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Aims: To examine the organisation of the nursing workforce in intensive care units and identify factors that influence how the workforce operates., Background: Pre-pandemic UK survey data show that up to 60% of intensive care units did not meet locally agreed staffing numbers and 40% of ICUs were closing beds at least once a week because of workforce shortages, specifically nursing. Nurse staffing in intensive care is based on the assumption that sicker patients need more nursing resource than those recovering from critical illness. These standards are based on historical working, and expert professional consensus, deemed the weakest form of evidence., Methods: Focus groups with intensive care health care professionals (n = 52 participants) and individual interviews with critical care network leads and policy leads (n = 14 participants) in England between December 2019 and July 2020. Data were analysed using framework analysis., Findings: Three themes were identified: the constraining or enabling nature of intensive care and hospital structures; whole team processes to mitigate nurse staffing shortfalls; and the impact of nurse staffing on patient, staff and intensive care flow outcomes. Staff made decisions about staffing throughout a shift and were influenced by a combination of factors illuminated in the three themes., Conclusions: Whilst nurse:patient ratios were clearly used to set the nursing establishment, it was clear that rostering and allocation/re-allocation during a shift took into account many other factors, such as patient and family nursing needs, staff well-being, intensive care layout and the experience, and availability, of other members of the multi-professional team. This has important implications for future planning for intensive care nurse staffing and highlights important factors to be accounted for in future research studies., Implications for Nursing Management: In order to safeguard patient and staff safety, factors such as the ICU layout need to be considered in staffing decisions and the local business case for nurse staffing needs to reflect these factors. Patient safety in intensive care may not be best served by a blanket 'ratio' approach to nurse staffing, intended to apply uniformly across health services., (© 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.)

Aims: To understand how COVID-19 affected nurse staffing in intensive care units (ICUs) in England, and to identify factors that influenced, and were influenced by, pandemic staffing models., Design: Exploratory qualitative study., Methods: Semi-structured, online interviews conducted July-September 2020 with regional critical care leaders including policy leads (n = 4) and directors/lead nurses (n = 10) across critical care networks in England., Findings: The six themes emerging from the framework analysis illustrate how the pre-pandemic ICU culture influenced ICU staffing models during the pandemic. Changes in staffing impacted on the workforce and the care delivered, whilst it was necessary to learn from, and adjust to, a rapidly changing situation. Variation across and between networks necessitated variation in responses. The overwhelming outcome was that the pandemic has challenged the central tenets of ICU nurse staffing., Conclusions: Pandemic nurse staffing models resulted in changes to ICU skill-mix and staffing numbers. Factors such as the impact of nurse staffing on care practices and on the workforce need to be taken into account when developing and testing future nurse staffing models for ICU. The extent to which ICUs will return to former staffing models is not yet known but there seems to be an appetite for change., Impact: In common with many countries, nurse staffing in English ICUs was adapted to address surge requirements during the COVID-19 pandemic. Findings highlight the challenge COVID-19 presented to pre-pandemic ICU nurse staffing guidelines, the impact on patient and staff well-being and the potential legacy for future staffing models. Study findings have implications for ICU nurse managers, researchers and policy makers: nurse staffing models need to be adaptable to the local context of care and future research should investigate the impact of different models on patients, staff and health service outcomes., (© 2021 John Wiley & Sons Ltd.)

