensed RNs. Almost all units, including recovery room/pacus, had standardized orientation programs for newly hired experienced RNs. But larger hospitals were more likely to have individualized components for each experienced nurse. The orientation programs for newly licensed RNs range varied considerably in length; some exceeded days. The median length was days, and the mean length was 8 days (the mean was skewed higher by a few facilities that had lengthy programs). The longest orientation programs were more likely to be run by ICUs; a higher proportion of progressive units than ICUs had programs that lasted only to days. (Many of the few PACUs in this study did not provide information, making any comparisons difficult.) Orientation programs for newly hired experienced RNs were shorter than such programs for newly licensed RNs. Some programs lasted more than days; more than one third of programs lasted between and days. The mean duration of an orientation program was days. Again, the longest programs were more likely to be conducted by ICUs and also PACUs; a higher proportion of progressive units had programs that lasted days or less. Larger facilities (> operating beds) and urban and rural hospitals were also more likely than other hospitals to run longer programs for newly hired experienced RNs. Wages. Survey respondents reported that the mean hourly wage of RNs employed in the unit at entry level was $. The entry-level wage paid most often was $8 to $ per hour (% of units). With years of experience, the mean hourly wage of RNs increased to $ (with most nurses earning between $ and $). Wage rates were the same among nurses who worked in ICUs, progressive units, and recovery rooms/pacus. Government nonfederal hospitals paid higher wages than did nongovernment, not-for-profit institutions. Hospitals with to operating beds paid the lowest wages. Entry-level wages were the same among small and large units and among urban, suburban, and rural hospitals. However, more of a wage discrepancy was apparent among experienced nurses. With years of experience, RNs in large units earned more than did those in the smallest units (< beds). Experienced RNs in urban and suburban facilities earned higher wages than did those in rural hospitals. Advanced Practice Nursing. Forty-two percent of critical units surveyed had hospital-employed clinical nurse specialists allocated to their units. In almost all cases, one clinical nurse specialist was assigned to the unit. Far fewer units (%) had been allocated hospital-employed nurse practitioners, especially smaller units. It was more often the larger units ( operating beds) that were assigned nurse practitioners. The number of nurse practitioners assigned to a unit varied among the small number of units that had them. A greater proportion of ICUs and progressive units than PACUs had clinical nurse specialists assigned to them. Units in larger hospitals (> operating beds), urban hospitals, and academic medical centers (which tended to be larger), and government nonfederal facilities were more likely than units in other institutions to have a clinical nurse specialist. We found no significant relationship between the size of a unit and the presence of a clinical nurse specialist. Most clinical nurse specialists earned an hourly wage at entry level of between $ and $, for a mean wage of $ per hour. With years of experience, the mean hourly wage for clinical nurse specialists had increased to $ (with wages mostly concentrated between $ and $ per hour). The number of respondents providing information about nurse practitioners wages was too small for analysis. Almost half of the units had a clinical nurse specialist allocated to their unit, whereas only % had been allocated nurse practitioners. Conclusion More details about facilities and units serving critically ill patients are now available as a result of the AACN national critical survey. We have more information about the scope and intensity of services offered and more specific figures about staffing issues and unit practices than has been accessible before. Health providers can use this information for benchmarking purposes, especially in instances in which the tables provide the information for the same type of critical unit. The methods for obtaining this information have now been tested, and adjustments can be made to increase response rates in future surveys. AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

15 This article offers a broad overview of the findings, and additional articles are planned that will focus more closely on specific areas of the findings, for example, the similarities and differences we validated between ICUs and progressive units. The full report of findings from the AACN national critical survey is available through AACN at or by calling ACKNOWLEDGMENTS Mi-Kyung Song and Rick Voland assisted with initial data analysis, and Elfa Gretarsdottir assisted with preparation of the tables and figures. Commentary by Mary Jo Grap (see shaded boxes). REFERENCE. Halpern NA, Pastores SM, Greenstein RJ. Critical medicine in the United States 8-: an analysis of bed numbers, use, and costs. Crit Care Med. ;:-. AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.

16 JOURNAL CLUB ARTICLE DISCUSSION POINTS In a journal club, research articles are reviewed and critiqued. General and specific questions help to aid journal club participants in probing the quality of the research study, the appropriateness of the study design and methods, the validity of the conclusions, and the implications for practice. When critically appraising this issue s AJCC journal club article, American Association of Critical-Care Nurses National Survey of Facilities and Units Providing Critical Care, consider the questions and discussion points listed below. Study Synopsis: This study reports on the findings of AACN s national critical survey, which was developed to provide information focusing on critical nursing, including issues related to workforce, compensation, and issues specific to critical units and nurses. Descriptive survey information was obtained from critical units of hospitals nationwide. Participants completed facility and unit survey questionnaires that assessed information on operations, staffing, quality indicators, acuity systems, administrative structure, and other aspects of nursing practice. Responding facilities include academic and general medical and surgical hospitals in urban, suburban, and rural settings with from to more than beds. The results of the survey provide important information on acute and critical nursing practice including staffing, documentation systems, shared governance, wages, and nursing recognition awards; unit characteristics include orientation programs, family visitation policies, end-of-life protocols, and characteristics of patients such as length of stay and acuity levels. The results of the national survey provide data on facilities and units serving critically ill patients that were not previously known. Additionally, the survey results offer important information on critical practices that can be used for benchmarking purposes. A. Description of the Study What were the objectives of the research? What specific information was collected on facility and unit practices? B. Literature Evaluation What previous research has been conducted evaluating critical practices? What contributions does the current study make to the research literature? C. Sample How were specific units and hospitals identified for study participation? D. Methods and Design What specific instruments were used in the study? How were the instruments developed and tested? What was the procedure used to contact sites and obtain survey responses? E. Results How did the respondents compare to national facilities with respect to size and geographic location? Why was a weighted profile developed? What were important facility-based findings? What were important unit-based findings? F. Clinical Significance What are implications of the survey for critical nursing? Information From the Authors: Karin Kirchhoff, RN, PhD, lead author of this journal club article, provided additional information about the study. She relates AACN was the initiator of this research effort. We developed the topics to be covered and the questions to be used. This paper reports on the major findings of the study. Kirchhoff adds that the study results have important implications for critical nursing. She states The data can be useful for benchmarking. For example, the study provides information on what units are doing about traveling with patients for procedures whether it is a common practice, and if not, what could we do instead? Kirchhoff reports that additional information on the study is available. She relates The full study report is available from AACN. There are many data tables that provide additional study information. She adds Another use for the study data is to query the results as issues arise in the unit so that you can see what others might have thought of, for instance with respect to nursing staffing, or what units have in place for EOL [end-of-life] issues. Implications for Practice: This national survey provides helpful information on facilities and units providing to critically ill patients. The study findings provide information to institutions as well as to the critical community on aspects of critical nursing, unit, and facility practices. Kirchhoff highlights the significance of the national AACN survey and adds This is the first report of some of these variables by type of unit. Also the inclusion of other units such as PACUs [postanesthesia units] gives us a better idea of how the patient transitions and what the issues are there. Journal Club feature commentary is provided by Ruth Kleinpell. 8 AMERICAN JOURNAL OF CRITICAL CARE, January, Volume, No.