principles of critical care nursing

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Part I: The Essentials presents core information that clinicians must understand to provide safe, competent nursing care to all critically ill patients, regardless of the setting or diagnoses. This part includes content on assessment, diagnosis, planning, and interventions common to critically ill patients and their families; interpretation and management of cardiac rhythms; hemodynamic monitoring; airway and ventilatory management; pain, sedation, and neuromuscular blockade management; pharmacology; and ethical and legal considerations. Chapters in Part I provide the critical care clinician with information to develop foundational competence.

Part II: Pathologic Conditions covers pathologic conditions and management strategies commonly encountered in critical care units, closely paralleling the blueprint for the CCRN certification examination. Chapters in this part are organized by body systems and selected critical care conditions, such as cardiovascular, respiratory, multisystem, neurologic, hematologic and immune, gastrointestinal, renal, endocrine, and trauma.

Part III: Advanced Concepts in Caring for the Critically Ill Patient presents advanced critical care concepts or pathologic conditions that are more complex and represent expert level information. Specific advanced chapter content includes ECG concepts, cardiovascular concepts, modes of ventilation, and neurologic concepts.

Part IV: Key Reference Information contains selected reference information including laboratory and diagnostic values that apply to the content cases in the text; cardiac rhythms, ECG characteristics and treatment guide and hemodynamic troubleshooting. New in this edition is a table that demonstrates how conventional, contingency, and crisis standards of care are implemented. Content in part IV is presented primarily in table format for quick reference.

Sarah A. Delgado, MSN, RN, ACNP

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Essential critical care skills 1: what is critical care nursing?

18 October, 2021

Critical care nurses provide highly skilled, expert care for the most severely ill or injured patients. This introduction - part one of a six-part series – provides an overview of their role

In this first article of a six-part series on critical care nursing, we introduce the role and what it involves, as well as looking at how critical care nurses can support the whole patient, from a physical and psychosocial perspective. The importance of rehabilitation, assessment of risk of ongoing morbidity and delirium are also discussed. Part 2 describes the assessment of the critically ill patient.

Citation: Credland N et al (2021) Essential critical care skills 1: what is critical care nursing? Nursing Times [online]; 117: 11, 18-21.

Authors: Nicki Credland is reader in critical care, University of Hull; Louise Stayt is senior lecturer, Oxford Brookes University; Catherine Plowright is professional adviser, British Association of Critical Care Nurses; David Waters is associate professor, Birmingham City University.

• This article has been double-blind peer reviewed
• Scroll down to read the article or download a print-friendly PDF here (if the PDF fails to fully download please try again using a different browser)
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Introduction

Critical care nurses provide expert, specialist care to the most severely ill or injured patients in intensive care units and the wider hospital. They are highly trained and skilled safety-critical professionals working as part of a multidisciplinary team. Critical care is classified using four levels of patient acuity, as outlined in Table 1. Updated guidelines for the provision of intensive care services (Faculty of Intensive Care Medicine, 2019) recommend that level-3 patients should have a minimum registered nurse–patient ratio of 1:1 and level-2 patients must have a minimum nurse–patient ratio of 1:2.

To deliver highly skilled care, critical care nurses undertake postgraduate study and ongoing training. The Step Competency Framework underpins critical care nurse education; it recognises that, to be able to deliver high-quality care to patients, staff need the knowledge and skills so they can work at the highest level, with standardisation across all critical care units. Step 1 for adult critical care begins when a nurse with no previous experience of the specialty starts working in intensive care medicine. Steps 2 and 3 should be incorporated into academic intensive care programmes.

Critical care nurses also lead many outreach teams that identify, monitor and initiate timely treatment to prevent clinical deterioration, and support ward nurses (Department of Health, 2000). They offer advanced system assessment and rescue before irretrievable deterioration and cardiac arrest takes place.

This article is the first in a six-part series on essential critical care skills, which aims to explore essential critical care nursing competencies.

Managing organ dysfunction

Admission to a critical care unit is usually because of organ dysfunction or organ failure. Respiratory failure alone leads to around 100,000 annual admissions to critical care in the UK (FICM, 2019). The goal is to correct or provide support to these dysfunctional organs. Technological and medical advances over the past few decades have meant significant growth in treatments and interventions, and more-effective management of patients who need organ support.

The interventions most commonly used include mechanical ventilators, infusion devices and renal replacement therapy. Table 2 outlines the interventions used for different physiological systems.

Patient monitoring and documentation

It is crucial to gather accurate data on physiological parameters – such as oxygen saturation (SpO2), heart rate and fluid balance – at the bedside of the patient who is critically ill. Typically, each patient will have their own monitor that will display a range of clinical factors (Box 1) and provide real-time feedback to help evaluate critical care interventions, and detect any deterioration or emergency situations promptly.

Box 1. Clinical factors recorded by bedside monitors

• Heart rhythm
• Oxygen saturation
• Respiratory rate
• Exhaled carbon dioxide concentration/partial pressure
• Non-invasive blood pressure
• Arterial blood pressure
• Central venous pressure
• Temperature

Critical care nurses need technical skill and knowledge to effectively use and interpret bedside monitors. A further common technical resource is the clinical information system (CIS), which can record and process large amounts of data, such as:

• Patient physiological observations;
• Care or interventions delivered;
• Medication plans.

The FICM (2019) highlights how a CIS can not only improve efficiency, but also reduce errors and improve compliance with standards or guidelines.

Psychosocial care

Holistic patient-centred care – as outlined by Jasemi et al (2017) – is vital in critical care, with effective psychosocial care, and cultural, spiritual and family care being of particular significance. Immediately on admission to a critical care setting, patients are subjected to an onslaught of physical and psychosocial stressors including:

• Physical pain;
• An unfamiliar environment; equipment and treatments;
• Sensory disturbances;
• Isolation from family;
• Loss of autonomy;
• Impaired communication;
• Fear for their life (Kiekkas et al, 2010).

It can lead to severe emotional distress and the development of delirium, anxiety, depression and post-traumatic stress disorder (PTSD) (Hatch et al, 2018) – all of which may persist long after the patient’s physical recovery and discharge from hospital (Ewens et al, 2018).