Objective: To determine associations between variations in registered nurse staffing levels in adult critical care units and outcomes such as patient, nurse, organisational and family outcomes., Methods: We published and adhered to a protocol, stored in an open access repository and searched for quantitative studies written in the English language and held in CINAHL Plus, MEDLINE, PsycINFO, SCOPUS and NDLTD databases up to July 2020. Three authors independently extracted data and critically appraised papers meeting the inclusion criteria. Results are summarised in tables and discussed in terms of strength of internal validity. A detailed review of the two most commonly measured outcomes, patient mortality and nosocomial infection, is also presented., Results: Our search returned 7960 titles after duplicates were removed; 55 studies met the inclusion criteria. Studies with strong internal validity report significant associations between lower levels of critical care nurse staffing and increased odds of both patient mortality (1.24-3.50 times greater) and nosocomial infection (3.28-3.60 times greater), increased hospital costs, lower nurse-perceived quality of care and lower family satisfaction. Meta-analysis was not feasible because of the wide variation in how both staffing and outcomes were measured., Conclusions: A large number of studies including several with high internal validity provide evidence that higher levels of critical care nurse staffing are beneficial to patients, staff and health services. However, inconsistent approaches to measurement and aggregation of staffing levels reported makes it hard to translate findings into recommendation for safe staffing in critical care., Competing Interests: Declaration of Competing Interest This paper presents independent research funded by the National Institute for Health Research (Programme Development Grants, Safe staffing in ICU: development and testing of a staffing model, NIHR200100). The views expressed in this publication are those of the author(s) and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care, neither of whom have had involvement in any aspect of the design, data collection, synthesis, interpretation or writing of, this review., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Purpose: We examined the concerns that nurses perceive patients to have, whether these are congruent with patients' concerns and whether they vary according to cancer site. We also examined Distress Thermometer scores according to cancer site., Method: A cross-sectional survey design: (i) secondary analysis of an existing Holistic Needs Assessment (HNA) and Distress Thermometer (DT) dataset was used, (ii) a survey of specialist nurse teams to identify their perceptions of patient concerns. Data collected between January 2015 and June 2016 from the HNA database from one NHS Trust in England (n = 1233 patients). Specialist nurse teams for breast, colorectal, gynaecology, skin and urology cancers identified the concerns that they perceived their patients would report., Results: The HNA showed high internal consistency (Cronbach's alpha 0.86). Across the five cancer sites, nurses identified between 3 and 6 of the top ten concerns (TTC) expressed by patients, with wide variation across cancer sites. Nine of the TTC were significantly associated (p < 0.05) with a specific cancer site. The breast and gynaecological cancer groups both recorded significantly higher median Distress Thermometer scores than the urology, skin and colorectal cancer groups (Kruskall-Wallis χ 2 (4, n = 1228) 186.695, p=<.01)., Conclusions: One of the aims of the eHNA is to enable service delivery appropriate to patient needs. Our findings suggest that this will only be achieved if eHNA is examined, and services developed, by individual cancer site. The misconception of patient needs by specialist nurses underscores the importance of review of information provided by patients during consultations., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Aims and Objectives: To explore how nurses navigate communication with families during withdrawal of life-sustaining treatment in intensive care., Background: Death in the intensive care unit is seldom unexpected and often happens following the withdrawal of life-sustaining treatment. A family-centred approach to care relies on the development of a therapeutic relationship and understanding of what is happening to the patient. Whilst previous research has focused on the transition from cure to palliation and the nurse's role in supporting families, less is known about how nurses navigate communication with families during treatment withdrawal., Design: A qualitative descriptive approach was used. Semi-structured focus groups were conducted with adult critical care nurses from four intensive care units, two in Australia and two in New Zealand., Results: Twenty-one nurses participated in the study. Inductive content analysis revealed five key themes relating to how nurses navigate family communication: (1) establishing the WHO; (2) working out HOW; (3) judging WHEN; (4) assessing the WHAT; and (5) WHERE these skills were learnt., Conclusions: Navigating an approach to family communication during treatment withdrawal is a complex and multifaceted nursing activity that is known to contribute to family satisfaction with care. There is need for support and ongoing education opportunities that develop the art of communication in this frequently encountered aspect of end-of-life care., Relevance to Clinical Practice: How nurses navigate communication with families during treatment withdrawal is just as important as what is communicated. Nurses need access to supports and education opportunities in order to be able to perform this vital role., (© 2016 John Wiley & Sons Ltd.)

