Crisis situations are common in the care of acutely and critically ill patients. A psychiatric crisis calls for de-escalation strategies, security personnel, sedation, and restraints. During a crisis, in addition to providing direct care in response to the patient’s urgent physiological needs for intervention, the nurse must also prepare, orchestrate, and coordinate multiple aspects of the environment. Acute and critical care environments are generally set up at all times for a possible emergency. Experiential leadership is seeing what needs to or must be done before or during a crisis and doing it, even though a physician is present. Recognizing clinical talent and marshaling skilled clinicians requires astute clinical judgment and skill and is a pervasive aspect of caring for critically ill patients in crisis. An aspect of skilled know-how required for smooth management of a crisis is modulating one’s emotional responses to assist others in their ability to function well.

This chapter presents some of the educational strategies and implications of integrative teaching and learning. It describes two major types of integrative strategies that follow the logic of practice. First, multiple examples of how to coach situated learning in actual practice that have proven successful in developing embodied knowledge and skillful, intelligent performance, are detailed. Second, a Thinking-In-Action approach to integrating classroom with clinical teaching exemplifies how to teach learners to use extensive scientific, technological, and theoretical knowledge in the context of an unfolding patient situation that changes over time, while imaginatively responding to the patient’s multiple needs and other demands in the situation. In order to be effective clinicians, the student and developing nurse must progress to grasping the nature of whole clinical situations, developing an experience-based sense of salience and using multiple frames of reference that encompass patient and family-focused care.

Spirituality is essential to the holistic health of patients, their families, and health care providers. It addresses the “inner reality of human beings”, and provides a deeper understanding of our life’s purpose. It cannot be easily defined, yet it is evident in the values and ethics of all individuals. Spirituality has an important role in patient care and impacts nursing theory, research, and education. Often the role religion plays in an individual’s personal sense of spirituality can obstruct maintaining an open and unbiased view of the spiritual needs of others. Spiritual patient care needs could be greatly compromised if holistic support remains based on religiosity. The strengths of the research can be found in the large number of studies, long periods of observation, different cultural groups studied, and the consistent results confirming the health benefits of religious and spiritual beliefs.

The needs and expectations of the family of critically ill patients are replete in the literature. A family-centered care concept views a patient’s family as a unit to be cared for and organizes care delivery around the patient’s family, as opposed to the more traditional patient centered model. Partnership with family serves to promote a holistic approach to the care of patients with critical illness. The American Association of Critical Care Nurses (AACN) reconceptualized the synergy model to form their AACN Synergy Model for Patient Care to address the needs of critically ill patients. An ongoing and proactive approach to the family ensures attention to patient care and may prevent conflict or crisis during periods of high family stress. As family presence becomes a more accepted practice, health care providers will need to accommodate families at the bedside and address unit and system specific barriers.

Overcrowding in EDs is a nationwide challenge. A new focus that links hospital reimbursement to customer satisfaction adds another element to the practice of patient care. These issues have prompted creative methods of resource utilization. One solution is to place a provider in triage to mitigate overcrowding challenges; reduce wait times; and rapidly and efficiently assess, diagnose, and initiate care for patients. This chapter offers ideas related to process and teamwork initiatives as well as communication tips that can help improve the communication and productivity of triage teams and enhance collaboration. It helps the reader to state the purpose of placing a provider in triage, discusses the importance of communication in triage, and lists out the tips for a provider in triage. Placement of a provider in triage serves a multitude of functions and offers numerous potential benefits that influence quality of care.

Triage entails the process of patient throughput from the point of entry to patient disposition and transfer of care to the next provider in the emergency treatment area. Documentation of this process is mandatory and serves multiple purposes. Many documentation components are necessary for a comprehensive triage assessment. This chapter focuses on the essentials of good triage documentation. It gives a systematic approach for the collection and recording of necessary triage data in the patient medical record. It helps the nurse to recognize a systematic approach for the collection and recording of necessary triage data in the patient medical record and to state one mnemonic to guide the subjective component of a triage assessment. The chapter also helps the nurse to state all elements of the objective component of a triage assessment and to identify key elements required for meeting best practice in triage documentation.

Core measures are national initiatives used to drive quality patient care, grounded by evidence-based research, with the goal of achieving best patient outcomes. Approximately 10 core measures exist with several specifically influencing ED care. Prehospital personnel, hospital-based employees, telephone triage nurses, and urgent care staff should be aware of these measures so actions can be taken to ensure the patient receives appropriate care. Acute myocardial infarction, pneumonia, and stroke are the most common core measure presentations seen in the ED, with sepsis being a likely up-and-coming core measure. This chapter helps the triage nurse to identify screening and assessment questions for core measure initiatives in the ED and to describe core measure treatment goals. It lists key core measure nursing actions. Triage nurses play an important role with time-sensitive conditions often referred to as core measures. Meeting core measure timelines requires the triage nurse to be familiar with the associated criteria.

Clinical forethought refers to the habits of thought that allow clinicians to anticipate likely clinical eventualities and to take the actions warranted. Clinical forethought requires prior experiential learning with similar patient care situations. It also requires clinical imagination. Effective clinical forethought requires the best scientific understandings of a particular patient problem and clinical wisdom gained through experience. Learning to think-in-action in any practice medicine, law, nursing, teaching, or social work is based on learning prototypical situations and then filling out these prototypes with actual clinical experience so that the prototypical cases become more nuanced and particularized in specific patient encounters. The nurse with a good map of the patient’s vulnerabilities, such as co-morbid conditions like diabetes, is in a better position to locate the risks and thereby anticipate and prevent problems for particular patients.

Increases in patient volumes and the need to expedite high-quality care have challenged healthcare leaders to implement creative methods in order to meet ongoing patient demands. The use of advanced triage protocols (ATPs) is one approach to working with these challenges. Understanding the purpose of ATPs and implementing them during the triage process can increase patient and staff satisfaction, decrease long wait times, and improve patient throughout while simultaneously enhancing patient safety. This chapter reviews the key concepts of ATPs and provides ideas for how to utilize ATPs to support patient care. It helps the nurses to understand what ATPs are and why they are used and to state considerations and concerns about ATPs. The chapter explains common ATPs and key points to remember. ATPs can direct care processes to continue regardless of routine or unexpected delays and are helpful when a medical provider or a treatment area is not immediately available.