Does Caring for Displaced Specialty UnitPatients Affect the Critical Care Nurse’s

Perceptions of Ability and Job Satisfaction?

Gayle McGlory, MSN, RN, Mary Burney, MSN, RN, CS, Jenny Hargrave, MS, RNC,Sue Luna, MSN, RN, CNS, Isaac Smith, MS, RN, and Douglas Wakhu, MSN, RN, CNS

Trauma centers are challenged to share beds with a larger hospital population of critical carepatients. Often, this means that patients may be shifted between units when beds are notimmediately available in the specialty unit that fits their diagnosis. They are admitted to thefirst intensive care unit bed that becomes available. This practice results in patients withspecial care needs being cared for by nursing staff who do not perceive themselves as trainedto provide those needs. This practice is referred to as displaced specialty unit (DSU)admission. A review of 2-year data from one large trauma center revealed a total of 1072 DSUpatients, of whom 50% were medical patients. A questionnaire given to intensive care unitnurses found that caring for DSU patients did affect their perceptions of their ability to carefor such patients and affected their sense of job satisfaction. Strategies to improve nurses’comfort level and competency in treating diverse critical care patients were recommendedand implemented. (Int J Trauma Nurs 2002;8:76-80.)

Large hospitals tend to have differenttypes of specialized intensive care units(ICUs) for optimally treating criticallyill or injured patients. The ICUs rely on

experienced, specialty-trained nurses to providebedside care. When the hospital or ICU censusfluctuates unpredictably, patients who need spe-

cialized care may not be able to be admitted to theappropriate unit. Referred to as displaced spe-cialty unit (DSU) admission by nursing adminis-tration, this practice causes concern for the nurs-ing staff.

Critical care nurses at Ben Taub General Hos-pital (BTGH) in Houston, Texas expressed dis-comfort with the necessity of caring for DSUpatients. Nurses may perceive that they do nothave the specialized knowledge and skills requiredto adequately care for the patient. Additionally,they lack familiarity with the physicians, equip-ment, or interventions used to treat DSU patients.The nursing administration feared that this dis-comfort would negatively affect patient care andthe nurses’ job satisfaction and would result in anincreased staff turnover. There were no statisticaldata available to support this impression; there-fore, a study was conducted that evaluated (1)DSU patient admission practice, and (2) perceivedlevel of comfort and satisfaction of ICU nurseswhen caring for DSU patients.

METHODS

Retrospective Review of AdmissionsUsing a consecutive sample, data were col-

lected from January 1, 1999 to December 31,2000. The patients’ admitting diagnoses as desig-

Gayle McGlory, MSN, RN, is Nursing Supervisor of EmergencyCenter & Adult ICUs at Ben Taub General Hospital, Houston,Texas.

Mary Burney, MSN, RN, CS, is Nurse Manager of MentalHealth Services at Ben Taub General Hospital Houston, Texas.

Jenny Hargrave, MS, RNC, is Professional Project Coordinatorat Ben Taub General Hospital Houston, Texas.

Sue Luna, MSN, RN, CNS, is Director of the Emergency Centerat Ben Taub General Hospital Houston, Texas.

Isaac Smith, MS, RN, is Nurse Manager of Medical IntensiveCare Unit (MICU) at Ben Taub General Hospital Houston,Texas.

Douglas Wakhu, MSN, RN, CNS, is Assistant Nurse Managerof MICU at Ben Taub General Hospital Houston, Texas.

Please write gale_mcglory@hchd.tmc.edu with comments.

Reprint requests: Gayle McGlory, MSN, RN, 1504 Taub Loop,Houston, TX 77030.

Copyright © 2002 by the Emergency Nurses Association.

1075-4210/2002/$35.00 � 0 65/1/126252

doi:10.1067/mtn.2002.126252

76 INTERNATIONAL JOURNAL OF TRAUMA NURSING/McGlory et al VOLUME 8, NUMBER 3

nated by the admitting doctor’s assessment werecompared with the ICU into which they wereadmitted, such as trauma surgical ICU (TSICU),medical ICU (MICU), neurological ICU (NICU),coronary care unit (CCU), and post anesthesia careunit (PACU). Table 1 provides representative di-agnoses for each critical care unit. A DSU admitwas operationally defined as an adult (18 years orolder) admitted from the emergency center (EC) toan ICU different than the admitting EC doctor’srequest. The medical records of the DSU patientswere obtained and reviewed to verify admissiondiagnosis, unit placement, and length of stay inhours. The authors served as the research team.All DSU admits were reviewed for generalizationand not individualized to any specific person.

