Intensive Care Unit Patients in the Postanesthesia Care Unit: A Case Study Exploring Nurses’ Experiences Crystal White, MSN, RN, Barbara Pesut, PhD, RN, Kathy L. Rush, PhD, RN Purpose: The purpose of this study was to understand the experiences of postanesthesia nurses caring for intensive care unit (ICU) patients in the postanesthesia care unit (PACU). Design: Qualitative interpretive description. Methods: Six PACU nurses participated in semi-structured interviews. Interviews were digitally recorded, transcribed verbatim, and analyzed using constant comparative analysis. Quality of the data collection and analysis process was maintained through constructing codes and themes jointly by several investigators and taking interpretive accounts back to participants. Finding: Three main themes were constructed: expert mind-set, specialty practice, and identity and relationships. The expert mind-set described knowing but not doing and straddling concurrent foci and duties. Specialty practice entailed doing but not knowing and the unsupportive context that perpetuated this. Identity and relationships described the lost identity of postanesthesia nursing and tension in the relationships with ICU. Conclusions: Findings illuminate the challenges expert nurses face when an unplanned practice change is implemented.

Keywords: perianesthesia nursing, ICU, PACU, qualitative studies, ICU Overflow. Ó 2014 by American Society of PeriAnesthesia Nurses

THE COMPLEXITY OF CURRENT health care requires new efficiencies to support high-quality care. One efficiency is placing intensive care unit Crystal White, MSN, RN, was a student in the Masters’ Program at the time of writing of this article, School of Nursing, University of British Columbia, Okanagan, BC, Canada; Barbara Pesut, PhD, RN, is an Associate Professor, School of Nursing, Canada Research Chair, Health, Ethics and Diversity, University of British Columbia, Okanagan, BC, Canada; and Kathy L. Rush, PhD, RN, is an Associate Professor, School of Nursing, University of British Columbia, Okanagan, BC, Canada. Conflict of interest: None to report. Address correspondence to Barbara Pesut, ASC 287 3333 University Way, Kelowna, British Columbia, Canada; e-mail address: [email protected]. Ó 2014 by American Society of PeriAnesthesia Nurses 1089-9472/$36.00 http://dx.doi.org/10.1016/j.jopan.2013.05.014

Journal of PeriAnesthesia Nursing, Vol 29, No 2 (April), 2014: pp 129-137

(ICU) patients in the postanesthesia care unit (PACU) as ‘‘overflow’’ patients when there are no beds in ICU. This practice seems logical: these are critically ill patients who require intensive care, postanesthesia nurses are critical care nurses, PACU is a critical care environment, and so this would seem a good solution to bed shortages. However, there has been little analysis of the impact of this practice on nurses, despite the fact that there might be risks in light of the increasing acuity and complexity of care. The site of this study, a 350-bed hospital, provided an opportunity to explore the experiences of PACU nurses as their work environment adopted the practice of caring for ICU patients in PACU. The purpose of this study was to understand the experiences of postanesthesia nurses caring for ICU patients in PACU.

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Literature Review The American Society of PeriAnesthesia Nurses (ASPAN) standards state that PACU is a critical care area and the nurses working in PACU should meet critical care competencies. ASPAN, in collaboration with the American Association of Critical Care Nurses and the American Society of Anesthesiologists, developed a position statement on ICU overflow patients in PACU1 indicating support for this practice and emphasizing the importance of appropriate staffing levels and nursing competencies. This position reflects the idea that it is appropriate for critical care patients to be cared for by critical care nurses in a critical care area. Less is known, however, about how nurses should develop and maintain those competencies or about the impact of this transition on nurses’ working lives. In an early account, Lindsay2 described a practice change of recovering surgical ICU patients overnight in PACU. Challenges that arose during this transition included determination of physician coverage, maintenance of low-frequency skills for the nurses working in PACU, and communication between ICU and PACU regarding patient flow and appropriateness of patient selection. Guidelines were provided to assist in making a smooth transition2; however, Lindsay acknowledged that it was challenging to keep staff feeling competent with low-frequency skills. Johannes3 distributed a questionnaire to postanesthesia nurses to explore the experiences of nurses caring for ICU overflow patients in PACU. Concerns included staffing levels, physician coverage, safety due to lack of central monitoring, documentation, and privacy for patients. Johannes concluded that guidelines for overflow patients and an educational component for PACU nurses would be beneficial. Appropriate staffing levels and education for nurses are important factors to consider in this transition.4 Callaghan et al5 conducted a study in the United Kingdom to analyze outcomes for patients who were cared for in PACU overnight after elective open aortic surgery. This study showed no change in patient outcomes. Unfortunately, although this study mentioned the importance of nursing expertise, there was no discussion of what supplemental education the nurses received or their experiences with this change in practice. Kiekkas et al6 conducted a study in Greece documenting the number of ICU overflow patients cared for in PACU over an