Psychosocial care is often considered the touchstone to person-centred care and, in this setting, refers to supportive interventions that may mitigate the stressors associated with critical illness. Evidence-based measures that may all help include:

• Providing information and explanations;
• Regularly orientating the patient to date, time and place;
• Reassurance;
• Empathetic touch;
• Early mobilisation;
• Family visits;
• Maintaining clear night and day routines;
• Minimising noise (Bani Younis et al, 2021; Alaparthi et al, 2020; Parsons and Walters, 2019).

Delirium is of particular concern in patients who are critically ill, and has an incidence range of 45-87% (Cavallazzi et al, 2012). It is characterised by the acute onset of cerebral dysfunction, with a change or fluctuation in baseline mental status, inattention, disorganised thinking or an altered level of consciousness (NICE, 2019). Delirium is associated with significant increases in mortality, morbidity and hospital stay, as well as having long-term ramifications such as cognitive impairment, PTSD, anxiety and depression (Cavallazzi et al, 2012) so the prevention, early recognition and effective management of it is of paramount importance. The ABCDEF bundle of care may help:

• A ssessment, prevention and management of pain;
• Awakening the patient and doing a spontaneous B reathing trial;
• C hoice of sedation and analgesia;
• Assessment, prevention and management of D elirium;
• E arly mobilisation;
• F amily engagement (Marra et al, 2017) .

Cultural and spiritual care

A patient’s cultural and spiritual background influences many aspects of nursing in critical care, such as patient and family roles, communication, nutrition, values and beliefs towards health, care and treatments, and end-of-life care. Careful assessment of the patients’ health beliefs, communication needs, social networks and family dynamics, dietary requirements, religious practices and values, is essential to plan and deliver culturally sensitive and spiritual care that contributes to the quality of life, care and satisfaction of patients as well as their families (Willemse et al, 2020).

Family care

Family members of patients who are critically ill can play an important part – often acting as surrogate decision makers – and be essential in providing emotional and social support. However, relatives may experience extreme stress, fear and anxiety, both during and after the patient’s admission. Relatives are also vulnerable to ongoing psychological illnesses such as PTSD, anxiety and depression (Johnson et al, 2019). Nurses need to develop a collaborative relationship with them to effectively identify and address their immediate needs, as well as prepare them to cope with their loved one’s discharge and ongoing rehabilitation. Families need honest and timely information, assurance, proximity, comfort and support (Scott et al, 2019).

Rehabilitation

Critical illness can cause significant long-term physical and non-physical problems for patients, and rehabilitation is important to improve recovery. National guidelines, such as those by the FICM (2019) and the National Institute for Health and Care Excellence (2017), have supported this, with the aim of improving these patients’ physical, psychological and cognitive outcomes.

Patients should be assessed at the following key stages:

• Within four days of admission to a critical care unit, or earlier if being discharged;
• Just before discharge to ward-based care;
• When receiving ward-based care;
• Before discharge to their home or community care;
• Two to three months after discharge from the critical care unit.

Rehabilitation should be patient centred, involve the whole multidisciplinary team and occur throughout the patient pathway, with plans updated as the patient’s condition changes (FICM, 2019). Physiotherapists, occupational therapists, dieticians, speech and language therapists, critical care nurses and doctors, as well as patients and their families, all have a role.

Short clinical assessments should be done with all patients in critical care to identify their risk of physical and non- physical morbidity. A short clinical assessment is applicable for patients who are expected to recover quickly, despite requiring initial level-3 care, and should assess a range of factors (Box 2). If the patient is deemed at risk, a comprehensive clinical assessment should be undertaken; this will also assess physical and non-physical risk (Box 3).

Box 2. Short clinical assessment

The following may indicate that the patient is at risk of physical/non-physical morbidity and needs further assessment:

• Unable to get out of bed independently
• Anticipated long duration of critical care stay
• Obvious significant physical or neurological injury
• Lack of cognitive functioning to continue exercise independently
• Unable to self-ventilate on 35% of oxygen or less
• Presence of pre-morbid respiratory or mobility problems
• Unable to mobilise independently over short distances

Non-physical

• Recurrent nightmares, particularly if the patient reports trying to stay awake to avoid them
• Intrusive memories of traumatic events that occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks)
• New or recurrent anxiety or panic attacks
• Expressing a wish not to talk about their illness or changing the subject quickly

Box 3. Comprehensive clinical assessment

This assessment should be undertaken for all patients identified as being at risk of physical or non-physical morbidity.

Physical issues

• Breathlessness
• Tracheostomy
• Artificial airway
• Swallowing issues
• Poor nutritional state
• Minor assistance needed
• Major assistance needed
• Full assistance needed
• Visual changes
• Hearing changes
• Altered sensations
• Sedated/pain
• Difficulties in speech
• Changes in voice quality
• Difficulty writing
• Poor wound healing

Non-physical issues

• Palpitations, irritability or sweating
• Hallucinations, delusions
• Flashbacks, withdrawal, traumatic memories of critical care
• Loss of memory
• Attention deficit
• Sequencing problems
• Lack of organisational skills
• Disinhibition
• Low self-esteem
• Low self-image
• Relationship difficulties
• Difficulty sleeping

During the assessment of these patients, a range of tools may be used including the following:

• Hospital Anxiety and Depression Score (Zigmond and Snaith, 1983);
• Barthel Activities of Daily Living Index (Wade and Colin, 1988);
• Chelsea Critical Care Physical Assessment Tool (Corner et al, 2013).

Many critical care units provide follow-up services for patients after discharge, giving them access to a range of health professionals, including critical care nurses, to assess physical and non-physical recovery (NICE, 2017). If these are not available, patients can be directed to ICU Steps (www.icusteps.org), which can help to support patients and families affected by critical illness.

This article aims to provide an overview of critical care and the critical care nurse role. The following articles in this series will explore in more detail key issues relating to the management of patients who are critically ill.