Aim: The aim of this study was to conduct an integrative review on how nurses prepare families for and support families during withdrawal of life-sustaining treatments in intensive care., Background: End-of-life care is widely acknowledged as integral to the practice of intensive care. However, little is known about what happens after the decision to withdraw life-sustaining treatments has been made and how families are prepared for death and the dying process., Design: Integrative literature review., Data Sources: MEDLINE, CINAHL Plus, PsychINFO, PUBMED, Scopus, EMBASE and Web of Knowledge were searched for papers published between 2000-May 2015., Review Methods: A five stage review process, informed by Whittemore and Knafl's methodology was conducted. All papers were reviewed and quality assessment performed. Data were extracted, organized and analysed. Convergent qualitative thematic synthesis was used., Results: From an identified 479 papers, 24 papers were included in this review with a range of research approaches: qualitative (n = 15); quantitative (n = 4); mixed methods (n = 2); case study (n = 2) and discourse analysis (n = 1). Thematic analysis revealed the nurses: equipped families for end of life through information provision and communication; managed the withdrawal of life-sustaining treatments to meet family need; and continued care to build memories., Conclusion: Greater understanding is needed of the language that can be used with families to describe death and dying in intensive care. Clearer conceptualization of the relationship between the medically focussed withdrawal of life-sustaining treatments and patient/family-centred end-of-life care is required making the nursing contribution at this time more visible., (© 2016 John Wiley & Sons Ltd.)

Background: A core component of family-centred nursing care during the provision of end-of-life care in intensive care settings is information sharing with families. Yet little is known about information provided in these circumstances., Objective: To identify information most frequently given by critical care nurses to families in preparation for and during withdrawal of life-sustaining treatment., Design: An online cross-sectional survey., Methods: During May 2015, critical care nurses in Australia and New Zealand were invited to complete the Preparing Families for Treatment Withdrawal questionnaire. Data analysis included descriptive statistics to identify areas of information most and least frequently shared with families. Cross tabulations with demographic data were used to explore any associations in the data., Results: From the responses of 159 critical care nurses, information related to the emotional care and support of the family was most frequently provided to families in preparation for and during withdrawal of life-sustaining treatment. Variation was noted in the frequency of provision of information across body systems and their associated physical changes during the dying process. Significant associations (p<0.05) were identified between the variables gender, nursing experience and critical care experiences and some of the information items most and least frequently provided., Conclusions: The provision of information during end-of-life care reflects a family-centred care approach by critical care nurses with information pertaining to emotional care and support of the family paramount. The findings of this study provide a useful framework for the development of interventions to improve practice and support nurses in communicating with families at this time., (Copyright © 2016 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

The majority of deaths of children and infants occur in paediatric and neonatal intensive care settings. For nurses, managing an infant/child's deterioration and death can be very challenging. Nurses play a vital role in how the death occurs, how families are supported leading up to and after the infant/child's death. This paper describes the nurses' endeavours to create normality amidst the sadness and grief of the death of a child in paediatric and neonatal ICU. Focus groups and individual interviews with registered nurses from NICU and PICU settings gathered data on how neonatal and paediatric intensive care nurses care for families when a child dies and how they perceived their ability and preparedness to provide family care. Four themes emerged from thematic analysis: (1) respecting the child as a person; (2) creating opportunities for family involvement/connection; (3) collecting mementos; and (4) planning for death. Many of the activities described in this study empowered parents to participate in the care of their child as death approached. Further work is required to ensure these principles are translated into practice., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Background: The majority of in-hospital deaths of children occur in paediatric and neonatal intensive care units. For nurses working in these settings, this can be a source of significant anxiety, discomfort and sense of failure., Objectives: The objectives of this study were to explore how NICU/PICU nurses care for families before and after death; to explore the nurses' perspectives on their preparedness/ability to provide family care; and to determine the emotional content of language used by nurse participants., Methods: Focus group and individual interviews were conducted with 22 registered nurses from neonatal and paediatric intensive care units of two major metropolitan hospitals in Australia. All data were audio recorded and transcribed verbatim. Transcripts were then analysed thematically and using Linguistic Inquiry to examine emotional content., Results: Four core themes were identified: preparing for death; communication challenges; the nurse-family relationship and resilience of nurses. Findings suggested that continuing to provide aggressive treatment to a dying child/infant whilst simultaneously caring for the family caused discomfort and frustration for nurses. Nurses sometimes delayed death to allow families to prepare, as evidenced in the Linguistic Inquiry analysis, which enabled differentiation between types of emotional talk such as anger talk, anxiety talk and sadness talk. PICU nurses had significantly more anxiety talk (p=0.018) than NICU nurses., Conclusion: This study provided rich insights into the experiences of nurses who are caring for dying children including the nurses' need to balance the often aggressive treatments with preparation of the family for the possibility of their child's death. There is some room for improvement in nurses' provision of anticipatory guidance, which encompasses effective and open communication, focussed on preparing families for the child's death., (Copyright © 2015 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it., Objective: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries., Design: This was a descriptive comparative study., Settings: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units)., Participants: A convenience sample of 157 handovers was studied., Methods: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors., Results: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01)., Conclusions: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool., (Copyright © 2014. Published by Elsevier Ltd.)