18-month period and used the Project Research in Nursing (PRN) workload measurement tool to estimate nursing workload. This study concluded that the increased PRN workload mean for ICU overflow translated into increased total care time of 6.1% during morning shift, 11.9% during evening shift, and 32.2% during night shift, which was not supported with increased personnel. In summary, although caring for ICU patients in PACU is seen to be a viable and safe practice, little has been written about the specifics of such a practice change from the nursing perspective.

Methods The design for this study was qualitative interpretive description, a method that was designed for a practice-based discipline such as nursing.7 Interpretive description is an inductive method that seeks to understand and interpret clinical phenomenon in such a way that the knowledge gained can be applied in practice. Convenience sampling was used to recruit nurses to participate in semistructured interviews about their experiences caring for ICU overflow patients. Six nurses chose to take part in the study, and although this is a small number, there were only 20 nurses working in PACU at the time. To be eligible for inclusion in the study, nurses had to hold a permanent parttime or full-time position in PACU and to have cared for an ICU overflow patient in the study period. The PACU under study was a 15-bed unit, located in a mid-sized hospital, staffed with registered nurses (RNs) from 0700-0200 7 days a week; two RNs provided on-call coverage from 0200-0700. Nurses were excluded if they were concurrently working in ICU. Participants were recruited through letters distributed in the workplace. Individual semi-structured interviews were completed by the principal investigator using an interview guide (Table 1) at a location of participant’s choice. Questions sought to elicit the participant’s experiences with the change, strategies they used to cope with the change, and thoughts on how the change might have been managed differently. Participants filled out a demographic form before the interview. Interviews lasted 20 to 35 minutes. Field notes were written after each interview and were used to inform the context of the findings but were not coded. Interviews were digitally recorded, transcribed, and checked for accuracy.

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Table 1. Interview Guide 1. Tell me about any changes of practice in relation to ICU patients you have experienced over the last 12-18 months. 2. a. Can you tell me about a time this was a good experience? b. Can you tell me about a time when this was a bad experience? Prompts: Can you speak about the complexity of care required? Can you remember the skill set required? Were there external factors to how you felt? (personal stress) 3. What strategies did you use to manage these patients?  What worked well?  What didn’t work well? 4. How has this change in practice affected you personally? 5. Do you have any ideas of how this change could be managed differently? 6. What haven’t I asked you that I should have? ICU, intensive care unit.

A coding framework was negotiated and constructed by two investigators after the first three interviews and was then used to code the remaining interviews. Interviews were hand coded and a word document was used to organize the data. Codes were then organized into broader themes and an interpretive account was created. Examples of codes were moral distress, dual focus/dual duty, lack of knowledge around standardized practices and routines, clinical expertise, contextual supports, geography, and relationship between PACU and ICU. Codes were subject to constant comparative analysis and refined by all investigators to ensure integrity of interpretation. In keeping with interpretive descriptive methods, saturation of data would not be an expectation with the limited number of participants in this study.7 Quality of the data collection and analysis process was maintained through ensuring strict confidentiality of participants to ensure they could be transparent, constructing codes and themes jointly by several investigators and taking interpretive accounts back to participants to ensure that they adequately represented their experiences. This study underwent ethical review through the University and Health Authority Ethical Review Boards. Limitations of the study

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include data collection at one site, single interviews with each participant, and the relatively short nature of the interviews; more in-depth interviews would have provided a richer description of the experience.

