concept of critical care nursing

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Critical care nursing, or intensive care unit (ICU) nursing, is a specialty focused on the care of unstable, chronically ill or post-surgical patients and those at risk from life-threatening diseases and injuries.

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• an understanding of human anatomy and physiology.
• sharp clinical assessment skills.
• vast knowledge about diseases and conditions.
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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
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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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Critical care: A concept analysis

Martin christensen.

a School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China

b The Interdisciplinary Centre for Qualitative Research, The Hong Kong Polytechnic University, Hong Kong, China

Mining Liang

Associated data.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

The terms critical care and the Intensive Care Unit (ICU) are often used interchangeably to describe a place of care. Defining critical care becomes challenging because of the colloquial use of the term. Using concept analysis allows for the development of definition and meaning. The aim of this concept analysis is to distinguish the use of the term critical care to develop an operational definition which describes what constitutes critical care.

Walker and Avant’s eight-step approach to concept analysis guided this study. Five databases (CINAHL, Scopus, PubMed, ProQuest Dissertation Abstracts and Medline in EBSCO) were searched for studies related to critical care. The search included both qualitative and quantitative studies written in English and published between 1990 and 2022.

Of the 439 papers retrieved, 47 met the inclusion criteria. The defining attributes of critical care included 1) a maladaptive response to illness/injury, 2) admission modelling criteria, 3) advanced medical technologies, and 4) specialised health professionals. Antecedents were associated with illness/injury that progressed to a level of criticality with a significant decline in both physical and psychological functioning. Consequences were identified as either death or survival with/without experiencing post-ICU syndrome.

Describing critical care is often challenging because of the highly technical nature of the environment. This conceptual understanding and operational definition will inform future research as to the scope of critical care and allow for the design of robust evaluative instruments to better understand the nature of care in the intensive care environment.

What is known?

• • Critical care is often associated with the use of advanced medical technologies focused around a medical model of care.
• • While well known, critical care is often widely discussed in general terms, yet is poorly defined within what could be described as the essence or nature of care.
• • Critical care is often referred to as a ‘process’ of looking after the seriously ill or injured.

What is new?

• • This paper provides a detailed conceptual definition of critical care.
• • The formation of a model case provides information for practitioners and researchers that will support future work to better understanding of basis of critical care across the health professions.
• • The results of this conceptual analysis provide a different view of what constitutes care from the perspective of the different health care groups that work in the intensive care space.

1. Introduction

The terms critical care and Intensive Care Unit (ICU) are often used interchangeably to describe a place of care. Yet, one is the function of a dedicated, specialist team of health professionals to support and care for the critically ill person during a medical emergency or crisis, while the other is a dedicated location where this focused care is undertaken. As a place of critical care, it is the technology that separates it from other areas of the hospital [ 1 ]. When used, the notion of intensive care often conjures up images of a specific place in the hospital where the seriously or critically ill are cared for. In many respects, the concept of critical care may not have a different array of meanings or be elusive and this is possibly because of the normal or ordinary day language that is used to describe this concept. Yet, the term intensive or critical care has a variety of different names and perhaps meanings to signify the essence of critical care, for example, the critical care unit, the intensive care unit or the intensive therapy unit [ 2 , 3 ]. Moreover, the term critical care has now become a more standardised term because of the inclusion of other areas in the hospital that effectively treat and care for the seriously ill or injured such as the accident and emergency department or the coronary care unit [ 4 ]. The intensive care unit differs significantly from other areas because its major focus is on invasive mechanical ventilation. What is potentially missing is what is encompassed in ‘critical care’. For this review the term critical care will be used to exemplify and describe the ‘inter-professional care’ that is undertaken in the intensive care unit (Step 1). Therefore, the aims of this concept analysis are to 1) distinguish the use of the term in developing an operational definition, 2) to explore the concept of critical care as a possible space for care, cure and function and 3) develop a conceptual/theoretical model of critical care (Step 2). Furthermore, it may be possible to describe, define and discuss the relationship between critical illness and critical care undertaken in an intensive care unit. Using Walker and Avant's [ 5 ] eight-step approach to concept analysis may aid in seeking conceptual clarity, therefore the analysis may make it possible to promote a single vocabulary for discussion, whilst allowing an understanding of what signifies the parameters of critical care to be. It will achieve this by providing background literature in the form of a scoping review to identify uses and meanings of the concept, explore the nature of critical care in the form of fictional model cases, determine the antecedents and consequences associated with critical care and finally ascertain the empirical referents that are conducive to this concept.

Concept analysis, as described by Walker and Avant [ 5 ] is a strategy that allows for an examination and exploration to define and evaluate the concept of critical care. In particular, it distinguishes between those critical characteristics and attributes of critical care that allowed for clarity of meaning [ 5 ] and is therefore fundamental to the formation of nursing knowledge. The result of which is a precise operational definition that meets the requirements of construct validity.

The basis of Walker and Avant’s [ 5 ] eight-step concept analysis approach to concept analysis guided this project. It is an iterative framework, which encompasses an entity based structural analytical approach. The central focus is the identification of the wider ranges of intentions coupled with the ability to distinguish between the defining attributes and the relevant attributes, which allows for the formation of distinct analytical goals.

2.1. Search strategy

A scoping review was undertaken using the Joanna Briggs Institute (JBI) System for the Unified Management of the Assessment and Review of Information (SUMARI) and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SCR) [ 6 ]. The pneumonic PCC (population, concept and context) for scoping reviews was considered for developing the search strategy – ‘what is care in terms of critical care’ in the intensive care unit, P = critically ill, C = critical care, and C = intensive care unit. Five databases were accessed for published works which stipulated intensive care, critical care, care and caring within their title between 1990 and 2022 (CINAHL, Scopus, PubMed, ProQuest Dissertation Abstracts and Medline in EBSCO). Additional searches were undertaken within the grey literature, discursive papers, conference papers, editorials and unpublished commentaries were also included. Search terms related to definition∗, car∗ AND intensive care OR critical care were paired with intensive care unit OR ICU OR intensive therapy unit OR ITU OR cardiac ICU OR neuro ICU. Additional searches were undertaken using wild card terms using ‘?’ and truncated terms ending with ∗ to elicit further combinations associated with intensive and/or critical care. Hand searching of reference lists along with the content pages of intensive and/or critical care specific journals was also undertaken. Papers were included if they discussed the nature of care and what constituted care within an intensive care environment. Papers were excluded if they did not adequately describe the ‘essence of care’ fully. The study design was inclusive of both qualitative and quantitative methods. This resulted in 47 documents that met the criteria for identifying the concepts use ( Fig. 1 ) [ 7 ].

Study selection flow chart.

After the search was completed, all identified citations were collated and uploaded into EndNote, and from there, all duplicates were removed. Using JBI SUMARI, all eligible titles and abstracts were screened by two independent reviewers and assessed for relevance against the inclusion criteria. Those studies that were potentially relevant were retrieved in full text. The full-text papers selected were then evaluated against the inclusion criteria by two independent reviewers. Reasons for exclusion were recorded as part of the PRISMA-ScR reporting [ 6 ]. Disagreements arising between the reviewers at each stage of the study selection process were resolved through discussion ( Fig. 1 ).

2.2. Identify uses of the concept: critical care (Step 3)

Identifying the uses of the concept is an important first step in establishing how the concept is defined/used in everyday parlance. This may include implicit and explicit uses of the concept so that a fully rounded view of the concept is initially established. This may include a search of the relevant literature, commonly used definitions, lay language or other narrative forms that may be relevant to the concept.