• Critical care nursing is highly skilled, and requires postgraduate study and training
• Critical care nurses provide outreach to support ward nurses who are caring for patients at risk of deterioration
• Care of patients on critical care units often involves organ system support and close monitoring is needed
• A holistic view of the patient – which takes into account physical and psychosocial matters – is vital, as is supporting families

Also in this series

• Essential critical care skills 2: assessing the patient
• Essential critical care skills 3: arterial line care
• Essential critical care skills 4: airway assessment and management
• Essential critical care skills 5: management of fluid balance
• Essential critical care skills 6: arterial blood gas analysis

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Oxford Handbook of Critical Care Nursing (2 edn)

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Reflecting current best practice, the Oxford Handbook of Critical Care Nursing, Second Edition is a practical, concise, easily accessible, and evidence-based guide for all levels of nursing staff working in critical care environments. It aims to provide a quick, easy-to-follow overview of critical care nursing, and is not intended as a specialist text. Rather it provides both the novice and the experienced nurse at the bedside with the answers to day-to-day problems experienced when caring for critically ill patients, and is also a guide to some of the less commonly encountered issues. The second edition has been updated to reflect recent significant changes in the management of the critically ill adult. Current guidance from organizations such as the National Institute for Health and Care Excellence (NICE), the British Association of Critical Care Nurses (BACCN), and the Intensive Care Society (ICS) has been included. In addition to the updating of clinical guidance, an emphasis has now been placed on nursing management, and the book is designed to help to facilitate systematic nursing assessment of the critically ill adult. New chapters focusing on changes in the delivery of critical care, systematic assessment, and end-of-life care have also been added.

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Basic Principles of Intensive Care Nursing

The Critical Care Team at the Royal Berkshire Hospital has developed a video demonstrating the basic principles of Critical Care nursing. Prompted by a significant surge in patients requiring Critical Care support, these videos are targeted at staff with little to no previous ICU experience.

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Basic principles of Critical Care Nursing - airway

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Original research

Clinical practice competencies for standard critical care nursing: consensus statement based on a systematic review and delphi survey, hideaki sakuramoto.

1 Department of Critical care and Disaster Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata, Fukuoka, Japan

Tomoki Kuribara

2 Department of Acute and Critical Care Nursing, School of Nursing, Sapporo City University, Sapporo, Hokkaido, Japan

Akira Ouchi

3 Department of Adult Health Nursing, College of Nursing, Ibaraki Christian University, Hitachi, Ibaraki, Japan

Junpei Haruna

4 Intensive Care Unit, Sapporo Medical University Hospital, Sapporo, Hokkaido, Japan

Takeshi Unoki

Associated data.

bmjopen-2022-068734supp001.pdf

bmjopen-2022-068734supp002.pdf

bmjopen-2022-068734supp003.pdf

bmjopen-2022-068734supp004.pdf

bmjopen-2022-068734supp005.pdf

bmjopen-2022-068734supp006.pdf

bmjopen-2022-068734supp007.pdf

bmjopen-2022-068734supp008.pdf

bmjopen-2022-068734supp009.pdf

bmjopen-2022-068734supp010.pdf

bmjopen-2022-068734supp011.pdf

All data relevant to the study are included in the article or uploaded as supplementary information.

A clear development process and scientifically validated clinical practice competencies in standard critical care nursing (SCCN) have not yet been developed in Japan. Thus, this study aimed to develop a consensus-based set of SCCN competencies to provide a framework for critical care nursing education, training and evaluation.

Multistep, modified Delphi study (a systematic review, focus group interviews, a three-round web-based Delphi survey and an external validation process).

Participants

A systematic review of 23 studies, focus group interviews by 12 experts, a Delphi survey by 239 critical care experts (physicians, nurses and physical therapists) and an external validation by 5 experts (physicians and nurses).

A systematic review identified 685 unique competencies. The focus group interviews resulted in the addition of 3 performance indicator items, a synthesis of 2 subdomains and 10 elements. Of the 239 participants, 218 (91.2%), 209 (98.9%) and 201 (96.2%) responded in rounds 1, 2 and 3 of the Delphi survey, respectively. After round 3, 57 items were below the consensus level and were removed in the final round. External validation process feedback was received from experts after two revisions to ensure that the final competencies were valid, applicable, useful and clear. The final set of competencies was classified into 6 domains, 26 subdomains, 99 elements and 525 performance indicators.

Conclusions

This study found a set of SCCN competencies after a multistep, modified Delphi study. The results of this study are robust, and the competency framework can be used in multiple areas to improve clinical practice, including the assessment, training and certification of standard critical care nurses.

Strengths and limitations of this study

• Contemporary clinical practice competencies developed for standard critical care nursing are highly reliable due to the use of a multistep, modified Delphi study (systematic review, focus group interviews, three rounds of web-based Delphi surveys and external validation process).
• Few studies on clinical practice competencies for standard critical care nursing have been reported.
• A limitation of the study is that patients and families were not involved, although they are important stakeholders in determining nursing competence.
• The lack of a prioritisation or ranking system in expert panels and Delphi rounds is a methodological limitation, which may have resulted in broad and highly detailed competency items.

Introduction

Critical care nursing deals with specific human responses to actual or potentially life-threatening problems. 1 According to the World Federation of Societies of Intensive and Critical Care Medicine, critical care is ‘a multidisciplinary and interprofessional specialty dedicated to the comprehensive management of patients having, or at risk of developing, acute, life-threatening organ dysfunction’. 2 In recent years, intensive care medicine has undergone significant changes because of the increasing number of older individuals and complexity and advancements in medical equipment. 2 It also serves the needs of survivors experiencing post-intensive care syndrome. 3 Thus, critical care nurses must have more complex competencies in the intensive care unit (ICU) than non-critical care nurses.

However, the education provided to critical care nurses involves a long-term training process and is unable to meet rapidly increasing demands, such as disasters. 2 4 The shortage of critical care nurses worldwide during the coronavirus disease 2019 (COVID-19) pandemic became a serious issue. 4 In Japan, there is no system to identify the number of nurses who can provide standard critical care; thus, determining the actual shortage of nurses and from where they should be supplied is impossible. 5 These issues highlight the lack of clinical practice competencies in standard critical care nursing (SCCN) in Japan.