Findings Table 2 presents the demographic information for the six RNs who participated in the study. Five of the six participants had worked in ICU previously, but the experience of four of those five was at least 10 years ago. Four of the six participants had completed specialty certification in critical care. Three main themes were constructed from these interviews: the expert mind-set, specialty practice, and identity and relationships. The Expert Mind-set The ‘‘Expert Mind-set’’ describes the participants’ thought processes and subsequent emotions as they cared for ICU overflow patients. This expert mind-set was characterized by participants feeling as if they were giving less than the best care and by their experiences of having to maintain a dual focus. Participants described the distress they experienced while caring for ICU overflow patients, primarily because they knew what they should be doing but felt incapable of doing it. We do the best we can do in the situation and none of us feels that we’re doing the best for the patient because we all know what the best is, we have worked there, and in an area where we know what to do (N 5 2). One participant spoke of the gap between knowing high-quality care based on her previous experience working in ICU and the care she could currently provide in a new context. This nurse knew what she did not know. She was aware of the complexity of the care of an ICU patient but felt she no longer had the knowledge necessary, or the familiarity with the current guidelines, to provide that care, resulting in a sense of distress. The distress participants felt was sometimes acute as indicated in the following quote: . it was very, very wearing, very upsetting that I was not able to give the optimum of

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Table 2. Demographic Characteristics of Study Participants Characteristics

Participants (n)

Highest level of education RN Diploma or Associative Degree Bachelor’s Degree in Nursing Other—Masters in Nursing Specialty education* Critical care Postanesthesia recovery Other None Years of experience in nursing ,2 2-5 6-10 11-15 16-20 .20 Years of experience in postanesthesia nursing ,2 2-5 6-10 11-15 16-20 .20 Worked in ICU (past or present) Yes No Number of years working in ICU ,2 2-5 6-10 11-15 16-20 .20 Number of years since working in an ICU #5 6-10 11-20 .20 Currently working in the PACU Yes No

3 2 1 4 2 2 2 0 0 1 0 0 5

0 1 1 1 2 1 5 1 0 2 2 0 0 1

Participants were functioning as both a PACU nurse and an ICU nurse at the same time. Several participants spoke of the different goals for these patients and how difficult it was to maintain those goals concurrently. One nurse captured this dual focus well. They’re totally different patients so it’s a totally different mindset taking care of an ICU patient as opposed to a PACU patient. So, you have to switch gears in that your goals are different . almost switching mindset to mindset . so you’re doing double duty so you can’t really focus on having an ICU patient (N 5 1). One participant struggled with not being able to give due attention to each patient under her care, particularly when vulnerable patients coming out of anesthesia required her undivided attention when she had concurrent responsibility for an ICU patient. You can’t focus on either one, and if you can’t focus on either one how do you give good care to either? You don’t, you don’t, somebody suffers and you hope that you are not going to have a problem, you just wing it and hope for the best (N 5 4). For this participant, the dual focus meant that at any point in time she was forced to simply trust and hope that nothing bad would happen, a situation that created stress and anxiety. Specialty Practice

1 0 3 1 4 2

ICU, intensive care unit; PACU, postanesthesia care unit. *Some participants had more than one specialty.

care because that’s how I was trained and that’s how my nursing philosophy is (N 5 6). This distress was exacerbated by participants feeling they also had to struggle with a dual focus.

The theme of Specialty Practice was constructed from participants’ tensions between being mandated to look after ICU patients as if critical care was a homogenous speciality and their own experiences of each critical care areas as having a specialized knowledge and routine. Just as in the previous theme, nurses knew there was a standard of quality care that they felt unable to provide; in this theme, nurses were required to have specialized knowledge and perform procedures and skills that they did not know. Furthermore, they spoke of how important speciality contexts were to specialty practice. Several of the participants talked about the differences in critical care skills between specialized units.

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. there’s a whole different set of skills that comes with a critical care patient than with a PACU, I mean you are a critical care nurse but in a different way (N 5 1). Participants further spoke of the relationship between the frequency of performing a particular skill and the ability to stay competent in that skill. Although this is common to all nursing practice areas, it is particularly difficult in the areas where there are many complex, technological skills. . when you do it so infrequently, once every six months say, it’s hard to pull that back and remember all those things that give good quality care to someone who is critically ill (N 5 1). Staying competent within a specialty was only possible when the applicable skills could be practiced on a routine basis. Furthermore, participants talked about not being familiar with the ICU standardized practices and routines. Some spoke of having had that knowledge in the past but over time they had either forgotten it or ICU practices and routines had changed since they had worked there. The unfamiliarity of orders was compounded by having to learn new routines under time pressure. Time constraints meant that participants had to provide care and follow protocols that they did not completely understand. . there’s nothing wrong with the orders, but when you’re not used to them, when you’re not orientated to them, I found it very overwhelming . if their potassium was such you give - you give whatever medication to replace potassium or decrease the potassium . then having to go back and trying to familiarize yourself with what does this mean, what does that mean? (N 5 3). There was a consistent expression of concern about not understanding the ‘‘whole picture’’ but rather simply following order sets and protocols. ‘‘We’re just muddling along trying to keep the patient ventilated, vital signs stable, and not really