The Concise Oxford Dictionary [ 8 ] defines critical care as “ the continuous care and attention, often using special equipment, for people in hospital who are seriously ill or injured”. Likewise, the Cambridge Dictionary [ 9 ], describes critical care “as the continuous treatment for patients who are seriously ill, very badly injured or have just had an operation or the department of a hospital that provides this care” . The notion of critical care was first observed by Florence Nightingale, during the Crimean War of 1854, where she first used the concept of triage to identify the seriously injured and set them apart from the others to receive more critical care from a specialist team of nurses [ 10 ]. Other examples, though not typically referred to as critical care appeared in the late nineteenth century where the unstable and critically ill patients were moved to a more observable vantage point for the nurses charged with their care. An example of this is in the exert from Louisa May Alcott’s [ 11 ] Hospital Sketches where she reflects :

“My ward was now divided into three rooms … I had managed to sort out the patients in such a way that I had what I called my “duty room”, my pleasure room and my pathetic room” and worked for each in a different way. One I visited, armed with a dressing tray, full of rollers, plasters and pins; another with books, flowers, games and gossip; a third with teapots, lullabies, consolation and sometimes a shroud … wherever the sickest or most helpless man chanced to be, there I held my watch …” (p47)

It is implied in this anecdote that the duty room (perhaps the nineteenth century ICU equivalent) was where the sickest and infirm were nursed and the pathetic room was similar in some respects to a hospice or palliative care unit. The notion of increased vigilance and observation eventually became the precursor to what is now known as critical care. For example, in the mid 40’s where the physiological instability of the post-operative patient and the dangers of anaesthesia meant that collective organisation of these patients into one specific area, the recovery room, occurred. With the continued hypervigilance of patient monitoring led directly to the birth of the ICU [ 4 , 12 , 13 ]. Jackson and Cairns ([ 14 ], p2) describe critical care as the “ process of looking after patients who either suffer from life threatening conditions or at risk of developing them ”. Equally they describe the intensive care unit as a “ distinct geographical entity in which high staffing ratios, advanced monitoring and organ support can be offered to improve patient morbidity and mortality ”. This is not too dissimilar to those definitions/descriptions identified by internationally recognised intensive care societies or organisations ( Table 1 ). However, the difference is that these definitions or more aptly descriptions of critical/intensive care are offered as lay comments specifically for patients and or families. It could be suggested, therefore, that healthcare professionals, whether they work in this environment or not, may be fully conversant with what critical care and what the intensive care unit are ( Table 1 ). Moreover, a recent concept analysis attempted to define critical care as the “ identification, monitoring and treatment of patients with critical illness through the sustained support of vital organ functions ” [15, p9], yet fails to distinguish between the different health professional roles in the delivery of critical care and therefore conforms to the technical-rational medical model of care [ 16 ]. Importantly, when attributing this definition of critical care to the fictional model case, it is difficult to distinguish the actual ‘care’ involved and what is deemed critical except to identify the geographical place the patient is admitted to and the administration of oxygen along with regular monitoring. Whilst this is valuable in finding a definition of critical care, the authors also make the important distinction of what critical illness might entail in order for critical care to be implemented – “ a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility.” ([15], p 8)

Table 1

Consensus definitions of critical care and ICUs.

3.1. Determining the defining attributes (Step 4)

Determining the defining attributes of the concept is attempting to identify those attributes frequently associated with the concept, in this case, critical care. Moreover, the specific phenomenon in question is reduced to those key features that differentiate the concept from other similar or related concepts, such as intensive care. To assist in this step of the concept analysis, an inductive content analysis described by Krippendorf [ 17 ] was undertaken with 47 papers identified from the literature search to ascertain uses of the concept critical care [ 1 , 12 , 13 , [18] , [19] , [20] , [21] , [22] , [23] , [24] , [25] , [26] , [27] , [28] , [29] , [30] , [31] , [32] , [33] , [34] , [35] , [36] , [37] , [38] , [39] , [40] , [41] , [42] , [43] , [44] , [45] , [46] , [47] , [48] , [49] , [50] , [51] , [52] , [53] , [54] , [55] , [56] , [57] , [58] , [59] , [60] , [61] ]. This resulted in the development of five categories ( Table 2 ). The defining attributes associated with critical care can be divided into three main categories – critical illness, supportive and treatment therapies, and critical care based around a technical-rational medical model of care [ 16 ]. Nursing and allied health play supportive and facilitative roles in the delivery of this care in conjunction with their individual scopes of practice. Therefore, in determining the defining attributes of critical care those distinctive features that emerged which are associated with the concept include ( Table 2 ):

• ⁃ The patient’s maladaptive response to illness/injury that results in a systemic inflammatory reaction (critical illness);
• ⁃ The patient must present with intensive care unit admission modelling criteria that denote critical illness;
• ⁃ The application and administration of advanced medical technologies to support and treat ongoing failing organ systems;
• ⁃ The application of specialised allied health, medical and nursing care that considers the micro and macro levels of care associated with critical illness;
• ⁃ That critical care is not to be confused with the intensive care unit, which is a geographical location within the hospital setting.

Table 2

Defining attributes of critical care.

Note: SAPS = Simplified Acute Physiological Score. SOFA = Sequential Organ Failure Assessment Score. TISS-28 = Therapeutic Intervention Scoring System. APACHE = Acute Physiological and Chronic Health Evaluation.

In order to identify the key components of the concept critical care, the development of a model, borderline and contrary case is useful in recognising and refining the defining attributes. It is often seen as a form of constant comparative examination so that the internal structure of the phenomenon has meaning and clarity.

3.2. Model case (Step 5)

The fictional model case contains all of the constituents identified in the defining attributes as well as the working definition of critical care from the diagnosis of critical illness and subsequent admission to an ICU along with the initiation of advanced medical technologies to support and treat the underlying condition. It also includes those activities associated with a macro level of care such as those undertaken by nursing and physiotherapy.

Mr. Melvin Jones, a 72-year-old widower who resides in a residential aged care facility, has a body mass index of 38 and was transported by ambulance to the Accident and Emergency department (A&E) after experiencing a chest infection for six days. He has a medical history of hypertension, peripheral vascular disease, insulin-controlled type 2 diabetes, and chronic bronchitis. Additionally, he smokes twenty roll-up cigarettes a day. As a result of worsening respiratory indices (oxygen saturations, arterial blood gas analysis and respiratory rate), he is electively intubated in the A&E and transferred to the ICU. Once in the ICU he is placed on continuous cardiac monitoring, a quadruple lumen right internal jugular central venous line (CVL) is placed for drug administration along with the monitoring of right atrial filling pressures (CVP). An intra-arterial line is placed in his right radial artery to continuously monitor his blood pressure while also allowing access for blood sampling in particular samples for arterial blood gas analysis (ABG). His vital signs showed marked hypotension (↓ mean arterial & central venous pressures), pyrexia, tachycardia and peripheral cyanosis. His ABG showed marked acute-on-chronic hypoxia and hypercarbia. Mr Jones is immediately given a fluid challenge as a result of his hypotension and started on an inotropic infusion. Blood samples taken in the A&E show elevated serum urea and creatinine indicative of renal insufficiency as a result of his hypotension. A sputum sample is taken for culture and sensitivity to identify the bacterium responsible for his chest infection, but in the mean while he is started on intravenous broad-spectrum antibiotics. Mr Jones’ chest x-ray reveals not only correct placement of his CVL and endotracheal tube, but increased opacity in the right lower and middle lobes consistent with pneumonia.

Once Mr. Jones is stabilised, the nursing team starts to document his baseline vital signs, ventilatory parameters, drug infusion rates, sedation score, pain assessment, and urine output hourly and often converse with the medical team as to current orders and results of blood and ABG tests, adjusting infusion rates to maintain prescribed physiological parameters. As part of their physical health assessment, Mr Jones’ nurse identifies him as a high risk of pressure injury and therefore institute positioning guidelines not only to reduce the risk of tissue injury but to also aid in secretion removal. When assessing his chest, his nurse notices decreased expansion on the right side along with coarse inspiratory crackles and bronchial breath sounds on auscultation consistent excess secretions and alveolar consolidation. In addition to positioning, they place Mr Jones on a pressure relieving mattress. They also implement other nursing activities like regular mouth, indwelling catheter, bowel and eye care. This information is documented in the nursing notes. When Mr Jones’ two daughters arrive, his nurse sits with them and explains the current situation and what they might expect to see in the ICU before showing them to their father’s bed-space. His nurse also explains what the ‘machinery’ is and how it is supporting and monitoring their father’s progress. They are invited to ask questions and stay as long as they feel able. The nurse asks the hospital chaplain assigned to the ICU to talk with them as well so as to offer another person to talk with while Mr. Jones is being cared for. As the daughters have arrived from other areas of the country, his nurse helps organise emergency accommodation.

When reviewed by the ICU physiotherapist, the nurse conveys their findings from their initial physical assessment in particular those associated with his chest infection. The physio also finds on auscultation those reported by his nurse and the findings from the chest x-ray. They implement chest physiotherapy which includes chest percussion, hyperinflation and suctioning to aide in mobilizing and removing the secretions as well as re-inflating collapsed areas of lung. The physio also starts range of movement (ROM) exercises. They also document their findings and treatment and develop a chest physiotherapy plan for the nurses to follow during out-of-hours.

3.3. Borderline case (Step 6)

The fictional borderline case in this instance possesses some of the defining attributes identified in the definition especially that of needing advanced medical technologies. In this case, Mrs. Smith required continued ventilatory support because of the failure of anaesthetic reversal and was therefore experiencing acute respiratory failure. Though potentially dangerous, Mrs. Smith was not critically ill.