Survey of Nurses’ AttitudesA questionnaire was devised by the research

team and was utilized to query ICU nurses whowere currently working on all adult specialty units.The survey determined the following informationfrom nurses: (1) their perception of the frequencyof DSU admissions; (2) their comfort level whencaring for DSU patients; (3) their self assessedability to care for DSU admissions; (4) their per-ceived stress when caring for DSU patients; and

(5) their suggestions for how to reduce stress, ifthey felt their care was negatively affected, and (6)their level of job satisfaction under these circum-stances. Permission to conduct the study was ob-tained from the Institutional Review Board of thepublic hospital before beginning the study.

FINDINGS

Displaced Specialty Unit PatientsEach year during the study period, there were

approximately 100,000 patients triaged throughthe EC, approximately 31,500 had a surgical di-agnosis and 3900 were considered to have majortrauma. During the 2-year study period, a total of29,363 patients were admitted to the hospital, ofwhom 6,193 were admitted to the ICUs. The au-thors found evidence that a total of 1072 (17.31%)of the ICU admits met the criteria for DSU (seeTable 2).

The major group of patients (n � 473 patientsor 44% of total DSU admits) affected by theadmission practice was classified as “medical”because they should have optimally been placed inthe MICU instead of another ICU. The unit andnursing staff that was primarily affected with DSUwas the TSICU, which averages approximately 95

Table 1. Examples of admitting diagnoses associated with designated intensive care units

CCU MICU NICU TSICUMyocardial infarction

Congestive heart failure

Bradycardia

S/P cardiac catherization

S/P cardiac arrest

Atrial fibrillation

S/P percutaneoustransluminal coronaryangioplasty

Supraventricular tachycardia

Respiratory failure

Renal failure

Hepatic cirrhosisInoperable cancer

Hypothermia

Epileptic seizures

Asthmatic orCOPDexacerbationrequiringintubation

Diabetic ketoacidosis

Cerebral vascularaccident notrequiring surgery

Spinal cord injury abovethoracic level 1 (T1)

Head injuries

Intracranial bleedSkull fracture

Brain tumors

Cerebral aneurysm

Cerebral vascular accidentrequiring surgery

Subarachnoid hemorrhage

Treatment of injuriesassociated with thefollowingmechanisms ofinjury: motor vehiclecrash, automobileversus pedestrian,gunshot wound atT1 or below; stabwounds

Spinal cord injuries atT1 or below

Liver laceration

Abdominal aorticaneurysm repair

S/P thoracotomy

Traumatic amputation

Coronary arterybypass graph

CCU, coronary care unit; MICU, medical intensive care unit; NICU, neurological intensive care unit; TSICU, trauma/surgical intensivecare unit; S/P, status post.

JULY-SEPTEMBER 2002 INTERNATIONAL JOURNAL OF TRAUMA NURSING/McGlory et al 77

admissions per month and has an 82.1% occu-pancy rate. Of the 2784 patients admitted from theEC to the TSICU during the study period, 497were admitted to TSICU (46% of the total of DSUadmits). This number included 214 medical pa-tients, 171 neurological patients, and 112 coronarycare patients. The practice of admitting criticalcare patients to the unit with the first bed availableresulted in 92 patients admitted for surgical carewho had to be initially sent to other units (89 toPACU and 3 to NICU).

The study revealed that critical care patientswere admitted to a variety of units, possibly de-feating the purpose of specialty care with a trainednursing staff. The DSU practice does not give thenursing staff consistent experience with a patientpopulation and affects their ability to develop nec-essary skills and knowledge. For example, out ofthe 232 DSU patients admitted for coronary care,112 were sent to the TSICU and 120 to PACU.There were 473 patients admitted for medical carethat were sent to an intermediate care unit (n �239), SICU (n � 214), PACU (n � 17), or NICU(n � 3). There were 259 patients admitted forneurological care that were sent to SICU (n �171) or PACU (n � 88).

Patients who experience DSU admissions weresubject to subsequent transfer to another criticalcare unit. The majority (51.3%) of the 550 DSUpatients stayed in the initial unit from 30 minutesto 72 hours with a mean length of stay of 54.4hours.

Nurses Attitude SurveyA survey was presented to 272 adult ICU nurses

and a total of 99 participated (91 female, 8 male).The nurses’ mean age was 37.54 years and theyhad an average of 8.25 years of critical care ex-perience (SD � 5.57). The nurses had extensiveexperience in their present ICU specialty (mean7.29 years, SD � 5.13 years) and on their current

unit (mean 6.97, SD � 5.00). Only 16 nurses heldprofessional certification (eg, Critical-Care Regis-tered Nurse or American Association of Critical-Care Nurses). An analysis of the questionnairecompleted by the nurses revealed:1. Perception regarding the frequency of DSU

placement: 82.8% of nurses stated it occurredoccasionally, frequently, or very frequently;17.2% reported rarely; none responded that itnever occurred.