Competencies are generally defined as a combination of knowledge, skills, attitudes and values that support effective and efficient performance in professional or occupational areas. 6 7 A competency framework is a range of required behaviours that provide structural guidelines, which enable admission, development, education, training and evaluation. 7 Therefore, by identifying competencies, SCCN competency helps define and provides a framework for the evaluation of actual knowledge, skills and abilities in the practice of critical care. 8 9 In addition, SCCN competencies lead to the development of a system to register critical care nurses with competence characteristics. 5 7 Several national and international clinical practice competencies for critical care nurses already exist. 8 9 However, a clear development process and scientifically validated competencies have not been previously developed in Japan. In addition, SCCN competency is strongly influenced by sociocultural factors related to healthcare and the era. 10

Therefore, developing a scientific method for identifying the characteristics of SCCN competencies in Japan is necessary. This study aimed to develop a consensus-based set of SCCN competencies for teaching and learning programmes, and a framework for the evaluation of critical care nursing. The standardised education provided to critical care nurses also presents challenges for several countries because of the differences in the era and healthcare culture. 8 11 Therefore, a detailed description of the design presented in this study and its results and other competencies can be used in several countries as a framework for standardised education of critical care nurses and a resource for future studies. 8 11 12

Material and methods

Study design.

This study was conducted as a multistep, modified Delphi study with reference to previous studies. 13 First, a systematic review (SR) was conducted to construct the initial competencies that include related potential competencies. Second, focus group interviews were conducted with expert nurses for supplementary and content expert validation. Third, a modified three-round Delphi survey was performed using an internet-based questionnaire to reach a consensus among critical care nurses. Finally, feedback on the final competencies was obtained from external experts ( figure 1 ).

Overall research methods. The overall research methods of the study are shown: A consensus-based set of standard critical care nursing competencies was developed in four stages. ICU, intensive care unit.

This study was contracted on behalf of the Committees of Nursing Education and Critical Care Nursing and Working group for Critical Care Nurse Survey Working Group and the AdHoc Committee of Intensive Care Registered Nurse, Japanese Society of Intensive Care Medicine (JSICM).

Development of initial competencies based on an SR

We conducted an SR according to the detailed methodology presented in online supplemental materials 1–3 . The eligibility criterion was competencies related to SCCN. MEDLINE using PubMed, Cumulative Index to Nursing and Allied Health Literature and Igaku-Chuo-Zasshi (Ichu-shi) databases were manually searched for related studies. Ichu-shi is a Japanese medical database managed by the Japan Medical Abstract Society. Only studies written in Japanese or English were included. Two author groups (HS and TK, AO and JH) independently screened the titles and abstracts for inclusion eligibility. After screening, two authors independently assessed the full text to identify eligible literature. Disagreements were resolved through a discussion. Subsequently, one of the authors (TK) extracted the competencies from the eligible literature. We translated all competencies into Japanese and reviewed this competency set as the initial competencies for duplication, overlap and clarity. Subsequently, the research team classified the words or phrases extracted from the literature into different themes and abstraction levels, such as nursing practice and communication. The researchers ultimately classified the domains, subdomains, elements and performance indicators at four abstraction levels.

Supplementary data

Focus group interview.

We conducted a focus group interview (FGI) with expert nurses and researchers according to the Benner’s clinical skills acquisition model. 14 The FGI was conducted to supplement and validate the initial competencies developed based on the SRs from an expert’s perspective. We recruited participants who met both the following criteria using the purposive snowball sampling method to include a diverse range of critical care researchers and experts: (1) critical care nurses who had experience in ICU nursing for >10 years and (2) researchers or expert nurses (certified nurses or nurse specialists who have received formal national critical care education as expert nurses) in the critical care field. The selection was made to ensure a balance between experts and researchers and a broad selection from different regions and institutions in Japan.

In total, 10 participants were recruited for the FGI. The FGI was conducted in two groups, comprising five members per group, for approximately 60 min using Zoom (Zoom Video Communications, San Jose, California, USA). The participants who wanted to join the FGI submitted their personal information through the internet. All the researchers were trained beforehand, and their roles for the day were predetermined. The FGI was recorded using the recording function of Zoom, and the interviews were transcribed. Subsequently, a qualitative analysis of the verbatim transcript was performed in three steps. First, we created a code that was shortened to a point where the meaning of the sentence could be understood. Second, the codes and selected keywords related to clinical practice competencies for SCCN obtained from the FGI were organised. Third, the organised codes and selected keywords from the FGI results were compared with the initial set of competencies obtained in the SR. Competency items for initial competencies were added or revised, as required.

Three-round Delphi survey

A modified three-round Delphi survey was conducted to attain a consensus on SCCN competencies among healthcare professionals who work in the critical care settings. 15 The invitation was distributed via the mailing lists of the JSICM and Japan Society of Education for Physicians and Trainees in Intensive Care. An invitation was also posted in community mailing lists and social network services, such as the Japan Association of Certified Intensive Care Nurses Twitter and Facebook. According to the Benner’s model of clinical skills acquisition, 14 only healthcare professionals who had more than 6 years of experience working in the ICU were eligible for the modified Delphi survey. Data were collected from 4 December 2021 to 10 February 2022. Owing to the large number of items, the initial competencies were divided into six groups. We planned to include 40 participants in each group, for a total of 240 participants, assuming 10 dropouts in each group in the three rounds.

SurveyMonkey (Momentive, San Mateo, California, USA) web-based survey service was used for all three rounds of the Delphi survey. Participants rated each SCCN competency using a Visual Analogue Scale (VAS) anchored with two descriptors labelled ‘not needed at all’ at the far left (0) and ‘fully needed’ at the far right (100), and they wrote free comments. In the first and second rounds, we decided to obtain a consensus for each competency using a median VAS score of >70. In the third round, consensus was obtained based on a median VAS score ≥80. A post-meeting to discuss the results of the Delphi round was conducted by the researchers after each Delphi round. In the post-meeting, based on the free comments, revisions or deletions for competency items that did not reach consensus based on the value of VAS were discussed.

External validation

The pre-final set of competencies was sent to five experts (intensivist, critical care nurse, clinical nurse specialist and nurse manager) to obtain feedback and ensure the validity, applicability, utility and clarity of competencies. These five experts were recruited using purposive sampling. The manuscript was revised based on comments from experts, the revised pre-final set of competencies was re-sent and a consensus was obtained from all experts.

Patient and public involvement

No patient or the public was directly involved in the development of this Delphi study.