Mrs. Jean Smith is a 49-year-old married woman who has undergone elective surgery for the laparoscopic removal of her gallbladder. The operation was uneventful, with very little blood loss. However, Mrs. Smith failed a reversal of anaesthesia and therefore remained intubated and ventilated whereupon she was transferred to the ICU until such time that she could be extubated. On arrival into the ICU she was placed on continuous cardiac monitoring. Her baseline vital signs were recorded which showed a systolic blood pressure (BP) of 95 mmHg, heart rate (HR) of 110 beats/min an axilla temperature of 37.6 °C, transcutaneous oxygen saturations (SaO 2 ) of 98% on an FiO 2 of 40% via the ventilator and a sedation score of −5 (unarousable to physical stimuli) on the Richmond Agitation and Sedation Scale (RASS). She was given a fluid challenge as a result of her lowered BP and rising temperature. She is receiving intravenous fluids at 120 ml/h, and regular morphine pain relief via a patient-controlled analgesia pump with a background infusion rate of 1 mg/h. Mrs. Smith is what would be affectionately known as a ‘warm, wake and wean’ patient. As the anaesthesia begins to wear off, Mrs. Smith’s RASS score improves, and she is able to respond to verbal commands. A trial of weaning is commenced where upon she is successfully extubated and placed on 6ltrs/hour of oxygen via a face mask. Mrs. Smith is monitored for 24 h and then discharged back to her admitting ward.

3.4. Contrary case (Step 6)

The fictional contrary case contains none of the defining attributes that would signify critical illness nor would require an intensive care unit admission for critical care.

Mr. Brian Koenig is a 35-year-old man with chronic gastritis and was admitted to the day case surgical unit for routine gastroscopy. Mr. Koenig, is given a mild sedative, placed on continuous cardiac monitoring (BP, HR, SaO 2 , RR) and receiving oxygen at 6 L/h via a face mask. The gastroscopy was uneventful, his vital signs remained stable, and Mr Koenig was transferred back to the day-case ward, monitored for 4 h and discharged home with a follow-up appointment for outpatients two weeks later.

3.5. Antecedents (Step 7)

Antecedents are those factors that must occur prior to an occurrence of the concept [ 5 ]. From the perspective of critical care, the antecedents are those factors attributable to illness, which over time progresses to a level of criticality and therefore would influence an admission to an intensive care unit. In this respect, critical illness can be considered along a spectrum of adaptation to complete organ failure with maladaptation being the demarcation necessitating immediate intervention ( Fig. 2 ). As in the example of the model case, the individual has underlying chronic disease which makes them more susceptible to illness because of a depressed or ineffective immune response. What then results is the transition from a simple chest infection (adaptive) to pneumonia (maladaptive) and then systemic inflammatory response syndrome (SIRS)/sepsis (overwhelming).

The antecedents of critical illness.

3.6. Consequences (Step 7)

Unlike antecedents, which occur before the concept, the consequences are those events that transpire as a result of the occurrence or the outcomes of the concept [ 5 ]. The consequences associated with critical care are concerned with the decline in both physical and psychological functioning, ranging from sarcopenia, depression, cognitive decline and post-traumatic stress disorder (PTSD) [ [18] , [19] , [20] ]. These result in a condition commonly known as post-ICU syndrome [ 62 , 63 ]. The effects are a combination of both critical illness and the treatment modalities being used. For example, positive pressure ventilation along with critical illness has been shown to cause respiratory muscle dysfunction as a result of mitochondrial dysregulation, muscle inactivity and metabolic oversupply [ 64 , 65 ]. Likewise, psychological impairment is related to both pre-ICU cognitive functioning and the incidence of delirious episodes each of which can lead to post-ICU PTSD, depression and worsening or new cases of dementia [ [66] , [67] , [68] ].

Moreover, while critical care is reliant on the patient being critically ill, there is also the nature of the ICU itself especially in terms of what level of critical care can be delivered. This is often dependent on the size of the hospital and the availability of resources, both human and physical. The human resource is very much dependent on patient acuity, which often necessitates an inter-professional team approach with advanced qualifications and experience to provide an immediate and critical level of care. Based on Marshall et al.’s [ 69 ] classification system of ICU’s from Level 1 to 3 denotes the level of care that can be provided safely and competently. A Level 1 ICU, for example, has many basic elements of critical care in terms of monitoring capacity and physiologic stabilisation, the level of invasive support and personnel expertise. A Level 2 ICU can provide basic support for failing organs such mechanical ventilation, inotropic support and renal dialysis, invasive monitoring and personnel often have additional critical care training and education. A Level 3 ICU provides critical care for more complex patients. This often involves more complex forms of haemodynamic monitoring and advanced modes of mechanical ventilation such as prone ventilation or extra-corporeal membrane oxygenation. It is evident that the level of medical (micro) care differs between the subsequent ICUs, the macro level care invariably remains unchanged. Both nursing and allied health practices remain relatively stable.

3.7. Empirical referents (Step 8)

The empirical referents are described as phenomenal categories that empirically demonstrate the actual occurrence of the concept in question. They are not, however, tools used to measure the concept, instead are used to measure the defining characteristics [ 5 ]. However, the difficulty with defining the empirical referents is that critical care is often associated with the ICU, which are two separate entities. One is a physical location while the other is deemed to be an advanced level of care required to support and treat a patient who is critically ill. The literature is resplendent with examples of the quality of the care experienced in the ICU [ 29 , 30 ], but less about measuring the actual care. Perhaps this is based on mortality and survival rates, suggesting that if the patient survived the ICU, care must have been appropriate and importantly evidenced based. As yet there are few valid tools to measure critical care apart from self-reported satisfaction scales [ [31] , [32] , [33] ], illness severity scores [ 34 , 70 ] or survival data [ 36 ].

3.8. Operational definition

Based on these defining attributes, it might be possible to form a working theoretical definition of critical care as well as construct a possible conceptual model of critical care.

Critical care is the application of advanced medical technologies administered by specialist health care professionals to alleviate the inherent physiopsychosocial complications associated with critical illness while treating the underlying disease process.

From this definition, the characteristics of critical care encompass the three health professions based on their respective expertise in supporting critical illness ( Fig. 3 ). Medicine as supporting and treating the underlying pathophysiology – the person as a disease process. Nursing as the administrators of care cooperating and supporting respective treatment options as well as applying their own specialised nursing care – the patient as a person. Allied health as the ‘rebuilders’– the patient as structurally dysfunctional.

Characteristics of Intensive Care incorporating the Antecedents, Attributes and Consequences.

4. Discussion

These early definitions refer to critical care as a service for those individuals with recoverable life-threatening illness or injury where more intense observation and treatment are available than on the general wards [ 37 ]. Referring to two separate criteria associated with the meaning of critical care, Lynaugh and Fairman [ [ 71 ], p20] suggest that first, the individual is at risk of dying as a result of serious physiological instability and secondly, “intensive care is usually given in the expectation or hope, however slim, of the person's survival”. More recently, Marshall et al. [ 69 ] defines critical care as:

“… a multidisciplinary and interprofessional specialty dedicated to the comprehensive management of patients having, or at risk of developing, acute, life-threatening organ dysfunction.” (p271)

However, the contemporary critical care medical and nursing literature also refers to intensive care or critical care as a physical space, geographically placed to enable easy access for patient admissions from a variety of places such as the operating theatres, the clinical wards or the emergency department [ 13 , 18 , 72 ]. Alcott’s [ 11 ] early description of an ICU room has changed considerably over time. The ICU as a space is mentioned as early as 1923 with the opening of a three-bedded ICU to monitor and treat post-operative neurosurgical patients [ 4 ]. It wasn’t until the early 1950s that the precursor to the modern ICU came into being as a result of polio epidemic [ 12 , 13 ]). Prior to this, what would be termed intensive care units appears to be simply recovery rooms [ 3 ]. What is significant in this initial identification of the concept in use, is that critical care is used to denote an interdisciplinary specialty [ 69 ], a critical level of illness and the congregation of the critically ill into one specialist place for care and treatment.

4.1. Critical care: a process of care, cure and function

The nature of critical care is perhaps dichotomous and symbiotic at the same time because of the inter-play between the pathology of disease processes and how care is delivered and perceived [ 1 , 40 ]. First, it has often been described as the application of technology to support and measure failing organ systems to determine appropriate treatment options, which would sit easily with the medical model of diagnosis, treatment and cure [ 12 , 41 , 42 ]. Second, critical care is also viewed from a psychosociospiritual aspect that is seen as the basis of holistic nursing care and practice and last, critical care is seen as the restoration of physical function which is more applicable to the work of allied health in particular physiotherapy. The centre of what is deemed critical care is the technological application associated with care. McClure [ 73 ], for example, defines technology as:

“… any means of delivering care using objects that are not part of a patient’s own body. This means that it includes not only the vast array of machinery we have come to take for granted, but also the pharmaceuticals that are prescribed and administered.” (p144)

Or more aptly, “… the substitution of machine labour in the performance of a given task ([ 74 ], p74) and “ … as a collection of technological acts within the technological environment” ([ 75 ], p438), in this case the intensive care unit.