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understanding the whole picture (N 5 6)’’. An example of this idea of understanding the ‘‘whole picture’’ or complexity of the patient was provided by one participant. . someone whose kidney function isn’t any good you probably wouldn’t give them ranitidine every 8 hours, as a critical care nurse, when you’re in that all the time you think ‘hey should we switch this to every 12 hours’ or you’d be concerned, even though that’s not my responsibility to know it, but that’s knowledge I have, it would be a red flag to me that maybe I should address this (N 5 1). These participants felt that the expert knowledge a nurse gains in a specialized setting helps to provide quality holistic care to the patient and in some cases averts medical errors. Along with the ability to see the whole picture, participants expressed the idea of being able to anticipate what you need before you need it as an important part of providing quality care. One participant spoke of being able to anticipate the needs of a PACU patient even when she felt tired from an extended shift but she did not have that ability with an ICU patient because of a lack of expertise. This inability to anticipate was particularly crucial in times of urgency; experienced nurses felt like novices as they struggled to stay ahead of rapidly changing conditions. It’s not there right at the tip of your fingers like it is when I get a patient from the PACU who needs this right now, I know what to do. I can do that. I can even anticipate they’ll need a lot of that stuff, but I can’t do that with an ICU patient because I have never worked in ICU . (N 5 4). These specialized skills and routines emphasized the differences between specialties within critical care nursing. One participant expressed frustration with the idea that all critical care nursing was the same: ‘‘You’re a ‘critical care nurse’ quote unquote, it’s different in whatever setting you’re working in whether in emergency, ICU, or PACU’’ (N 5 3). Differences were further reinforced through the available contextual supports. Participants talked

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about the lack of support and resources to care for ICU patients including knowledgeable colleagues, support personnel, specialized equipment, break relief, and preparatory education. One of the greatest challenges of caring for ICU patients in PACU was not having experienced colleagues to consult. Nurses in ICU were surrounded by colleagues, a charge nurse, respiratory therapists, and other resources to draw upon when in doubt. A highly experienced nurse with fairly recent ICU experience spoke of the challenge of not having experienced colleagues to consult as illustrated in the following situation where she was responsible for monitoring the perfusion of a deteriorating new skin flap. . that was not such a good experience because I felt I was responsible for that flap but normally there are so many people you would call, yeah that’s what you do as nurses, and when you’re up there you feel like you’re floating by yourself (N 5 1). This feeling of being isolated from colleagues was exacerbated by the fact that PACU itself was physically isolated from the other patient care areas. Other important contextual factors that were perceived to be lacking were support personnel who performed essential functions such as a unit clerk who would obtain and process orders, access to specialized medications as well as equipment such as pressure lines and ICU infusion pumps, and coverage for breaks. A change in the management structure from clinically knowledgeable supervisors to administrative supervisors meant that nurses did not have clinical coverage for breaks from these individuals. Finally, participants struggled with what they perceived to be a lack of educational support. The idea of needing education related to ICU order sets, paperwork, protocols, procedures, and equipment was repeated throughout the interviews. Some participants did not feel well prepared for the change. In summary, nurses in this study felt an acute tension between a care delivery system that assumed that all critical care nurses had the same knowledge and skills and their experiences of a unique body of knowledge and skills typical to each sub-specialty and further embedded within a necessary unit context.

Identity and Relationships The specialist knowledge and context discussed previously was further reflected in unique cultures that characterized PACU and ICU and a nursing identity that was reflected through that culture. When that culture and identity was challenged, as it was in the experience of having to care for ICU overflow patients, it had implications for relationships. Participants spoke of PACU as having a unique and specialized identity that was potentially devalued when it was assumed they could care for PACU and ICU patients concurrently. I think they feel that it’s not a big deal to just wake someone up from anesthetic, that doesn’t, you know, take any expertise; it’s when you get an ICU case, that’s when you will really show what you can do . I feel undervalued (N 5 2). Participants used expressions such as ‘‘being dumped on’’ and ‘‘being taken advantage of’’ to characterize this devaluing. This feeling of being undervalued was compounded by what some participants felt was a pre-existing tension, characterized by certain stereotypes, between ICU and PACU nurses. Part of this poor relationship was a failure to appreciate the nature of the work done by PACU nurses, a failure that arose because of the isolation of the work done in PACU. One nurse suggested that because ICU nurses did not have the experience of having to look after PACU patients they were unable to sympathize with their plight. The expectation from the ICU staff is that we should be doing it to their level, well we’re not going to be able to any more than they’re able to come over and look after PACU people the way we do it because we do it every day, they do ICU every day so I think there has to be a bit of give and take between the departments. Therefore, the anxiety of having to provide care for patients for whom they felt less competent to care was exacerbated by a feeling that the dilemma they were in was not well understood.