2. Self-reported comfort level while caring forDSU patients: 26.3% felt “less than comfort-able” in caring for these patients; 39.4% felt“neutral”; and 34.3% felt “comfortable” or“very comfortable.” PACU nurses felt thattheir job satisfaction was significantly moreaffected by DSU patients than other nurses.The PACU received the second highest numberof DSU patients (Table 1).

3. Self report of the nurse’s ability to care forDSU patients: about 74% ranked themselves asa “novice,” “advanced beginner,” or “not sure;”21% ranked themselves as “competent”; andonly 5% indicated that they felt as an “expert.”

4. Stress factors associated with working withnonspecialty patients: 35% identified “workingwith MDs from other specialties” as the moststressful element of DSU placement; 21% iden-tified “unfamiliar equipment;” 20% identified“unfamiliar interventions;” 15% identified “notknowledgeable about pathophysiology;” 4%noted “different assessment needs;” 3% listed“unfamiliar with medication;” and 1% listed“different patient/family education needs.”

5. Suggestions for reducing stress: Commentsfrom the nurses included “train all ICU nursesto function in all ICUs,” “education on spe-cialty equipment,” and “designate resource per-sons to contact.” The nurses found that whenworking with displaced patients that it was

Table 2. Pattern of DSU ICU admissions over a 2-year period at Ben Taub Hospital (n � 1072)

Diagnostic group (no. admittedto non-specialty unit):

ICU actually admitted to:

TSICU PACU NICU OtherCoronary care (232) 112 120 0 0Medical (473) 214 17 3 239Neurological (259) 171 88 0 0Trauma/Surgical (92) 0 89 3 0Other (16) 0 5 3 8(Total: 1072) (497) (319) (9) (247)

Note: Medical ICU received no DSU admitted patients. TSICU, trauma/surgical intensive care unit; PACU, post anesthesia care unit;NICU, neurological intensive care unit.

78 INTERNATIONAL JOURNAL OF TRAUMA NURSING/McGlory et al VOLUME 8, NUMBER 3

“difficult to locate the patient’s physician whennecessary.”

6. Self-reports of job satisfaction: 60.6% of ICUnurses surveyed said they occasionally or fre-quently experienced job dissatisfaction due toDSU patient placement. Of that number, 64%of TSICU nurses; 57.2% of MICU nurses;56.3% of CCU nurses; 86.7% of PACU nurses;and 40% of NICU nurses felt job dissatisfac-tion.

DISCUSSION

BTGH is a level 1 trauma center that serves asa county hospital. It is licensed for 647 beds, ofwhich 72 are classified as adult ICU (30 trauma/surgical, 16 MICU, 16 NICU, 8 CCU, and 2PACU overflow beds). This number does not in-clude the pediatric or neonatal ICU beds. The needfor 30 TSICU beds was based on the high surgicalload handled by the hospital and the fact that thereare only 2 level 1 trauma centers in a metropolitanarea of 4 million people.

The retrospective review verified that DSU ad-mission was a common practice.

Although there is a need for more MICU beds,it is not easy to forecast the specific number re-quired in each specialty unit. When patients areinitially placed in nonspecialty unit beds, they are“on hold” until another transfer can be arranged.They can stay for as little as several hours or aslong as several days.

The questionnaire provided evidence that theDSU practice did have a negative impact on thenurses. Only 1/3 of the ICU nurses felt that theywere comfortable caring for DSU admissions.Even nurses with extensive clinical experiencereported feeling like a “novice” or “advanced be-ginner” when caring for DSU patients. Accordingto Benner1 it is essential that nurses develop clin-ical expertise, which is “highly influenced by ex-perience with similar patient populations . . . Thenurse’s monitoring and assessment function re-quires graded qualitative distinctions that can bemade only by someone who has experiential basisfor comparing similar and dissimilar cases.” Shefurther theorizes that experience is the “transfor-mation of preconceived notions and expectationsby means of encounters with actual practical sit-uations.” Benner2 further states that as nurses prac-tice in a specialty area they progress from novice,to advanced beginner, to competent, to proficient,to expert in that specialty. When confronted witha patient from another specialty area, expert nursesmay feel their levels of skills are only those of an

advanced beginner when caring for the DSU pa-tient placed in the unit.