Technology in the sense of critical care involves two distinct processes – monitoring/measurement and supportive treatment. First, the monitoring/measurement capabilities are used to analyse and display indirect and/or direct physiological functions, for example electrocardiography, intra-arterial blood pressure, central venous pressure and transcutaneous oxygen saturation. Second, supportive treatment includes equipment used to support compromised or failing organ systems such as a mechanical ventilator either invasive or non-invasive, extra-corporeal membrane oxygenator, dialysis machine, intra-aortic balloon pump, all used within the context of the patient condition. Included in this array of equipment are volumetric and syringe driver pumps used for drug and/or intravenous fluid administration and an enteral feeding pump to support the nutritional needs of the patient [ 46 ]. In terms of ICU personnel, the equipment when employed in this fashion is used to primarily aide decision making regardless of the how or what equipment is being used [ 47 ]. For example, an increase in airway pressures (monitoring/measurement) would necessitate a change in ventilatory parameters (supportive treatment) to reduce these while optimising oxygenation and carbon dioxide elimination or a change in mean arterial pressure might mean a change in inotropic support or an intravenous fluid challenge.

When described in this manner, it is easy to attribute this as the technical-rationale [ 16 ] medical model of care and as mentioned earlier fits within the domain of medicine. Nursing, however, can also be ascribed this process of care because of the technological environment that is encompassed in the ICU. This has been articulated by a number of authors who have concluded that nurses can and do become unwittingly machine-like in their approach to patient care especially in this environment as a means of supporting, to a large part, medical decision-making [ 1 , 48 ]. However, ICU nursing is also focused on the psychosociospiritual aspect of care especially in supporting the family members in the early stages of the ICU admission and then in the latter rehabilitative stages to both the patient and family. This is a unique position for the ICU nurse when compared to medicine and allied health for one specific reason – nursing offers 24-h care whereas medicine and allied health tend to provide care as ‘snap-shots of activity’, for example, medical ward rounds or chest physiotherapy sessions. In Price’s [ 47 ] ethnographic study, she found that, in contrast to those behaviours of care which might be easily attributable to technological care (monitoring/measurement), ‘being present’ and compassionate was distinctive to nursing. Likewise, the work of Bishop et al. [ 49 ], Jones et al. [ 50 ], Jakimowicz et al. [ 51 ] and Efstathiou and Ives [ 52 ] discuss that compassionate care is a hallmark of nursing practice in the ICU. They all describe compassionate care as encompassing those elements of humanness that responds to individual suffering. For example:

“Compassion asks us to go where it hurts, to enter into places of pain, to share in brokenness, fear, confusion, and anguish. Compassion means full immersion into the condition of being human .” ([ 53 ], p52)

Structural dysfunction in critical illness can be considered both at the macro and micro levels ( Fig. 2 ). At the micro level, this is often seen as supporting organ systems affected by mitochondrial or cellular dysfunction [ 54 ], for example, adrenal insufficiency [ 55 ], diaphragmatic ineffectiveness [ 56 ], gastro-intestinal dysfunction [ 57 ] and neurocognitive dysfunction [ 76 ]. At the macro level, restoring structural dysfunction entails reversing the effects of illness-induced sarcopenia and aiding in normal physiological processes, sometimes complicated by supportive therapies such as mechanical ventilation. These may include early enteral nutrition to reduce gut mucosal degradation, therefore reducing the incidence of bacterial translocation [ 59 , 60 ], ROM exercises to reduce joint contractures, early mobilisation to reduce muscle wasting [ 21 , 61 ] and chest physiotherapy to improve secretion removal and reduce the incidence of ventilator-induced alveolar collapse [ 22 , 23 ]. Medicines’ role at the micro level is focused on those supportive therapies, for example, the inception of mechanical ventilation and the prescribing of drug therapy. Their role at the macro level is minimal except perhaps the placing of invasive lines and prescribing care that will normally be undertaken by either nursing or allied health ( Fig. 2 ). While equally conversant and responsible with the macro level of care, nursing as the administrator of the medical model will naturally adopt a supportive, facilitative and cooperative role with both medicine and allied health. Alternatively, allied health will generally provide and direct the functional recovery such as mobility and ROM exercises as well as chest physiotherapy and as such facilitates in reducing the overall effects of critical illness [ 22 , 24 , 61 ].

4.2. Critical illness

The natural progression to critical illness is seen as a fine inter-play between pathophysiological adaptation and maladaptation. This is generally seen as a result of disruption to oxygen supply and demand at the micro-circulatory level in response to a potentially life-threatening insult [ [24] , [25] , [26] , [27] , [28] ] ( Fig. 3 ). During the adaptive phase, the normal processes associated with acute inflammation come into play involving both the innate immune and haemopoietic systems in an attempt to contain the injury or infection locally. However, if these systems become overwhelmed, a systemic inflammatory response then ensues causing organ dysfunction (maladaptive). If there is no reversal to the maladaptive stage multi-organ failure follows leading to death. The criteria which decides when adaptation becomes maladaptive is generally governed genetically and by co-morbid conditions present in the individual [ 25 ]. Therefore, the basis of diagnosing critical illness is often dependent on a number of pathophysiological processes [ 35 , 38 , 39 ] seen through the presenting disease symptomology for example, pyrexia, tachycardia and hypotension.

However, describing and defining critical illness based on diagnosis alone is often difficult and typically critically ill patients fall between two separate categories – too well to benefit (low risk of death) or too sick to benefit (high risk of death) [ 77 ]. Therefore, what determines critical illness is generally based on admission criteria often involving a significant decline in physiological functioning [ 39 ] in some form and the application of illness severity classification systems such as SAPS (Simplified Acute Physiological Score) [ 34 , 70 ] or SOFA (Sequential Organ Failure Assessment Score) [ 43 ] or TISS-28 (Therapeutic Intervention Scoring System) [ 44 , 45 ]. At present, there are three distinct models of ICU admission – prioritisation, diagnosis and physiological function (objective parameters) each of which serves as the basis, singularly or collectively, of defining and describing illness severity [ 77 ]. The prioritisation model determines patient characteristics based on benefit and need – those who will benefit versus those that won’t. The diagnosis model determines illness severity based on survivable outcomes, similar in some respects to the prioritisation model, but instead focused on an admission diagnosis such as myocardial infarction or traumatic brain injury. Finally, the objective parameter model uses physiological and investigative information to determine illness severity. However, there are also ethical and economic factors, which may influence an admission to ICU.

While these criteria provide some assistance for the clinician in determining who gets an ICU admission, there is perhaps a ‘loose’ connection as to defining or indeed describing critical illness. As mentioned previously illness severity classification systems such as SAPS or APACHE (Acute Physiological and Chronic Health Evaluation) scores are used to classify patients within specific groups of illness severity, the difference being that this is a mortality risk predicative tool as opposed to a decision-making tool [ 78 ]. There was an attempt to define illness severity in palliative care patients undergoing elective surgery. Using a Delphi method and a current evidence base of care, Lee et al. [ 58 ] were able to define illness severity based on ASA (American Society of Anaesthetists) risk and age (a subjective physiological based tool designed to predict perioperative risk, the higher the number the higher the risk of mortality). However, like the use of criteria modelling and severity classification scores, the definition identified here is also based on a classification system, which considers not only those mentioned above such as comorbid states, age, gender and cognitive function but also frailty. Therefore, building on the definition described by Kayambankadzanja et al. [ 15 ] it might be possible to find a single definition of critical illness which might consider the following:

Critical illness is a process in which normal or optimal physiological functioning has been severely compromised where advanced medical treatment is a necessity to preserve life.

5. Implications for practice and potential future research

Therefore, the implications for future research could encompass studies that accurately reflect the ‘care’ of the intensive care environment. In addition, describing critical care is challenging because each health professional group defines the concept based on their specific expertise. In other words, what is defined and described as critical care as opposed to the current medical model of care. As a result, nursing care associated with the critically ill, for example, can be considered universal across the spectrum of nursing, the major difference being the acuity of the patient. Therefore, further evidence of what constitutes critical care is required so that the defining attributes clearly articulate what is critical care is and is not, for example: adherence to nursing guidelines, implementation of new concepts for monitoring/documentation of wellbeing and satisfaction, and perhaps defining suitable nurse-patient ratios.