Background: Changes in health care and an ageing population have meant that more people are dying in the acute hospital setting. While palliative care principles have resulted in quality care for the dying, many patients die in an acute care, still receiving aggressive/resuscitative care., Aims: The aims were to explore nurses' 'recognition of' and 'responsiveness to' dying patients and to understand the nurses' influence on end-of-life care., Design: A qualitative approach was taken utilising non-participant observation to elicit rich data, followed by focus groups and individual semi-structured interviews for clarification., Setting/participants: This study was conducted in two acute medical wards in one health service, identified as having the highest rates of death, once palliative care and critical care areas were excluded. Twenty-five nurses consented to participate, and 20 episodes of observation were conducted., Results: Nurses took a passive role in recognising dying, providing active care until a medical officer's declaration of dying. Ward design, nurse allocation and nurses' attitude to death impacts patient care. End-of-life care in a single room can have negative consequences for the dying. Nurses demonstrated varying degrees of discomfort, indicating that they were underprepared for this role., Conclusion: When patients are terminally ill, acknowledgement of dying is essential in providing appropriate care. It should not be assumed that all nurses are adequately prepared to provide dying care. Further work is necessary to investigate how the attitudes of nurses towards caring for dying patients in the acute hospital setting may impact care of the dying patient.

Background: The Intensive Care Unit (ICU) Liaison Nurses (LNs) emerged as a member of the multidisciplinary team to: assist in the transition of patients from ICU to the ward, respond to the deteriorating patient in an appropriate and timely manner, and in some instances act as an integral member of Rapid Response Teams (RRT)., Purpose: To identify the common core aspects and diversity within the ICU LN role across Australia and to determine whether the ICU LN hours of operation and the participation in MET teams has any impact on the activities undertaken by the ICU LN., Method: This descriptive survey of 152 Australian ICUs was conducted in April 2010. The Advanced Practice Nurse (APN) framework was used to develop the survey instrument, which comprised of four scales, education (5 items), collaboration (6 items), practice (8 items) research and quality (6 items) and a number of demographic questions. Descriptive statistics (mean, standard deviation (SD), median, interquartile ranges (IQR) and frequency) were used to summarise the data. Student's t-tests and Pearson's correlations were used to test the hypotheses., Results: Surveys were received from 113 hospitals (55 metropolitan, 58 regional): a 74% response rate. ICU LN services operated in 31 (27%) of these hospitals. LN services tended to operate in larger hospitals with higher ICU admission rates. The median weekly hours of operation was 56 (IQR 30; range 7-157), delivered by a median of 1.4 (IQR 0.9; range 0.0-4.2) Full Time Equivalent (FTE) staff. The median weekly patient visits made by the LN was 25 (IQR 44; range 2-145). The LN was reported to be a member of the Medical Emergency Team (MET) in 17 (68%) of the 25 hospitals that provided both MET and ICU LN services. The ICU LN activities were grouped under four key Advanced Practice Nurse (APN) domains: education, collaboration, practice and research/quality. Mean scale scores were calculated for each APN domain. The ICU LN reported being involved in activities associated with all four APN domains, and more frequently they were involved in education and expert practice during their daily work. Neither the presence of a MET nor the weekly operational hours of the LN service significantly affected the key activities undertaken by ICU LNs (education, collaboration, practice, research and quality)., Conclusion: Whilst many hospitals across Australia have introduced an ICU LN service, the staffing, hours of service, job classifications, reporting lines, referral processes and APN activities undertaken by the ICU LN, vary between hospitals, highlighting the diverse nature of ICU LN services across Australia., (Copyright © 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To measure the impact of the Feedback Incorporating Review and Simulation Techniques to Act on Clinical Trends (FIRST(2) ACT) simulation program on nursing observations and practice relevant to patient deterioration in a rural Australian hospital., Design: Interrupted time series analysis., Setting: A rural Australian hospital., Participants: All registered nurses (Division 1) employed on an acute medical/surgical ward., Intervention: The FIRST(2) ACT simulation program., Outcome Measures: Appropriate frequency of a range of observations and administration of oxygen therapy., Results: Thirty-four nurses participated (83% of eligible nurses) in the FIRST(2) ACT program, and 258 records were audited before the program and 242 records after. There were statistically significant reductions in less than satisfactory frequency of observations (P = 0.009) and pain score charting (P = 0.003). There was no measurable improvement in the administration of oxygen therapy (P = 0.143), while the incidence of inappropriate nursing practice for other measures both before and after the intervention was too low to warrant analysis., Conclusion: FIRST(2) ACT was associated with measurable improvements in nursing practice., (© 2012 The Authors. Australian Journal of Rural Health © National Rural Health Alliance Inc.)

Background: The majority of hospitals in the United Kingdom (UK) use some form of track and trigger scoring system, such as early warning scores, to identify deteriorating patients; however, response by the multi-professional team is not always timely and problems with recognition of deterioration persist., Aim: To examine ward nurse and critical care outreach staff perceptions of the management of patients who deteriorate in acute wards., Methods: A qualitative design was used with critical incident (CI) technique employed to structure data collection. Semi-structured interviews were undertaken with nurses who had managed a patient who was referred to the outreach team (n=11) and members of the outreach team (n=3)., Results: Registered nurses in this study looked at trends when assessing their patients visually. However, early warning scoring was not a key component of patient assessment and was used more commonly to quantify deterioration once the patient's changing condition had been recognised. Findings demonstrated some tensions in team communication., Conclusions: The results of this study suggest that clinicians need a better understanding of the value of track and trigger scoring systems in identifying trends in the patient's condition. Further, our data suggest that steps need to be taken in acute hospital wards to improve team members' understanding of each others' roles and capabilities., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

Aim: This paper is a report of a study to identify experienced rural nurses' perceptions of key issues related to the provision of effective psychosocial care for people with cancer in rural settings., Background: A cancer diagnosis has a major impact on psychological and emotional wellbeing, and psychosocial support provided by nurses is an integral part of ensuring that people with cancer have positive outcomes. Although, ideally, people with cancer should be managed in specialist settings, significant numbers are cared for in rural areas., Methods: Using a qualitative descriptive approach, three focus groups were conducted in 2005 with 19 nurses in three hospitals in rural Victoria, Australia., Findings: Participants indicated that a key issue in providing psychosocial care to patients with cancer in the rural setting was their own 'emotional toil'. This Global Theme encapsulated three Organizing Themes- task vs. care, dual relationships and supportive networks--reflective of the unique nature of the rural environment. Nurses in rural Australia are multi-skilled generalists and they provide care to patients with cancer without necessarily having specialist knowledge or skill. The fatigue and emotional exhaustion that the nurses described often has a major impact on their own well-being., Conclusion: In the rural context, it is proposed that clinical supervision may be an important strategy to support clinicians who face emotional exhaustion as part of their cancer nursing role.