An additional finding in this survey was the lownumber of nurses (16%) who held a nationallyrecognized professional certification. According toBiel et al3 “Critical care nursing practice is chang-ing . . . and certification is an assurance to health-care consumers that they are receiving care frompractitioners who have the qualifications, knowl-edge, and skills necessary to practice.” The mili-tary has recognized the necessity for critical carespecialty education.4 The Army reserve nursesmust complete the Critical Care Nursing Resi-dency Program and other supplemental education.The Army’s Critical Care Nursing Residency Pro-gram prepares the medical surgical nurse to func-tion in a critical care situation and to sit for theCritical-Care Registered Nurse (CCRN) certifica-tion exam.4

The concept of critical care medicine was ini-tiated in 1923 when a 3-bed unit was opened atJohns Hopkins Hospital in Baltimore, Maryland totreat postoperative neurosurgical patients.5 Asearly as 1958; the American Hospital Associationindicated that 25% of the larger hospitals in theUnited States had at least one ICU.5,6 By 1993,approximately 40% of large hospitals in theUnited States had an ICU and 38.7% were spe-cialty ICUs.7 During this time there was no cre-dentialing agency and nurses were working indifferent specialty units without certification. In1975, the American Association of Critical-CareNurses (AACN) developed a critical care certifi-cation program that was based on a set of coreknowledge needed to practice in the critical careareas. Since then, “the AACN Certification Cor-poration has a commitment to ensure that certifi-cation, while being valid and reliable, reflects theneeded knowledge and experience to effectivelymeet patients’ needs”.3 The AACN periodicallyupdates the exam blueprints based on trends andcurrent practice.3 To retain the designation ofCCRN, the critical care nurse must document con-tinuing education in their specialty area or retest atspecific intervals.

Hind et al8 examined the current role of criticalcare nurses with the possibility of expanding thenurse’s practice. Throughout the study, informa-tion was given on the need to acquire new skills,“in response to changing demands in practice. . .” and “a need for appropriate education andtraining to support these developments along withthe need for on-going assessment strategies toensure that individuals are, and remain competent

JULY-SEPTEMBER 2002 INTERNATIONAL JOURNAL OF TRAUMA NURSING/McGlory et al 79

in the performance of these skills.” There was nomention of nurses becoming certified to documenttheir competency.

Strategies DevelopedThe authors used the data from the DSU eval-

uation and nurses’ survey to implement the fol-lowing strategies to help improve staff knowledgeand satisfaction:

Encourage professional certification. Accord-ing to Niebuhr,9 “Changes in the sophistication ofspecialty nursing practices have made it increas-ingly apparent that basic state licensure alone isnot sufficient to insure safe nursing practice in aspecialty area, especially critical care nursing.”Considering that only 16% of ICU nurses in thestudy had any specialty certification, it was de-cided to strongly encourage the acquisition of suchcertification to improve confidence and self-image. The hospital instituted an incentive pro-gram designed to encourage nurses to seek spe-cialty certification, offering a bonus for attainingcertification and recertification. ICU managementwas urged to emphasize this opportunity to thestaff. CCRN certification was recommended be-cause it includes care contents from all specialties.

Increase availability of resources. Resourcemanuals from other specialties were placed on allcritical care units to provide readily assessableinformation. Resource persons were designatedfor each specialty, on each shift, that could becontacted for assistance with operating equipmentor other problems.

Promote education. Self-study modules ineach specialty were provided to all ICU staff.Monthly nursing critical care grand rounds wereinitiated so each specialty area can share informa-tion with other areas.

Indications for Future EvaluationThe hospital has developed a step-down unit

and increased the number of telemetry beds tohelp move patients out of the ICU as quickly aspossible. The intent is to free beds for newlyadmitted critical care patients. This approachshould be monitored to determine if the concept orits implication is functioning as intended.

This study raises questions regarding why sofew nurses have sought certification and what the

level of certification is at similar institutions. Thehospital has an incentive program in place fornurses to obtain certification. It would be helpfulto determine if the certified nurse’s level of com-fort was different from the uncertified nurse withthe same number of years of experience.

CONCLUSION

A retrospective review was used to documentthe practice of admitting critical patients to non-specialty ICU beds. The goal of providing a spe-cialty level of care for patients may be affected bymultiple factors, including the nurses’ perceivedlack of knowledge or skills and the decreasedability to coordinate medical services on units thatdo not routinely provide such services. Nursingadministrators used the findings of this study topromote educational activities for the ICU nurses,however, the bigger issue of DSU admissions re-mains an open issue.

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