6. Limitations

The idea of concept analysis is to get a broader, deeper understanding and clarification of a concept. The limitations of this analysis lie in that it only considered published work reported in English and those from within a western context. Therefore, this may limit the depth and breadth of work reported elsewhere because of issues related to translation and interpretation. In addition, the nebulous nature of what defines and describes critical care means that the care provided in this area could equally be transposed into other clinical areas; the difficulty is that the subjectiveness of the term critical care means many different things to many different people. Yet, in saying that it is the patient acuity that may truly define what ‘critical care’ is.

7. Conclusion

When the term critical care is used, it invariably conjures up images of a physical space – ‘ the patient is being transferred to intensive care’ or ‘ the patient is in intensive care’ or ‘I work in intensive care’ . It is often taken for granted that the patient is receiving critical care, as such describing or defining the nature of the care provided is often challenging and consumed within the medical model of care. This concept analysis of what constitutes critical care has identified key defining attributes of what comprises ‘critical care’, namely micro and macro levels of care. Additionally, in providing a working definition of critical care, it has used hypothetical clinical cases to highlight what is deemed critical care and what is not. Therefore, given that care is multi-dimensional and multi-factorial, providing a conceptual framework of what denotes critical care may give rise to more focused research in addition to that already undertaken.

Nothing to declare.

Data availability statement

Credit authorship contribution statement.

Martin Christensen: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Mining Liang: Conceptualization, Writing – original draft, Writing – review & editing.

Declaration of competing interest

There are no conflicts of interest.

Peer review under responsibility of Chinese Nursing Association.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2023.06.020 .

Appendix A. Supplementary data

The following is the Supplementary data to this article:

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CRITICAL CARE NURSING GUIDELINES, STANDARDS AND COMPETENCIES

Drafted as of JULY 1, 2014

INTRODUCTION

The health care industry all over the world has been undergoing significant changes over the past two decades and the Philippines has been part of these transformational events having great impact on the quality of nursing practice. There are new expectations in the way nurses and the nursing practices are to be delivered particularly now that there are many challenges that besiege the nursing profession as a consequence of the complexities of globalization.

Critical care nursing is the specialty within nursing that deals specifically with human responses to life-threatening problems 1 .These problems deal dynamically with human responses to actual or potential life-threatening illnesses.

The framework of critical care nursing is a complex, challenging area of nursing practice. It utilizes the nursing process applying assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The critical care nursing practice is based on a scientific body of knowledge and incorporates the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative care, based on identified patient’s need 3 . It upholds multi and interdisciplinary collaboration in initiating interventions to restore stability, prevent complications, achieve and maintain optimal patient responses. The critical care nursing profession requires a clear description of the attributes guidelines and nursing practice standards in guiding the critical care nursing practice to fulfill this purpose.

In the Philippines, the Professional Regulation Commission – Board of Nursing (PRC-BON) is committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources. To respond to this mission and commitment, a PRC-BON Working Group in Developing the Nursing Specialty Framework was formed in the 1996 to take on the task of setting the process -based framework and guidelines for specialty nursing services. The Working Group members are clinical nurse practitioners, nurse educators and nurse managers 1 .

The expanding healthcare and nursing knowledge together with new and evolving healthcare sites, structures, and technologies all have contributed to the need and desire for specialty nursing organizations like the Critical Care Nurses Association of the Philippines, Inc. (CCNAPI) to revisit the existing statements of its Standards of Nursing Practice to provide clear and updated statements regarding the scopes of practice and standards of critical care nursing. This will ensure continued understanding and acknowledgment of nursing’s varied specialty professional contributions in today’s healthcare environment.

The CCNAPI Standards of Practice of 1982 has been revisited and revised to be aligned with the 2005BON statements of the 11 Core Competencies for Entry Level for Safe and Quality Nursing Care. The CCNAPI Core Competencies of a Critical Care Nurse are stated according to the levels of expected behavior defining the actual knowledge, skills and abilities in the practice of critical care by a nursing professional. These statements cover expected behavior of a Nurse Clinician I, Nurse Clinician II and Nurse Specialist that will serve as the basis for assessing competence in critical care practice. The statement of the goals, scope of practice, competencies and standards on the care of the critically ill are all important aspects that are emphasized in this paper.

The focus of care for the critically ill patient is holistic. However, to organize statements in this paper, physiological focus has been categorized under bodily functional systems such as pulmonary system, cardiovascular system, renal system, neurological system and other system.

The specific objectives of this paper are to:

• To identify Critical Care Nursing Service characteristics and contributions of nurses to patient care in the specialty.
• To develop specific competencies required for the delivery of nursing care in the critical care.
• To provide a framework for evaluation of nursing practice within the specialty of critical care.
• Provide a basis for the assessment of continuous staff development needs in critical care nursing.
• Guide the development of collaborative working relationships with other members of the health care team.

This process-based framework not only describes the critical care nursing services in the Philippines, but also assists critical care nurses to have a better understanding of what is expected of them from the organization and the public perspectives.

PHILOSOPHY OF CRITICAL CARE NURSING

Critical Care Nursing reflects a holistic approach in caring of patients. It places great emphasis on the caring of the bio-psycho-social-spiritual nature of human beings and their responses to illnesses rather than salary on the disease process. It helps maintain the individual patient’s identity and dignity. The focus of caring includes preventive care, risk factor modification and education to decrease future patient admissions to acute care facilities.

The Critical Care Nurses of the Philippines, Inc. (CCNAPI) is responsible for the promotion of man’s health and welfare for national development. It desires to support the professional and personal growth and development of initial core nurses. CCNAPI has organized itself into a national association committed to the ideals of service to the people, equality, justice and social progress.

In the Critical Care Units, each patient is viewed as a unique individual with dignity and worth. The critically ill patient should receive comfort and provided privacy in a highly technological environment. In collaboration with other health care team members, critical care nurses provide high level of patient care which includes patient and family education, health promotion and rehabilitation. To achieve this holistic care process, participation by the patient and his/her family is always emphasized. At the forefront of critical care science and technology, critical care nurses maintain professional competence based on a broad base of knowledge and experience through continuous education and evidence-based research.

With the advances in sophisticated biomedical technology and knowledge, critical care nurses are able to continuously monitor and observe patients for physiological changes to confront problems proactively and to assist patients achieve and maintain an optimum level of functioning or a peaceful death.

In other words, this nursing philosophy of the CCNAPI is accomplished by looking after critically ill patient in an environment with specially trained nurses, appropriate equipment, adequate medical supplies and other members of the health care personnel.

THE RIGHT OF THE CRITICALLY ILL PATIENT

The International Council of nurses (ICN) views health care as the rights of every individual regardless of financial political, geographical, racial and religious consideration. This right includes the right to choose or decline care, including the right to accept or refuse treatment or nourishment; informed consent; confidentiality and dignity, including the right to die with dignity. It involves both the right of those seeking care and the providers⁵.

The World Federation of Critical Care Nurses (WFCCN) has considered the rights of the critically ill patients, WFCCN has agreed that the statement of the patient’s right from the ICN covers the requirement for position statement on the rights of the critically ill patients.

CCNAPI being a founding member of WFCCN likewise supports the ICN position statement on Nurses and Human Rights as stated in Annex I.

GOALS OF CRITICAL CARE NURSING

Critical or intensive care is a complex specialty developed to serve the diverse health care need of patients (and their families) with actual or potential life threatening conditions 3 . It is therefore important that a clear statement of what critical care nursing wishes to achieve and provide should be articulated.

Goals of Critical Care Nursing include the following:

• To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the physiological dysfunction as well as the psychological stress in the ICU are under control;
• To care for the critically ill patients with a holistic approach, considering the patient’s biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting;
• To use relevant and up-to-dateknowledge, caring attitude and clinical skills, supported by appropriate technology for the prevention, early detection and treatment of complications to facilitate recovery.
• To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the patients and families go through their painful sufferings.

On the whole, critical care nursing should be patient-centered, safe, effective, and efficient. The nursing interventions are expected to be delivered in a timely and equitable manner.

LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN PHILIPPINES

With respect to the physical set-up and supporting facilities of critical care units in the Philippines, the Department of Health (DOH) Standards requires the critical care units / intensive care unit to be a self-contained area, with the provisions for resources that will support critical care practice. Currently, the DOH is reviewing these standards to come-up with updated requirement.

In 2003, the Philippine Society of Critical Care Medicine (PSCCM), Society of Pediatric Critical Care Medicine (SPCCM) and the CCNAPI stratified the care provisions in critical care practice into different levels and categories  to make it similar to its counterparts overseas with the goal of having effective utilization and organization of resources. Hence, as a guide, CCNAPI will incorporate these standards into this guideline.