Objective: This paper examines strategies used by nurses to manage patients at risk of deterioration in smaller rural hospitals in Victoria, Australia., Design: A two-stage design comprising a postal questionnaire (n = 20) and case studies (n = 7). Case study participants were interviewed and their practice was observed for one shift., Setting: Smaller rural hospitals in Victoria., Participants: Registered Nurses (Division 1)., Main Outcome Measure: Observed and reported strategies used to manage deteriorating patients., Results: Nurses in this study used clinical strategies and communication strategies when managing patients who might deteriorate. These strategies were adapted to suit the individual rural context. The ability to anticipate patient requirements and confidence to act on clinical presentation were central. Nurses also had to learn the art of referral and they tailored communication according to their perception of the knowledge and skills of medical colleagues. Strategies were also influenced by staffing patterns and expectations of the community and health service., Conclusions: We conclude that rural nurses play an essential role in assessing and managing risk of deterioration across a range of patient presentations and often in challenging situations. Strategies used by nurses required an understanding of the rural context of care delivery.

This descriptive exploratory study investigated the reported practices and perceptions of emergency nurses related to infection control in the context of the Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) pandemic in Botswana. Quantitative and qualitative data were collected using a self-administered questionnaire. Forty questionnaires were distributed to nurses with emergency department experience in Botswana, with a response rate of 55% (n = 22). Quantitative data were analysed using descriptive statistics while qualitative data were subjected to thematic and content analysis. The majority of respondents reported compliance with universal precautions at the hospital emergency department. However, qualitative data highlighted resource constraints that may hinder compliance with universal precautions such as a lack of appropriate facilities, a shortage of equipment and materials, inadequate staffing and absence of sustainable in-service education programs. Further, the reported compliance with Universal Precautions had not removed the fear of exposure to HIV/AIDS and perceived risk of transmission to family. The authors recommend in-service education and practice initiatives to promote sustainable compliance with universal precautions and realistic risk perception among nurses. Further research is required to evaluate nurses' compliance with universal precautions in developing countries using observational methods or in-depth interviews. This would enable exploration of nurses' actions regarding compliance with universal precautions.

In the UK, recent policy guidelines emphasize the role of nurses in managing the minute-by-minute care of critically ill patients (Department of Health 1996). This article reports on a study that explored the extent to which the nurse at the bedside (the allocated nurse) and the nurse in charge of the shift (the shift leader) make decisions about the needs of children who are critically ill. The study also identified areas of need using a modified Delphi study and explored how nurses perceive and act on the needs of critically ill children. These aspects are presented elsewhere.

A telephone survey of 89 GICUs in England was performed, using stratified quota sampling. 75 (84%) units reported changes in practice over the past 3 years. The reported changes were not only task orientated but also encompassed increased autonomy, organisational changes and increased workload. The absence of significant relationships between the activities suggests that nursing practice development is dependent on patient need and/or local factors. The lack of pattern suggests that it may be inappropriate to compare units for the purpose of nurse staffing.

Intensive care nurses are an expensive and scarce resource. The internal market within the National Health Service requires greater scrutiny of expenditure in all areas, not least staffing. Inevitably questions are raised regarding the evidence to justify the nurse:patient ratios in specialist areas such as intensive care. This paper addresses some of the issues surrounding staffing in intensive care and discusses the impact of changes in medical practice on the nursing role. The nurse:patient ratio is lower in the USA, therefore a brief comparison between the two countries is provided in order to inform discussion and debate. The importance of these issues for all intensive care nurses is emphasised, together with a plea for a substantive study to provide evidence of nursing work and inform future decision-making by the purchasers and providers of intensive care services.

This article discusses the issues surrounding the measurement of nursing work. The authors highlight a Royal College of Nursing (RCN) survey of critical care units which identified the extent of the use of patient scoring systems. The authors also examine the implications of using scoring systems to determine nursing workload and estimate staffing requirements.