Specialty Nursing: Critical Care

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In the nineteenth and early twentieth century, the majority of nursing training was provided in hospital schools of nursing. Medical knowledge and technology of that time was limited and nurses were taught to provide basic care for all patients. As the patient’s physicians was ‘in charge’ and his orders were to be obeyed, nurses were often told to give a specific medicines at a specific time but not told the name of the medicine. The nurse was told to observe her patient but this did not include the use of a thermometer. Thermometers were glass, expensive and kept on the ward nurses’ desk for use by physicians

Students staffed the hospital units and while a few of the new graduate nurses were hired as head nurses, supervisors and administrator the majority of graduates of the hospital school of nursing were expected to find work outside the hospital. The majority of hospital patients had longer lengths of stay as they remained in the hospital after the acute stage of their illness they remained in the hospital until fully recovered.

When hospitals began hiring registered nurses to staff units; these nurses were considered ‘general duty’ nurses -expected to provide total care for all patients. General duty nurses were expected to be flexible and ‘float’ anywhere in the hospital as well as in hospital outpatient clinics.

Time and two World Wars resulted in increasing medical knowledge and technology. The role and functions of nurses expanded to meet the need of sicker patients. Nursing management, accustomed to moving nurses around to where needed, was met with the need for better staffing to care for sicker and less stable patients. To meet this need, management hired less skilled workers to provide basic care ‘freeing’ the RN to lead a team and provide care that required a higher order of skills.

Nurses began to specialize in areas such as maternity, pediatrics and surgery. After WWII, as Faiman and Lynaugh[i] point out, during the 1950’s, 60’s and 70’s, “essential elements of patient needs, growing medical knowledge, increased governmental funding and changing societal values came together to stimulate a radical and sometimes chaotic reorganization of nursing care in hospitals.”

Early hospitals generally were usually designed with open wards – divided into male and female wards. The open wards with the nurse’s desk in the middle or at one end, allowed nurses to observe all patients. Technology and advances in medicine and surgery resulted in more requiring treatment that could only be provided in a hospital. Patients with private funds and /or insurance began to demand increased privacy. To meet this need, hospitals remodeled some of their open wards and built additions whose design included units with private and semiprivate rooms –ranging from 2 to 4 bed rooms. While patients generally appreciated their privacy, the nurses could no longer sit at the desk and easily observe patients. Those who could afford to do so hired private duty nurses. While hospital administration tended to agreed that there was a need for additional staff but argued that hiring additional higher paid registered nurses would be too costly. Their solution: hire assistants for the nurses to help provide basic care and free the RN to provide skilled care. While nursing assistants could and did make rounds, sicker, less stable patients’ required closer, skilled assessment.

Nurses, conscious of the need for closer observation and meeting the needs of sicker, less stable patients, resolved the problem by assigning these patients to rooms closer to the nurses’ station. As patients improved they were moved to rooms further away. Still, nursing administration continued to consider all registered nurses to possess ‘equal’ skills and continued to ‘float’ staff nurses to wherever they determined the need was greatest. As medical knowledge, skills and technology allowed doctors to save those who, in an earlier time, would not have survived, the role of nurses caring for these patients required specialized skills. ‘Floating’ a nurse to an area which required specialized skills was no longer a realistic option.

Faiman and Lynaugh (1998)[i] quote historian Sydney Halpern “Professionals come into being through the efforts of practitioners who build new types of careers amid changing social and economic circumstances.”The advent of intensive care units provided the environment which gave rise to a new specialty in nursing. Nursing in critical care units such as ICU’s required special skills and knowledge; these were acquired on the job rather than through formal education. Expanded responsibilities and experiential expertise resulted in a gradually developing collegial relationship between intensive care nurses and physicians.”

According to Rose Pinneo[ii]:

“The cardiac monitoring system in a specially designed facility never replaces the personnel. In fact, the most vital element to the success of a coronary care unit is the staff of physicians and nurses involved in patient care. A new outlook in nursing is experienced when a team approach is evident in which each team member fills his own responsibility and shares problems with the others. When physicians and nurses can work together as a team in identifying and solving problems, the effectiveness of the program is enhanced. As a result, patients ' need s are met and all team members derive satisfaction from their work. Because the nurse member of the team is responsible to continuously assess the Patient’s clinical status and make decisions when warranted, she becomes the key to success of the program. To function in such a responsible capacity, she must be equipped with specialized knowledge in recognizing all arrhythmias and the ability to initiate treatment for those which are life-threatening.”