Levels of Care Provision

The role of a particular critical care unit will vary, depending on the staffing, facilities and support services as well as the type and number of patients it has to manage. Taking into consideration the recommendation of the Guidelines on Critical Care Personnel and Services published in 2003 by the Critical Care Medicine⁴, the critical care service provision in the Philippines can adapt theses guidelines and apply the 3 levels of classifications accordingly:

• Should be capable of providing immediate resuscitation for the critically ill and short term cardio-respiratory support because the patients are at risk of deterioration;
• Has a major role in monitoring and preventing complications in “at risk” medical and surgical patients;
• Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;
• Has a formal organization of medical staff and at least one registered nurse.
• A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related clinical specialties; and
• Has a nurse: patient ratio of 1:1 for all critically ill patients.
• Should be capable of providing a high standard of general critical care for patients who are stepping down from higher levels of care or requiring single organ support/support post-operatively;
• Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
• Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times;
• The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and
• A nurse: patient ratio is 1:1 for all critically ill patients.
• Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring advanced respiratory support but also patients with multi-organ failure);
• Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff with an appropriate level of experience present in the unit at all times;
• A nurse in-charge and the majority of nursing staff have intensive care certification; and
• A nurse: patient ratio is at least 1:1 for all patients at all times.

Categories of Critical Care Unit

The Critical Care Unit can be categorized according to patients’ age group or medical specialties.

A. Age Group

B. Specialty

In the existing environment, majority of the Critical Care Units in the Philippines provide service for patients of various specialties. They are labeled as General ICUs. In certain hospitals, the critical care unit / service is dedicated to the following specific groups:

• Cardio-thoracic
• Respiratory
• Neurosurgical

System Operation of Critical Care Units

The operation of critical care units can be classified into Open System and Closed System.

A. Open System

The admitting and other attending doctors dictate management, change management or perform procedures without consultation or communication with a Critical Care Specialist. A Critical Care Specialist may be available for advice or be consulted to provide interventional skills (optional). No designated person who assumes the “gatekeeper” role.

B. Closed System

Management is coordinated by a qualified Critical Care Specialist. The critical / intensive care specialist has clinical and administrative responsibility. There is a multi-disciplinary team of specially trained critical care staff. The “intensivist” is the final common pathway for all medical decision-making including the decision to admit or discharge patients.

Irrespective of the ICU “System” Operations, i.e. open system or closed system, or a mixture of the two, there should be a designated group of registered nurses under unique management to provide highly specialized care to the critically ill patients. The nurse in-charge and the majority of nursing staff in each unit should have the relevant qualification in the specialty of the respective Unit.

SCOPE OF CRITICAL CARE NURSING

The scope of critical care nursing is defined by the dynamic interactions of the critically ill patient/family , the critical care nurse and the critical care environment to bring about optimal patient outcomes through nursing proficiency in an environment conducive to the provision of this highly specialized care 4 .

Constant intensive assessment, timely critical care interventions and continuous evaluation of management through multidisciplinary efforts are required to restore stability, prevent complications and achieve optimal health. Palliative care should be instituted to alleviate pain and sufferings of the patient and family in situations where death is imminent.

Critical Care Nurses are registered nurses, who are trained and qualified to practice critical care nursing. They possess the standard critical care nursing competencies in assuming specialized and expanded roles in caring for the critically ill patients and their family. Likewise,  each critical care nurse is personally responsible and committed to continuous learning and updating of his/her knowledge and skills. The critical care nurses carry out interventions and collaborates patient care activities to address life-threatening situations that will meet patient’s biological, psychological, cultural and spiritual needs.

The critical care environment constantly support the interactions between the critically ill patients, their family and the critical care nurses to achieve desired patient outcomes. It entails readily available and accessible emergency equipment, sufficient supplies and effective support system to ensure quality patient care as well as staff safety and productivity.

CRITICAL CARE NURSE QUALIFICATION

A critical care nurse is a licensed professional nurse who is responsible for ensuring that all critically ill patients and their families receive optimal care.

To be able to work in a critical care area other requirements are necessary and may vary depending on the institution.  In the nursing schools, critical care nursing is considered an elective subject and  the exposure  of students to critical care practice may not be enough to prepare  them for the complexity of critical care nursing practice once these student nurses  become licensed professional nurses.  Therefore, it is necessary that the health institution as employer provide newly hired nurses with a basic critical care nurse specialty education and orientation prior to the deployment in the critical care areas. In the Advanced Practice Nursing level, the advanced practice nurses in the critical care, must earn an advanced degree either at the master’s or doctorate level in nursing.

CRITICAL CARE NURSING WORKFORCE

The CCNAPI adopt the Position Statement of the World Federation of Critical Care Nurses on the Provisions of Critical Care Nursing Workforce also called” the Declaration of Buenos Aires” ratified in the full council meeting last

August 27, 2011 at the Sheraton Hotel, Buenos Aires, Argentina.

The declaration presents guidelines universally accepted by critical care professionals, which should be adopted to meet the critical care nursing workforce and the system requirements of a particular country or jurisdiction. The declaration states the specific central principles governing the provision and provides for specific recommended critical care nursing workforce requirement. The complete declaration is attached as Annex II to this guideline.

ROLES OF THE CRITICAL CARE NURSES

In response to the changes and expansions within and outside the healthcare environment, critical care nurses have broadened their roles in the practice levels. Competencies of critical care nurses are honed and developed to achieve their roles in practice, management / leadership and research.

Practitioner Role

The critical care nurses execute their practice roles 24-hours a day to provide high quality care to the critically ill patient.

1. Care Provider

A. Direct patient care

• Detects and interprets indicators that signify the varying conditions of the critically ill with the assistance of advanced technology and knowledge;
• Plans and initiates nursing process to its full capacity in a need driven and proactive manner;
• Acts promptly and judiciously to prevent or halt deterioration of patients’ condition when conditions warrant, and
• Co-ordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes.

B. Indirect patient care – Care of the Family

• Understands family needs and provide information to allay fears and anxieties and
• Assists family to cope with the life-threatening situation and/or patient’s impending death.

2. Extended roles as critical care nurses

Critical care nurses have roles beyond their professional boundary. With proper training and in accordance with established guidelines, algorithms, and protocols that are continuously reviewed and updated, critical care nurses also perform procedures and therapies that are otherwise done by doctors. Such procedures and therapies are:

a. Sampling and analyzing arterial blood gases;

b. Weaning patients off ventilators;

c. Adjusting intravenous analgesia / sedations;

d. Performing and interpreting ECGs;

e. Titrating intravenous and central line medicated infusion and nutrition support;

f. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia;

g. Removal of pacer wire, femoral sheaths and chest tubes,and

h. Other procedures deemed necessary  in their respective institutions under a clinical protocol.

3. Educator

As an educator, the critical care nurse must be able to:

• Provides health education to patient and family to promote understanding and acceptance of the disease process thus facilitate recovery and
• Participates in the training and coaching of novice healthcare team members to achieve cohesiveness in the delivery of patient care.

4. Patient Advocate

The critical care nurses’ role includes being an advocate – someone who acts or intercedes on behalf or another. Typically, the critical care nurse may be in the best position to act as the liaison between patient and family and other team members and departments because they are the healthcare professionals with the most interpersonal contact with the patients. To perform this function adequately, the nurse must be knowledgeable about the involved in all aspects of the patient’s care and have a positive working relationship with other team members. The critical care nurses are expected to:

• Acts in the best interests of the patient and
• Monitors and safeguards the quality of care which the patient receives.

Management and Leadership Role

The critical care nurse in her management and leadership role will be able to  assume the following responsibilities:

• Performance of management and leadership skills in providing safe and quality care;
• Accountability for safe critical care nursing practice;
• Delivery of effective health programs and services to critically-ill patients in the acute setting;
• Management of the critical care nursing unit or acute care setting;
• Taking the lead and supervision of nursing support staff, and
• Utilization of appropriate mechanism for collaboration, networking, linkage –building and referrals.

Role in Research

The critical care nurse’s role in research will entail the following responsibilities:

• Engage self in nursing or other health – related research with or under the supervision of an experienced researcher;
• Utilization of  guidelines in the evaluation of research study or report
• c. Application of the research process in improving patient care infusing concepts of quality improvement in partnership with other team-players.

ADVANCED PRACTICE LEVEL

The development of the Advanced Practice Nursing is the future direction in the Philippines and to be bench marked with other countries. For now, a thorough study of Advanced Practice in critical care  is being undertaken to align with the PRC- BON initiative on specialization framework.

