1953-1954

Opening of first ICUs (including at Chestnut Hill Hospital, PA), usu. of 4-6 beds (Fairman & Lynaugh, 12-13). ICUs neutralized patient stratification via gender and economics and race (16) and promoted equality with physicians: “physicians would have to relinquish their traditional monopoly on clinical knowledge and decision-making (18). ICU nurses organized into American Association of Cardiovascular Nurses in 1969, renamed American Association of Critical-Care Nurses (AACN) in 1971, but ANA refused affiliation with them as an ANA interest group (18-20). ICUs are response to several post-WWII developments in hospitals: (1) increased utilization (via Hill-Burton Act); (2) newly complex and demanding (e.g., postsurgical cardiac patients [now with early postsurgical ambulation (31)]l; stroke patients; dialysis patients; more complicated drug regimens; (3) shift to predominantly semiprivate (covered by private insurance) and private rooms and elimination of large (e.g., 30-50 patient) wards (also promoted by Hill-Burton Act). Nurses could no longer monitor critically ill patients in semiprivate rooms: privacy always entailed sacrifices of continuous supervisions; nurses’ work moved from patient’s room (general ward) to hallways between rooms, etc. (40-43). Division of labor within ICUs results from grassroots movement outside of hospital bureaucracy “as nurses and physicians informally negotiated, through trial and error, new boundaries in patient care” (84) . . . . Emotional and geographic closeness, in turn, supported informal knowledge ‘trades.’ Nurses’ strategic position at the patient’s bedside enabled them to trade knowledge of the patient’s condition for physician’s knowledge of physiology or interpretation of data” (85). Yet, “By sharing decision-making, physicians yielded some level of responsibility and conceded the expertise of nurses without relinquishing any real power or control. Nurses gained only uncodified authority in physicians’ absence” (80). In physicians’ absence, they followed prescribed protocols and, absent protocols, they relied on “informal contracts defining expanded boundaries of nurses’ authority and responsibility (e.g., re, beginning in early 60s, performing closed-chest cardiac massage for cardiac arrest (82).