How did you get into nursing? Teaching?

When I was young, my sister and I had a playhouse that we would split up. She would play house on one side while I played teacher/nurse on the other. High school counselors tried to dissuade me because I had an aptitude for math and science, but I wanted nursing and started a three-year diploma program.

What are intensivists?

Intensivists are anesthesiologists, internists, surgeons and pediatricians who continue their education with one to three years of additional specialized training in ICU. Intensivists are ICU physicians who intend to spend most of their time caring for patients in the ICU, much like the ER model. Appallingly, most ICU patients who are the most vulnerable and unstable patients are not under the care of an intensivist. Yet the standard of care does not dictate the 24-hour presence of a specially trained physician. Nurses need intensivists present to improve patient care in many different ways.

Nurses without intensivists end up initiating emergency measures without orders, juggling conflicting medical orders, begging physicians for the right care for their patients, teaching physicians about critical care and hunting down attending physicians. Nurses should be directing their valuable talents to caring for patients, not trying to get physicians to do their jobs properly.

Each year, the lack of ICU-dedicated intensivists costs at least $5.3 billion with a minimum of 54,000 lives wasted.

As a critical care educator, what do you see as the changing environment in critical care?

Shortages, not just of nurses, but the entire critical care core team. Nurses have to become more efficient and continually prioritize. They have to ask, "What is the top priority for the recovery of the patient and the family?" Nurses need to take control, focus on their plan and not let external forces divert precious time and energy.

I strongly believe protocols facilitate efficiency and improve the quality of care. The Society of Critical Care Medicine Web site [www.sccm.org] has many resources available. Most are downloadable and free. For example, there are 30 evidence-based guidelines written by various experts on clinical topics such as hemodynamic monitoring and ARDS.

There is a manual for first-year medical students orienting them to the ICU that is excellent. There are five extremely helpful patient/family brochures. There is a quality corner with more than 100 ideas from members on how they improved their quality of care. Three of my favorites are a guide to establishing the intensivist model, an ICU index that you can use to rate your own ICU and a primer on talking money to hospital administrators.

What are some strategies that can increase patient safety?

Nurses can create a culture of zero tolerance for harm. There are units that have done this with great success. The first step is for the ICU team to decide that all avoidable harm will be eliminated. The second step is to document every near miss. All errors are then systematically evaluated because near misses can become real misses another time.

The second strategy is what I call invisible excellence. The better the nurse, the better the care. Every day, nurses prevent harm to patients by recognizing the early signs of danger and eliminating complications before they occur.

What do you see in the future for critical care nursing?

With increased demand and diminished supply, retaining and recruiting nurses will be key.

Successful ICU units will be those with a team that takes pride in what it does. Satisfaction comes with a team's success at the end of the day. This is the kind of unit that draws nurses.

Successful hospitals are those that treat their nurses well and appreciate their presence and expertise. The public and hospitals don't realize how much nurses need to know. Hospitals that do not value and respect highly trained expert nurses will see their nurses walk because there will be a site nearby that does.

Anything you'd like to add?

I have dedicated my professional life to two issues. First, I am passionate about establishing the intensivist model. Second, I am devoted to teaching ICU nurses things that will help them take better care of patients and families. I am on the road seven or eight months every year, to large and small centers in large and small cities, with 25 hours of teaching per week and have made contact with thousands of nurses. No job is more challenging or exciting. I love nursing and nurses and I try to instill in all the value of what they do.