The current global healthcare environment demands critical care nurses to have advanced knowledge and skills to provide the highest possible level of care to the critically ill patients. CCNAPI supports the following descriptions of advanced practice roles.

Expanded Roles

• Nurse Specialist / Clinical Nurse Specialist

The education and preparation of the critical care nurse practitioner is provided by the respective hospitals. CCNAPI recommends that a graduate study or a master’s degree program should support the development of critical care nursing specialization goes beyond the basic baccalaureate nursing degree. Advanced educational preparation refers to the critical care nursing educational program  run by the university offering Advanced Nursing Studies or other recognized advanced critical care program offered in the Philippines and overseas.

A registered nurse who is a nursing degree holder, should have more than 3 years of uninterrupted practice experience in the critical care field.He/she can function as a critical care nurse specialist when he/she has attained advanced education and expertise in caring patients with critical problems. He/she is  also eligible to be certified by the PRC- Board of Nursing as a Clinical Nurse Specialist.

The critical care nurse specialist is responsible for building up nursing competencies in the ICU entity. He / She contributes to continuous improvement in critical care nursing through staff and clients education and uphold quality nursing guidelines  on patient care through clinical research and refinement of ICU Standards.

B. Acute Care Nurse Practitioner

Acute Care Nurse Practitioner (ACNP) in the critical care unit takes lead in developing evidence-based practices to meet changing clinical needs and facilitates patient care processes across professional and organizational boundaries. The qualification of Acute Care Nurse Practitioner (ACNP) includes:  should have the recommended number of post registration (licensed experience) nursing experience which are spent in the critical field, exhibiting in –depth professional knowledge and skills. An Acute Care Nurse Practitioner (ACNP) is a holder of: a) clinical master’s degree in a clinical nursing specialty (Medical-Surgical) such as Critical Care Nursing or b) master’s degree in nursing or related discipline such as management together with recognized critical care training qualifications. The Acute Care Nurse Practitioner executes the nursing team leader’s responsibilities as designated in the position of Advanced Nurse Practitioner.

C. Outcome Specialist

Outcome management has been introduced into the healthcare system to ensure achievement of quality and cost-effectiveness in the delivery of patient care. Some critical care units have adopted clinical pathways (e.g., Critical Pathways, Protocols, Algorithms and Orders) in the management of specific diseases such as Acute Myocardial Infarction and Cardio-thoracic Surgeries. Qualified nurse experts are involved in the development and implementation of patient outcomes management.

CHALLENGES OF CRITICAL CARE NURSES

The challenging needs that the advanced critical care practitioner will face from the critical care nursing service and its environments demand for them to consider the following objectives:

• To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of illness, health and care needs of the people;
• To analyze and evaluate critical care nurses specialty skills and their evolving roles;
• To review current studies and researches and to examine contextual issues that will enable evaluation and synthesis of new knowledge, traditional techniques, religious and cultural influences to be applied in nursing practice, particularly evidence-based nursing practice, and
• To exercise professional judgments expected of them in the critical care clinical setting.

TRAINING OF NURSES FOR CRITICAL CARE SERVICES

The institution / hospital should provide training opportunities to ensure staff competencies.  This will enable the nurses working in the critical care units to cope with the complexities and demands of the changing needs of the critically ill patients.  The following training activities should be supported  by the higher level of management to maintain a high standard of care:

Orientation Program / Preceptorship and Mentoring Program

New recruits to the critical care units shall attend an orientation program and be given opportunities to work under senior staff supervision. Experienced staff in the unit should be readily available for consultation.

In-Service Training Program

a. Unit / hospital based training courses / workshop / seminar at hospital level

b. On-the-job training and bedside supervision

Critical Care Nursing Program (Post Graduate Specialty Program)

Critical Care Nurses Association of the Philippines, Inc. recommends that all practicing CCN shall continuously update their knowledge, skills and behavior through active participation in Critical Care Nursing Education or its related field.

The following are categorization of critical care nursing education:

• Post Graduate Courses

Post graduate courses are part of higher education taken after a Bachelor’s Degree that are accredited from the Commission on Higher Education (CHED) or the Professional Regulation Commission—Board of Nursing (PRC-BON).

It is recommended that this course has been reviewed, evaluated and endorsed to the accrediting body by the Critical Care Nurses Association of the Philippines, Inc.

Likewise it is further recommended that the World Federation of Critical Care Nurses policy statement of education shall be used as a framework for designing a critical care nursing program. (Please see Declaration of Madrid, 2005 Annex I)

• Certification Course

Certification courses provides recognition and designation earned by a professional nurse after completing with satisfaction the requirements of the course and has earned qualification to perform a job or task.

The certification courses should be recognized and accredited by the Professional Regulation Commission— Board of Nursing (PRC-BON) or other authorized accrediting body.

This shall include but not limited to the following:

• Advanced Cardiac Life Support
• Pediatric Advanced Cardiac Life Support
• Newborn Resuscitation
• Continuous Renal Replacement Certification
• Advanced Intravenous therapy
• Stroke Nursing

Continuing Professional Education (CPE)

Continuing Professional Education Programs is a type of education that consist of updated knowledge and other pertinent information that will help the Critical Care Nurse to attain broader understanding  of criticalcare practice and its related field. The goal includes Critical Care Nurses development of skill, behavior that will help them view the critically ill person in a holistic dimension

CCNAPI recommends that all practicing CCN shall ensure the they continuously update their knowledge, skills and behavior through active participation in related critical care nursing education and must earn at least 20 credit units per year.

The updated educational component includes but not limited to the following:

• Advanced/Comprehensive Critical Assessment
• Critical Care Practitioner
• End-of-Life and Palliative Care

STANDARDS OF CRITICAL CARE NURSING PRACTICE

Critical care specialty addresses the management and support of patients with severe or life-threatening illness. The goal of critical care nursing is to promote optimal adaptation of critically ill patients and their families by providing highly individualized care, so that the critically ill patients adapt to their physiological dysfunction as well as the psychological stress in the Critical Care Unit or Intensive Care Unit (ICU). To achieve this, standards should be developed to serve as a guide for monitoring and enhancing the quality of intensive care nursing practice.

Care standards for critical care nursing provide measures for determining the quality of care delivered, and also serve as means for recognizing the competencies of nurses in intensive care specialty.

Procedures standards for critical care nursing practice provide a step-by-step guideline for nurses to carry out day-to-day nursing procedure in a most appropriate manner.

The following 11 Standards are intended to furnish nurses with directions in providing quality care and excellence in Critical Care Nursing:

1.  The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.

2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.

3. The critical care nurse practices current critical care nursing competently.

4. The critical care nurse delivers nursing care in a way that can be ethically justified.

5. The critical care nurse demonstrates accountability for his/her professional judgment and actions.

6. The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

7. The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

8. The critical care nurse protects the patients from developing environmental induced infection.

9. The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.

10. The critical care nurse carries out health education for promotion and maintenance of health.

11. The critical care nurse acts to enhance the professional development of self and others.

The Structure-Process-Outcome model is used. Emphasis is put on management systems, nursing activities and interactions between the nurse and the care recipients, as well as the outcomes of nursing care provided.

Standard Statement 1: The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.

Standard Statement 2: The critical care nurse provides care to meet individual patient needs on a 24-hour basis

Standard Statement 3: The critical care nurse practices current critical care nursing competently

Standard Statement 4: The critical care nurse delivers nursing care in a way that can be ethically justified.

Standard Statement 5: The critical care nurse demonstrates accountability for his/her professional judgment and actions.

Standard Statement 6: The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

Standard Statement 7: The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

Standard Statement 8: The critical care nurse protects patients from developing environmental induced infection.

Standard Statement 9: The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.

Standard Statement 10: The critical care nurse carries out health education for promotion and maintenance of health.

Standard Statement 11: The critical care nurse acts to enhance the professional development of self and others.

COMPETENCIES FOR CRITICAL CARE NURSES

The competence of critical care nurses together with established nursing standards and the identified core competencies for registered nurses will result to excellence in critical care nursing practice. This three-pronged holistic framework ensures quality performance through an adherence to nursing standards, the demonstration of competencies, and the integration of appropriate nursing model/s into the health care delivery process.

To achieve safe and quality client-centered care, nurses working in the critical care units are envisioned to adopt not only the stated core competencies of registered nurses but also the specific competencies stipulated in the following eleven major key responsibility areas:

Safe and Quality Nursing Care

Management of Resources

Legal Responsibilities

Ethico-Moral Responsibilities

Collaboration and Teamwork

Personal and Professional Development

Communication

 Health Education

Quality Improvement

Record Management

Position Statement on the Provision of Critical Care Nursing Education - Declaration of Madrid, 2005

Introduction

At the 6th World Congress on Intensive Care and Critical Care Medicine in Madrid, Spain 1993 the World Federation of Societies of Intensive Care and Critical Care Medicine endorsed what has become know as the Declaration of Madrid on the preparation of critical care nurses.