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 [i] Ibid pg 94

[ii] Pinneo, Rose, 1967, A New Dimension in Nursing: Intensive Coronary Care. American Association of Industrial Nurses Journal, February, 1967.p. 7

[i] Fairman, Julie and Joan Lynaught, (1998), Critical care Nursing: A History, University of Pennsylvania Press, pg.1

 

Memories of Critical Care Nursing circa 1969 – 1978.

Writing about the history of critical care nursing and reading “Critical Care Nursing: A History” by Fairman and Lynaugh brought back memories of my experiences working in several intensive care units and having the privilege of being a part of starting the first ICU in a community hospital . My first position as a new graduate of Genesee Hospital School of Nursing in Rochester N.Y. was in their newly opened Intensive Care Unit.

Early Cardiac Monitoring on a General Medical-Surgical Unit

The general medical surgical units in Genesee Hospital were designed using a “T” shape with the top of the “T” having a two long .arms of private and semiprivate rooms; the stem of the “T” was a short hall with semi-private rooms. The nurses’ station was in the center where the ‘arms’ and stem of the “T” joined. In response to demands by physicians and surgeons who wanted their patients to receive closer observation and cardiac monitoring; monitors were placed on utility carts and located in the hall outside the patient rooms. As the rooms were semi-private the hall quickly became crowded with utility carts all with blinking lights and alarms..

The nurses’ station was at the end of the hall – there was no central bank of monitors – so when an alarm went off nurses had to investigate the cause of the alarm. Monitors were checked to see if they were working and if the monitor had the capability to generate a short rhythm strip this was checked, the nurse then entered the room to check the patient. If a patient was restless and their monitor went off too frequently, some staff would turn it off - later the term “alarm fatigue” was coined for this problem. Staffing was increased on this unit and, as students, we were welcomed. As you can imagine, this system was not optimal.

In my senior year we learned that the hospital was converting the old surgical suite to a 10 bed Intensive Care Unit. Our instructor informed (threatened) us - if our grades in the Senior Medical-Surgical course were not good we would not be allowed to work in ICU after graduation. While there were some who desired a career in Pediatrics or OB/GYN, the thought of working n either CCU or ICU appealed to many of my classmates. I had hoped to work in ICU after graduation and, as I was married with two young children, this shift would allow me to be at home during the day. I requested the 12 midnight to 8 am or ‘deep nights’ shift and was hired .After graduation our little family celebrated mother’s new career and took a short vacation to celebrate. Read More - pdf

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Cardiac Monitor on Utility Cart

This equipment was brought out into the corridor .As the rooms were semi-private the hall quickly became crowded with utility carts all with blinking lights and alarms...

Memories of Critical Care: Starting First ICU Community Hospital (Excerpt)

In the mid-1970’s Newark-Wayne Community Hospital planned to expand from less than 100 beds to 235 beds. The addition would include new surgical suite and surgical unit on the second floor; a fourth floor maternity unit and the third floor a skilled nursing / rehab unit[i]. The plan was to transform the former operating room and recovery room into to 10 bed intensive care unit. The small Emergency Room on the first floor would be enlarged. One day the Director of Nurses asked to speak to me privately. Would I work with the Medical Director to develop the new ICU and then become the ICU “Charge Nurse”? As I, along with hospital staff nurses, thought that the current charge nurse on medical unit would assume that position, I expressed my concern to the Director. I was told that she was resigning to help her husband in his new business.[ii]

The intensive care unit was designed and constructed with input from the medical director, nursing and a healthcare facilities consultant. In order to accommodate preexisting column containing plumbing, heat and air conditioning ducts and electrical wiring that could not be moved; the plan included two nurse’s stations. The longer side became the primary patient’s area; the second station developed into a “step down” patient area for patients that required monitoring but were considered less critical. (Read More)

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Author at the primary nurse station –~1975 ~ showing monitors with several patient rooms in the background. The photograph was mounted on a cross section of a tree – that is tree bark at the edge

[i] As I recall, the skilled nursing unit was actually licensed separately under long term care facility regulations’ and was not part of the hospital.

[ii] I later learned that the charge nurse’s husband had just started a ‘waste disposal’ business and she wanted to assist in driving the truck. Privately, I think she was concerned about the amount of time that was involved in starting a unit from ‘scratch’ and wanted more personal time to be home with her children.