Generation of an initial set of relevant SCCN competencies

In total, 685 SCCN competencies were identified in the SR. These competencies were classified into 6 domains, 29 subdomains, 111 elements and 639 performance indicators after removing duplicates ( online supplemental materials 4–6 ). The two FGIs were conducted by 12 experts. One expert withdrew from the interviews. The characteristics of the experts who conducted the FGIs have been presented in online supplemental material 7 . The FGI resulted in the addition of 3 performance indicator items, a synthesis of 2 subdomains and 10 elements. Revisions were also made to the SCCN’s competency representation by FGIs.

The demographic characteristics of the participants are presented in table 1 . Among the registered professionals, 53.6% were women and the median (IQR) healthcare work and ICU work experiences were 15 (11–20) and 10 (8–13) years, respectively. Of the 239 professionals who registered, 218 (91.2% of registered professionals), 209 (98.9% of round 1 participants) and 201 (96.2% of round 2 participants) responded in rounds 1, 2 and 3 of the Delphi survey, respectively. The withdrawal rates between enrolment and each round were <10% each ( table 1 and figure 2 ).

Characteristics of the participants in the three-round Delphi survey

*Duplicate responses available, percentage of total nurses.

†CNS is an advanced practiced nurse who completed a graduate master’s programme and accreditation by the Japanese Nursing Association.

‡CN is an expert nurse who completed half a year of formal education and accreditation by the Japanese Nursing Association.

CN, certified nurse; CNS, certified nurse specialist; ICU, intensive care unit.

Flow diagram for development of competencies. The number of competencies obtained after the systematic review and subsequent stages is shown in the figure. The number of competencies revised, deleted or added to each group in the three Delphi rounds is indicated. The number of participants that dropped out in each round is shown. FGI, focus group interview; SCCN, standard critical care nursing; SR, systematic review.

After round 1, 89 items were below the consensus level (VAS <70) or required revision based on the free comments. After discussions among the researchers, 22 items were deleted and 67 items were revised. In addition, a new item was added based on the free comments. After round 2, 17 items were below the consensus level (VAS <70) or required revision based on the free comments. After discussions among the researchers, 8 items were deleted and 9 items were revised. In addition, a new item was added based on the free comments. After round 3, 57 items were below the consensus level (VAS <70) and were deleted in the final round. When the entire document was rechecked, 17 items were additionally deleted because they were duplicates. After discussions among the researchers, based on the free comments, 2 items needed revision and 1 item was added. Figure 2 illustrates the results of the modified Delphi survey. Online supplemental file 8 presents the detailed results for each round. No revisions were made to the domain subdomain elements.

Based on the expert comments, 21 performance indicator items were generated, 5 performance indicator items were added and 60 performance indicator items were revised for representation; one subdomain and two elements were generated after discussion among the researchers. Feedback was received from experts after two revisions to ensure that the final competencies were valid, applicable, useful and clear. After three rounds of the Delphi survey and external validation by experts, the final set of competencies was classified into 6 domains, 26 subdomains, 99 elements and 525 performance indicators.

Final SCCN competencies

A summary of the overall results is shown in figure 2 and table 2 , and details of the final SCCN competencies are shown in online supplemental materials 9, 10 . Domain 1 required critical care nurses to understand each organ’s anatomy and physiology and the techniques and knowledge required for physical assessment. Domain 2 required critical care nurses to develop a series of nursing processes for critically ill patients and provide nursing care that considers the mental and psychological aspects of patients and their families. Domain 3 required critical care nurses to support patients and families in decision-making and practice in compliance with ethical principles and laws. Domain 4 required critical care nurses to acquire new knowledge, skills and practices based on evidence to constantly improve the quality and safety of nursing care. Domain 5 required critical care nurses to manage their unit’s work environment and collaborate with other healthcare providers. Finally, domain 6 required critical care nurses to reflect introspectively on practice and keep learning to change their behaviours.

Final set of competencies

*Total number of each item.

ICU, intensive care unit; PDCA, plan-do-check-assessment; PICS, post-intensive care syndrome.

In this study, the expert panel reached consensus on the importance of 541/643 competencies for SCCN, after a three-round Delphi survey. Subsequent revisions through external validity assessment resulted in 525 competencies. Finally, the developed clinical practice competencies for SCCN were categorised into six domains: therapeutic management and clinical judgement; caring, advocacy and moral agency; evidence-based practice; collaboration and management ability; and educational and self-development ability.

When the competency frameworks implemented in this study were compared with those of developed countries, the six domains generally overlapped with the existing competency frameworks that assessed SCCN characteristics. An SR was used to develop the main framework based on previous studies, which was then adjusted to fit the national legislation and the needs of patients’ families. Therefore, the domains were categorised as cultivating caring, advocacy, altruism and humanity and patient treatment management, physical assessment and clinical judgement, as in other countries. 8 16 With respect to differences, there were differences in the level of practice by law and in the performance indicator level according to the needs of the population. Multicultural considerations are common in critical care nursing practice in developed countries. In contrast, most Japanese patients are homogeneous 10 ; thus, cultural considerations are less prioritised.

The results of this study are highly trustworthy. Delphi results are evaluated with respect to trustworthiness rather than validity, as in quantitative surveys. Trustworthiness encompasses ‘sub-concepts’ that consist of the components of credibility, transferability, confirmability and dependability. 17 18 Previous studies have developed a set of standard critical care competencies, but they did not use an SR to support the Delphi survey. 8 9 16 The credibility of the findings was also confirmed by using previous relevant studies and by the number and expertise of the panellists, who represented various professional groups in critical care. The confirmability of the findings was verified using a replicated study design, as all data were obtained from identifiable sources. 18 The dependability of the findings indicated the repeatability of the results in other studies and confirmed a detailed description of the study design. 17 18 The findings of this study were robust, with low attrition rates and were from experts across several regions in Japan. The attrition rate at each stage of the Delphi survey is a hindrance. 19 In this study, a high response rate was achieved, with an attrition rate of <10% in the three rounds. In addition, the experts recruited for this study were active in various areas of critical care and were able to ensure that the competency framework constructed was comprehensive and specific to SCCN practices.