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The resulting negativity shaped the work environment and was difficult to escape. Furthermore, some recognized the political nature of the negativity that had developed around the practice change and how it detracted from the quality of patient care, . it comes down to the patient and we need to at least stay focused on that and sometimes we get focused off of that and onto politics (N 5 1). In summary, the findings reflect how caring for ICU patients in PACU challenges the expert mind-set of the postanesthesia nurse. This is largely a reflection of the specialized skills, routines, and contextual supports that these nurses felt were lacking.

Discussion The purpose of this research study was to understand the experiences of postanesthesia nurses caring for ICU patients in PACU. Findings from this study support many of the issues identified in other studies such as heavy workloads for nurses, challenges in obtaining and maintaining competence, and the importance of having personnel and technical support.4,6 This study adds to that literature by providing in-depth insight into nurses’ experiences of this practice change. These experiences were typified by their dilemmas of ‘‘Doing but not Knowing’’ and ‘‘Knowing but not Doing.’’ Doing But Not Knowing: The Dilemma of Generalist Versus Specialist in Critical Care Practice Participants in this study spoke of the challenges they encountered ‘‘doing’’ nursing care without truly ‘‘knowing’’ the skills and standardized routines and orders that were typical of ICU care. Benner’s classic work on expert nursing practice brings important insight into the experiences of these nurses. Expert nursing practice is characterized by nurses’ abilities to see the big picture and expect the unexpected.8 In this study, nurses’ biggest concerns were their inabilities to see the big picture or to anticipate for ICU patient in the same way that they were able to do so for their PACU patients. These expert nurses felt like novice

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nurses but still had the expertise to recognize that what they did not know could have potentially serious consequences for patients under their care. Theoretical work on the knowledge that nurses require for practice helps to further illuminate the challenges these nurses encountered. Expert caring requires a complex understanding of case knowledge, patient knowledge, and social knowledge.9 Case knowledge is the knowledge such as pathophysiology, therapeutics, and pharmacology that can be learned from a book. However, patient knowledge and social knowledge are often derived from practice as they include things such as how patients will typically respond to therapeutics, how to get things done in a particular context, and how other health care providers work, including their preferences for care. These other essential forms of knowledge were the ones missing for these nurses. They could no longer predict typical responses, they did not have well-established mechanisms for getting things done for their patients, and they did not have ready access to other key providers of care. This lack of ICU contextual and social knowledge made these expert practitioners feel less than competent in care. The complexity of the types of knowledge required to give expert care highlights the question of whether critical care nurses should be considered competent to care for all patients across the critical care spectrum or whether there are sub-species of knowledge and skills that make each critical care area unique. This question is not a trivial one because of its implications for nursing education. In a practice transition of this nature, how much responsibility lies with the individual nurse for lifelong learning and how much responsibility lies with the organization to provide formal education for the nurses? Insights from the nature of expert knowledge and practice suggest that some knowledge could be learned through independent learning but that there is more patient and social knowledge that must be gained through mentored experience. Knowing But Not Doing: The Dilemma of Not Being Able to Deliver a Standard of Care Nurses in this study expressed anxiety at knowing the quality of care that was possible for ICU patient