Therefore, the results of this study are robust, and the competency framework can be used in multiple areas to improve clinical practice, including the assessment of competency and competent level certification of critical care nurses. During the COVID-19 pandemic, the number of competent nurses who could provide intensive care nursing care was unknown in Japan. 5 Therefore, it was difficult to respond to the problem of critical care nurse shortage during the pandemic. In the future, nursing associations and academic societies will be able to use the results of this study to assess competency and certify the competent level of critical care nurses. If a system for education, assessment and certification of nurses who can provide standardised critical care nursing care is implemented based on these competencies, a system that can respond to unknown disasters, such as the COVID-19 pandemic, where nurses are in shortage, can be designed in the future.

This study may contribute to the standardisation of education in critical care nursing in Japan. Several countries in Europe and the USA have systems for educating and evaluating the competencies of clinical nurse specialists and critical care nurses. 8 The frameworks of these systems are also based on the identification of competencies. 8 9 16 In addition, previous studies have reported that higher level of competencies among critical care nurses established using competency-based certification systems is associated with lower complications and infection rates. 20 21 However, the education of general nurses working in the critical care field, being entrusted to each hospital in Japan, is not standardised. Using competencies for standard Japanese critical care nurses and developing educational programmes may lead to improvements in the quality of critical care, and subsequently the patient’s outcomes in Japan.

Strengths and limitations

A key strength of this study is the SR and Delphi survey approach used to achieve national consensus on a contemporary set of SCCN competencies. However, our study has some limitations. First, although the participants in the Delphi survey were selected to represent a multiplicity of health professions and expertise, they may not adequately represent the full range of views held by professionals. In addition, patients and families were not involved in this study, although they are important stakeholders in determining nursing competence. The competency in which consensus was reached in this study is the necessity to consider cultural influences on patient attitude toward health, illness, compliance and care. 10 A more comprehensive research design that involves patients and families is required in the future. Second, the methodological limitation of the lack of a prioritisation or ranking system in expert panels and Delphi rounds may be the reason for the broad and highly detailed competency items, reflecting the scope of work that a standard critical care nurse is expected to accomplish. Therefore, the competency framework may ultimately need to be shortened to improve its learning curve and applicability in clinical practice, in conjunction with professional needs. Moreover, a prioritisation or ranking system in expert panels and Delphi rounds should be added to the study methodology in future studies.

Clinical implications and further research

The competency framework in which consensus was achieved in this study can be used in multiple areas to improve clinical practice, including the assessment, training and certification of standard critical care nurses. A previous study suggested that nurses with more clinical experience and higher educational level had significantly better critical thinking and intuitive decision-making skills than less experienced and less educated nurses. 22 Therefore, in future studies, changes in these skills and patient outcomes should be measured before and after the implementation of a system for competency-based education, and certification programmes should be investigated. By contrast, we view this set of standard critical care competencies as a dynamic set that reflects the current state of healthcare. As the field matures, new competencies will need to be added and others need to be removed. Therefore, this set of competencies should be revised regularly. The detailed methodology presented will be a useful reference for future studies. In addition, future studies based on several study designs are also required, as indicated by the limitations. Moreover, further studies will be required to create excerpted versions (eg, informing educational programmes and performance evaluations) from the current set of competencies that are more amenable to knowledge mobilisation/use.

This study established a set of SCCN competencies and categorised them into 6 domains, 26 subdomains, 99 elements and 525 performance indicators after a multistep, modified Delphi study. The results of this study are robust, and the competency framework can be used in multiple areas to improve clinical practice, including the assessment, training and certification of standard critical care nurses.

Supplementary Material

Acknowledgments.

We thank the members of the Japanese Society of Intensive Care Medicine’s Committees of Nursing Education, Critical Care Nursing, Critical Care Nurse Survey Working Group and AdHoc Committee of Intensive Care Registered Nurses for their cooperation in this survey ( online supplemental material 11 , Contributors list). We would like to thank Editage ( www.editage.com ) for English language editing.

HS and TK contributed equally.

Collaborators: Miya Hamamoto (Nursing Department, Tosei General Hospital, Seto, Japan); Junko Tatsuno (Nursing Department, Kokura Memorial Hospital, Kitakyusyu, Japan); Yasunobu Tsuda (Nursing Department, St. Marianna University Hospital, Kawasaki, Japan); Megumi Moriyasu (Center of Critical Care, Kitasato University Hospital, Sagamihara, Japan); Satoshi Nakata (Graduate School of Nursing Science, St Luke’s International University, Chuo, Japan); Sachie Nishimura (Nursing Department, Okayama City Hospital, Okayama, Japan); Ryutaro Seo (Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan); Akihisa Okuda (Department of Clinical Engineering, Jikei University Katsushika Medical Center, Katsushika, Japan); Etsuko Moro (Department of Nursing, Jichi Medical University Hospital, Shimotsuke, Japan); Mio Kitayama, Nursing Department, Kanazawa Medical University Hospital, Uchinada, Japan); Yusuke Kawai (Department of Nursing, Fujita Health University Hospital, Toyoake, Japan); Yukiko Katayama (Nursing Department, Sakakibara Heart Institute, Fuchu, Japan); Kosuke Kitabeppu (High Care Unit, Kurashiki Central Hospital, Kurashiki, Japan); Noriko Inagaki (Faculty of Nursing, Setsunan University, Hirakata, Japan); Uemura Sakura (Emergency and Critical Care Medical Center, Osaka City General Hospital, Osaka, Japan); Tomomi Furumaya (Nursing Department, Saitama Red Coss Hospital, Saitama, Japan).

Contributors: HS: Guarantor, Conceptualisation, methodology, validation, investigation, data curation, formal analysis, writing—original draft and project administration. TK: Conceptualisation, methodology, validation, investigation, data curation, formal analysis, writing—original draft and project administration. AO: Conceptualisation, methodology, validation, investigation, data curation, formal analysis, writing, review and editing. JH: Conceptualisation, methodology, validation, investigation, data curation, formal analysis, writing—review and editing. TU: Conceptualisation, methodology, writing—review and editing.

Funding: This study was supported by grants from Sapporo City University (grant number: N/A) and grants from the Japanese Red Cross Kyushu International College of Nursing (grant number: N/A). The funders had no role in the study design, data collection and analysis, decision to publish or manuscript preparation.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Contributor Information

on behalf of the Committees of Nursing Education and Critical Care Nursing and Working group for Critical Care Nurse Survey Working Group and the AdHoc Committee of Intensive Care Registered Nurse, Japanese Society of Intensive Care Medicine : Collaborators: Miya Hamamoto, Junko Tatsuno, Yasunobu Tsuda, Megumi Moriyasu, Satoshi Nakata, Sachie Nishimura, Ryutaro Seo, Akihisa Okuda, Etsuko Moro, Mio Kitayama, Yusuke Kawai, Yukiko Katayama, Kosuke Kitabeppu, Noriko Inagaki, Uemura Sakura, and Tomomi Furumaya

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Definition and principles of nursing

Eight principles that apply to all nursing staff and nursing students in any care setting

Nursing is the largest safety critical profession in health and social care. The nursing team is diverse and includes the nursing support workforce.

The RCN last published a definition of nursing in 2003. This resource includes a new definition that depicts the change and increased complexity that the nursing profession has seen over the last two decades. 

The Principles of Nursing are mapped to and complement the NMC Code (for registrants).

Definition of Nursing

Nursing is a safety critical profession founded on four pillars: clinical practice, education, research, and leadership. Registered nurses use evidence-based knowledge, professional and clinical judgement to assess, plan, implement and evaluate high-quality person-centred nursing care.

Definition of Nursing (expanded version)

The work of registered nurses consists of many specialised and complex interventions. Their vigilance is critical to the safety of people, the prevention of avoidable harm and the management of risks regardless of the location or situation.

Compassionate leadership is central to the provision and co-ordination of nursing care and informed by its values, integrity and professional knowledge. Responsibility includes leading the integration of emotional, physical, organisational, and cognitive nursing work to meet the needs of people, organisations, systems, and populations.

Registered nurses are decision makers. They use clinical judgement and problem-solving skills to manage and co-ordinate the complexity of health and social care systems to ensure people and their families are enabled to improve, maintain, or recover health by adapting, coping, and returning to live lives of the best quality or to experience a dignified death. They have high levels of autonomy within nursing and multi professional teams, and they delegate to others in line with the NMC Code.

Footnote The leadership pillar for some nurses will include management responsibilities.

• RCN New Definition of Nursing: Background research and rationale . This summary explanation aims to provide the background to developing the revised RCN definition of nursing in support of the professional framework. It explains the reasons for the choice of language terms and the emphasis placed on the definition.
• RCN position on preserving safety and preventing harm: Valuing the role of the registered nurse

The Principles of Nursing

The Principles of Nursing are applicable to all of the nursing workforce. The Principles describe what everyone, from nursing staff to people and populations, can expect from nursing to deliver safe and effective nursing care. They cover the aspects of behaviour, attitude and approach that underpin good care and they are mapped to and complement the NMC Code .

Principle A - Equality, Diversity and Inclusion

Principle B - Accountability

Principle C - Safety Critical, Safe Care

Principle D - Personalised Person-Centred Care

Principle E - Communication and Informatics

Principle F - Knowledge and Skills

Principle G - Professional Standards

Principle H - Leadership

The term ‘nursing staff’ includes the nursing support workforce who work with the registered nurse to support the provision of nursing care. This term, as defined in the RCN Nursing Workforce Standards encompasses a wide range of roles and titles which may include nursing associate (England only), assistant practitioner, health care assistant, health care support worker, and nursing assistant.

The RCN Nursing Workforce Standards  support achieving the principles of nursing.

For registrants, the principles are mapped to the Nursing and Midwifery Council Code of Conduct .

How you can use the principles

As a nursing professional or nursing student you can use the principles to:

• understand what patients, colleagues, families and carers can expect from nursing 
• help you reflect on your practice and develop as a professional
• generate discussions with your colleagues or if you are student with your mentor, tutor or fellow students on the aspects of behaviour, attitude and approach that underpin good nursing care
• identify where the principles are being practised within your organisation, and to identify instances where you think they are not being practised
• see how they relate to a trust’s own set of nursing values.   

Further reading

• The NMC Code for nurses and midwives

The RCN has started a programme of work to co-create an overarching UK wide professional framework for nursing. This is led by the Professional Nursing Committee and in collaboration with forums and fellows.

It will bring together the vast variety of career and competency frameworks across all settings to show the opportunities our profession has, which will support recruitment and retention of the nursing workforce.

Glossary of terms

Absences - Agreed and non-agreed non-attendance at a workplace. Absenteeism is habitual absence from work.

Direct care - Care provided personally by a member of staff. May involve any aspect of health care including treatments, counselling and education regarding people who use services. Indirect care - Nursing interventions that are performed to benefit people who use services but do not involve direct contact with these individuals and communities. Independent employer - Any independent contractor, employer organisations that may or may not be commissioned by the public sector. This will include private health care providers, most social care providers; GP practices; out of hours/call centres; social enterprises and community interest companies; charities, private surgical, mental health and learning disability hospitals; independent treatment centres; public/private schools; private industry. Missed care - Required care for people who use or need services that is omitted in part or fully, or care that is delayed. Nurse-patient/staff ratios - Number of people who need or use services assigned to an individual or team of nurses; based upon the acuity and/or dependency of the service user for nursing care. Nurse retention - A strategy which focuses on preventing nurse turnover and keeping nurses in an organisation's employment. Nursing establishment - The total number of staff to provide sufficient resource to deploy a planned roster that will enable nurses to provide care to people who need or use services that meets all reasonable requirements in the relevant situation. This includes: a resource to cover all staff absences, and other staff functions that reduce the time available to care for people who need services. Supernumerary persons such as students and sisters/charge nurses/managers should not be included in the planned roster. Nurse staffing - Rota and whole time equivalent (WTE) for a nursing team. The nurse staffing level refers to both the required establishment and the actual staffing level per shift/allocated workday. The maintenance of the nurse staffing level should be funded from the organisation’s revenue allocation. Nursing workforce - The total number of nursing staff, of all levels of experience and qualification, currently working within an organisation, sector or country. Patient acuity - Acuity can be defined as the measurement of the intensity of nursing care that is required by a person in need of service. An acuity-based staffing system regulates the number of nurses on a shift according to the individual's needs and not according to numbers of people who use or need services. Patient/client dependency - Measuring the differing reliance of individual people who use services on nursing staff, a means to classify patients in order to predict staffing needs. Patient safety - Patient safety is the prevention of errors and adverse effects to patients associated with health care. It is closely correlated to safe staffing levels. Public sector - Refers to employers that are publicly provided – either as an arm’s length body of the department of health and social care, or via another government department or directorate such as education, home office, and criminal justice. Examples include local authorities, statutory agencies such as inspectorates and regulators.