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but being unable to provide that care. All but one of these nurses had previous ICU experience. While from an administrative perspective, it might appear that these were the ideal nurses to take on such a practice change, the past experience actually gave them the ability to know what they were not doing. Whether these nurses were actually competent in their care was not the focus of this study; however, what was significant from their perspective was that they perceived themselves as knowing a higher standard of care than they were able to fulfill. Participants used words like stressful, wearing, and overwhelming to describe their experiences. There was also a sense of feeling alone and unsupported, in part because of the physical isolation and lack of resources available to them in PACU. The substantial body of work done around moral distress in nursing helps to inform the situation these nurses perceived themselves to be in. Moral distress arises in situations whereby nurses are unable to provide the quality of care they envision because of circumstances that are outside of their control. Such was the case in this study where nurses felt they were providing substandard care because of a decision made at an organizational level. This type of distress may be particularly acute for nurses because of their proximity to the patient; they see firsthand the day-to-day impacts of broader organizational decisions.10 Liaschenko and Peter11 suggested that these types of dilemmas have worsened as nurses have transitioned to viewing themselves as autonomous professionals. Autonomy of practice is one of the key characteristics of a profession. However, decisions around patient flow, educational requirements, and staffing ratios are organizational decisions and are thus outside professional autonomy. Participants in this study seemed to shoulder a burden of

care for decisions that were outside their control. The degree to which nurses should have input into administrative decisions of this nature is controversial but what is clear is the potential impact on nurses’ working lives and the organizational climate if there is a gap between the care they envision and the care they deliver. Ironically, the expert nurses who are so integral to high-quality care may be the ones that feel it most acutely.

Conclusion Expert postanesthesia nurses caring for overflow ICU patients in PACU may experience distress and a sense of giving substandard care. The assumption that critical care nurses, regardless of sub-specialty, can transfer skills and knowledge to any critical care patient situation denies unit specific cultures and contributes to nurses knowing but not doing and doing but not knowing. An important clinical application of this study is the use of a planned change process and appropriate access to resources and standards to support a practice change of this nature. The nurses in this unit were able to identify very specific learning needs. A planned change process would have provided a forum for these nurses to discuss these concerns and ideas promoting engagement and ownership of the change process. One of the needs expressed repeatedly was to receive systematic orientation and easy access to current order sets and protocols. A planned change process would have identified this concern and allowed a system to be put in place to ensure necessary information and resources were available to the nurses at the bedside. Findings from this study suggest that this process of planned change may be even more important for experienced nurses who know that they do not know.

References 1. American Society of PeriAnesthesia Nurses. A joint position statement on ICU overflow patients developed by ASPAN, AACN, ASA’s Anesthesia care Team Committee and Committee on Critical Care Medicine and Trauma Medicine. 1999. Available at: http://www.aspan.org/ Portals/6/docs/ClinicalPractice/PositionStatement/1214/Po s_Stmt_4_Joint_ICU_Overflow.pdf. Accessed November 2, 2013. 2. Lindsay M. Is the postanesthesia care unit an intensive care unit? J Perianesth Nurs. 1999;14:73-77.

3. Johannes M. A new dimension of the PACU: The dilemma of the ICU overflow patient. J Perianesth Nurs. 2002;9:297-300. 4. Odom-Forren J. The PACU as critical care unit. J Perianesth Nurs. 2003;18:431-433. 5. Callaghan C, Lynch A, Amin I, et al. Overnight intensive recovery: Elective open aortic surgery without a routine ICU bed. Eur J Vasc Endovasc Surg. 2005;30:252-258. 6. Kiekkas P, Poulopoulou M, Papahatzi A, Androutsopoulou C, Maliouki M, Prinou A. Workload of postanaesthesia care unit nurses and intensive care overflow. Br J Nurs. 2005;14:434-438.

INTENSIVE CARE UNIT PATIENTS IN PACU 7. Thorne SE. Interpretive description. Walnut Creek, CA: Left Coast Press; 2008. 8. Benner P, Tanner CA, Chesla CA. Expertise in nursing practice: Caring, clinical judgement, and ethics, 2nd ed. New York, NY: Springer; 2009. 9. Liaschenko J, Fisher A. Theorizing the knowledge that nurses use in the conduct of their work. In: Reed P, Shearer NC, Nicoll LH, eds. Perspectives on nursing theory,

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4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2004: 473-483. 10. Peter E, Liaschenko J. Perils of proximity: A spatiotemporal analysis of moral distress and moral ambiguity. Nurs Inq. 2004;11:218-225. 11. Liaschenko J, Peter E. Nursing ethics and conceptualizations of nursing: Profession, practice, and work. J Advan Nurs. 2004;46:488-495.

Intensive care unit patients in the postanesthesia care unit: a case study exploring nurses' experiences.

The purpose of this study was to understand the experiences of postanesthesia nurses caring for intensive care unit (ICU) patients in the postanesthes...
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