Registered Nurse  - "Nursing is a safety critical profession founded on four pillars: clinical practice, education, research and leadership. Registered nurses use evidence-based knowledge, professional and clinical judgement to assess, plan, implement and evaluate high-quality person-centred nursing care."

Seasonal variation in nursing workload - Variations and fluctuations in demands for care by people who need or use services, such as differing attendance rates. Shift patterns - Is the organising of shifts to ensure patients have continued access to nursing care whatever the day or time of day. The shifts could be rotational between day, night and weekend working, or fixed or a continuous working pattern. Skill mix - Percentage of different health care personnel involved in provision of care, for example between registered nurses and nursing support workers, or between different health care professions. Social care - Is 60% publicly funded by local authorities. However, most UK residential and domiciliary care and employment is provided by independent employers, which include private care home companies, domiciliary care agencies, charities, private care management companies. Staff rosters/schedules - A list of staff and associated information such as working times, responsibilities and locations for a given time period. Staffing levels - To ensure effective staffing there needs to be the right numbers of the right people, in the right place at the right time. It is not just a matter of having enough staff, but also ensuring they have suitable knowledge and experience. Substantive position - An employee's permanent position of employment. Team - A group of staff brought together to achieve a common goal. Often associated with a multidisciplinary approach to care for people who use services. Understaffing - A situation where there are insufficient numbers of staff to operate effectively, such as to impact upon service user safety. Uplift - Adding an allowance when calculating staff numbers for planned and unplanned staff absence. Vacancies - Paid posts which are newly created, unoccupied, or about to become vacant and the employer is actively searching for suitable staff. Temporary staff may be able to fulfil posts during the recruitment of permanent staff. Whole-time equivalent - This is a standardised measure of the workload of an employee. Workforce planning – The process of analysing the current workforce and determining future needs, including identifying any gaps between current and future provision.

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• 1 University of South Florida
• PMID: 29763112
• Bookshelf ID: NBK499937

In 1958, Ida Jean Orlando started the nursing process that still guides nursing care today. Defined as a systematic approach to care using the fundamental principles of critical thinking, client-centered approaches to treatment, goal-oriented tasks, evidence-based practice (EDP) recommendations, and nursing intuition. Holistic and scientific postulates are integrated to provide the basis for compassionate, quality-based care.

Copyright © 2024, StatPearls Publishing LLC.

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Disclosure: Tammy Toney-Butler declares no relevant financial relationships with ineligible companies.

Disclosure: Jennifer Thayer declares no relevant financial relationships with ineligible companies.

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Principles and Practice of Critical Care Nursing

Course code:

Contact the University

Qualification:

Coventry University (Coventry)

School of Health and Care

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CPD Admissions Team

[email protected]

This module aims to build upon the knowledge developed from critical care module 6023CPD . The module will focus on specific conditions and clinical issues found in the critical care environment. This module will give students the opportunity to explore in detail the evidence base, treatment and management practices related to the different clinical issues.

Course detail

This module provides students with the opportunity to:

• Gain valuable knowledge of the principles and practice of critical care nursing, which can expand their employment opportunities within the field of healthcare and nursing.
• Gather evidence towards the achievement of the Knowledge and Skills Framework core dimensions: Communication, Personal and People Development, Service Improvement, Equality and Diversity.

Benefits include:

• Academic credit for a named award.
• Opportunity to network with fellow students from a range of disciplines and specialities.
• Access to experts.
• Individuals will be able to challenge current practice and embed evidence based practice into their delivery of care.
• Individuals gain greater job satisfaction which leads to a deeper commitment to service delivery and patient care.

On successful completion of this module you should be able to:

• Recognise and appropriately evaluate the various treatments for patients with critical illnesses.
• Discuss recent developments and resources used in the management of critically ill patients.
• Discuss the implications of recent developments and initiatives for professional, legal and ethical practice.
• Recognise early clinical signs of illness and take appropriate action.
• Evaluate the changing clinical presentations of major clinical illnesses found in the critical care environment.
• Analyse the various working practices and their impact upon effective patient care, treatment and management.
• Apply theoretical knowledge and specific clinical skills within a critical care environment.

How will this course be taught

This module will be delivered through a combination of lectures, debates, discussions, workshops, presentations and seminars. Some sessions may be shared with modules of similar clinical content.

Spring term: Wednesdays 9am - 1pm.

Induction will take place on the first day of each module (excluding Mentoring).

We welcome students with disabilities. We recognise that education is a right for all who can benefit from it and that students with disabilities have an equal right of access to higher education. Our staff also recognise that individuals with disabilities are the best source of expertise about themselves and their needs. All students with disabilities should be able to participate as far as is reasonably practical in the educational and social activities we make available. Such students should be encouraged to expect equal treatment as individuals and that they and their work will be considered solely on the basis of their quality. 

For further information please contact the Disabilities Officer on +44 (0)24 7688 8029 or email [email protected] .

Guided student activity – 30 hours Self-guided student activity – 170 hours Total activity – 200 hours

Entry requirements

• Registered healthcare professional with the NMC/HPC.
• At least six months of critical care experience.
• Successful completion of 6022CPD .
• Ability to complete a set number of clinical placement hours within critical care clinical areas.
• Excluded combinations: 365AN.
• Coursework 1: 2500 word Teaching Package (100% of module mark)
• Coursework 2: 1000 word Portfolio

How will this course enhance my career prospects?

• Successful completion of degree level modules can enable progression to master’s degree studies in a range of Health Care and Professional Practice studies which are offered at Coventry University.
• Upon the successful completion of this module students should possess the qualities and knowledge to assist their further development as professionals within the field of critical care nursing.

Related courses

Introduction to critical care nursing 6022cpd.

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