In May 2003 the World Federation of Critical Care Nurses under took a review of the Declaration of Madrid and recommendations from the Australian College of Critical Care Nurses position statement on critical care nursing education and other similar documents from member associations. The current position statement aims to inform/assist critical care nursing associations, health care providers, educational facilities and other interested parties in the

development and provision of critical care nursing education.

The first draft of this position statement was distributed to member societies of the WFCCN between February 2004 and September 2004 and changes made following discussion and meeting of the WFCCN in Cambridge September 2004.

The second draft of this position statement was distributed to a wider audience including member societies of WFCCN, other international nursing and medicine organisations and individuals with an interest in critical care nursing between October 2004 and April 2005.

The third draft of this position statement was distributed to an ever-wider audience again including member societies of WFCCN, other international nursing and medicine organisations and individuals with an interest in critical care nursing between May2005 and August 2005.

A full meeting of the World Federation of Critical Care Nurses on Saturday 27 August 2005 at the Sheraton Hotel, Buenos Aires, Argentina, ratified this position statement.

Copyright of this statement is owned by WFCCN. Whilst this statement is freely available for all people to access its wording may not be changed under any circumstances.

Critical or intensive care is a complex specialty developed to serve the diverse health care needs of patients (and their families) with actual or potential life threatening conditions.

The role of the critical care nurse is essential to the multidisciplinary team needed to provide specialist knowledge and skill when caring for critically ill patients. The critical care nurse enhances delivery of a holistic, patient centred approach in a high tech environment bringing to the patient care team a unique combination of knowledge and caring. In order to fulfil their role, nurses require appropriate specialised knowledge and skills not typically included in the basic nursing programs of most countries.

Government, professional and educational bodies governing the practice of nursing must recognise the importance of dedicated specialised preparation for critical care nurses in order to assure the optimum health care delivery of their community. This declaration presents guidelines universally accepted by critical care professionals, which may be adapted to meet the educational and health care requirements of a particular country or jurisdiction.

Central Principles

  1. Critically ill patients and families have the right to receive individualised critical care from qualified professional nurses.

• Critical care nurses must possess appropriate knowledge, attributes and skills to effectively respond to the needs of critically ill patients, to the demands of society, and to the challenges of advancing technology.
• Where a basic nursing education program does not include these required specialised knowledge, attributes and skills, access to such further education must be provided to nurses responsible for the care of critically ill patients and their families.
• Nurses with specialised knowledge and expertise in the provision of care to critically ill patients should play an integral part in the education of critical care nurses, even when a multidisciplinary, educational approach is utilised.
• The preparation of critical care nurses must be based on the most current available information and research.

Recommendations for Critical Care Nursing Education

The World Federation of Critical Care Nurses believe that critically ill patients have very special needs and must be cared for by nurses with specialist skills, knowledge and attitudes.

The following recommendations have been adopted to represent universal principles to help guide health services, educational facilities and critical care nursing organisations in the development of appropriate educational programs for nurses who are required to care for critically ill patients and

their families:

• As a minimum, the critical care dimensions of the following topics should be included in programs to prepare critical care nurses. The categories are not listed in order of importance:
• Anatomy and physiology
• Pathophysiology
• Pharmacology
• Clinical Assessment (including interpretation of diagnostic and laboratory results)
• Illnesses and alterations of vital body functions
• Plans of care and nursing interventions
• Medical interventions and prescriptions with resulting nursing care responsibilities
• Psychosocial aspects (including cultural and spiritual needs)
• Technology applications
• Patient and family education
• Legal and ethical issues
• Professional nursing issues and roles in critical care, including clinical teaching strategies, team leadership and management issues
• Use of current research findings to deliver evidence based multidisciplinary care
• Caring for the carer (including dealing with stress and peer support)
• Programs preparing critical care nurses to function at a specialist level of practice should be provided at a post-registration level and conducted by a higher education provider (for example, a university or equivalent provider).
• The curricula of critical care nursing post-registration courses must provide an appropriate mixof theoretical and clinical experience, to prepare nurses to meet the challenges of clinical practice effectively.
• WFCCN recommends that national critical care nursing associations establish agreed Standards for Specialist Critical Care Nursing to be utilised as a framework for both critical care curriculum development and assessment of clinical practice.
• Post-registration courses for critical care nurses must provide a balance between clinically oriented content and broader generic content that enables the specialist nurse to contribute to the profession through processes such as research, practice development and leadership.
• Close collaboration between the health care and higher education sectors is important, in order that post-registration critical care nursing education be provided at a standard that meets the expectations of both sectors.
• Graduates of post-registration courses in critical care must be able to demonstrate clinical competence as well as a sound theoretical knowledge base. A strong emphasis on the application of theory to practice, and the assessment of clinical competence, should be an integral component of post-registration critical care courses.
• The provision of appropriate clinical experience to facilitate the development of clinical competence should be a collaborative responsibility between education and health care providers. Critical care nursing students should have access to support and guidance from appropriately experienced staff such as clinical teachers and nurse preceptors.
• Clinical teachers and nurse preceptors for post-registration critical care nursing students should be appropriately supported in their role by both education and health care providers.
• Critical care education providers should have in place policies and processes for recognition of prior learning and alternative entry pathways into formal post-registration specialist courses, in order to create a more flexible yet consistent means for students to attain recognition of competence.
• Health care and higher education providers need to establish strategies to help reduce the financial burden faced by nurses undertaking post-registration critical care courses.
• Education providers must implement educational strategies to facilitate access to post registration courses for critical care nurses from a range of geographical locations.
• Innovative strategies need to be implemented to address the deficit of qualified critical care nurses, rather than resorting to short training courses to resolve the problem. Such strategies could include comprehensive critical care workforce planning, innovative retention strategies, nurses undertaking post-registration critical care courses, refresher ‘training’, professional development programs and the provision of greater support for nurses undertaking post-registration critical care courses.
• Providers of short critical care training courses should seek credit transfer (recognition of prior learning) within the higher education sector for nurses completing these courses.

References:

• Australian College of Critical Care Nurses, Critical Care Nursing Education Advisory Committee, Position Statement on postgraduate critical care nursing education – October 1999. Aust. Critical Care, 1999 (vol 12, No 4. p160-164)
• World Federation of Societies of Intensive and Critical Care Medicine. Declaration of Madrid on the preparation of Critical Care Nurses. Aust. Critical Care 1993 vol 6 No 2 p.24.
• International Nursing Council. The Global Shortage of Registered Nurses: An Overview of Issues and Actions (and accompanying Issues Papers) www.icn.ch/global

Position Statement on the Provision of Critical Care Nursing Workforce - Declaration of Buenos

Aires, 2005

In May 2003 the World Federation of Critical Care Nurses undertook a review of available national critical care nursing associations’ position statements on critical care nursing workforce requirements. The current position statement aims to inform and assist critical care nursing associations, health services, governments and other interested stakeholders in the development and provision of appropriate critical care nursing workforce requirements.

Development of the nursing workforce within of critical care units requires careful planning and execution to ensure an appropriate balance and mix of staff skills and attributes that allow for safe and effective care. In parallel is the provision of a learning environment for novice critical care nurses, a flexibility to respond to changes in demand and efficiencies to ensure economic

sustainability without clinical compromise.

Critical Care nursing workforce planning must be considered in the context of the total hospital requirement for access to critical care beds in addition to the regional requirement for integrated and accessible critical care services across a number of hospitals and institutions in a population defined health service.

Governments, hospital boards and professional bodies that inform and support the provision of critical care services must recognise the importance of providing adequately skilled, educated and available critical care nurses, doctors and other support staff to assure the health and safety of some of the most vulnerable patients in the health care system.

This declaration presents guidelines universally accepted by critical care professionals, which may be adapted to meet the critical care nursing workforce and system requirements of a particular country or jurisdiction.

• Every patient must be cared for in an environment that best meets his or her individual needs. It is the right of patients whose condition requires admission to a critical care unit to be cared for by registered nurses. In addition the patient must have immediate access to a registered nurse with a post registration critical care nursing qualification (refer to WFCCN Declaration of Madrid on the provision of critical care nursing education).
• There should be congruence between the needs of the patient and the skills, knowledge and attributes of the nurse caring for the patient.
• Unconscious and ventilated patients should have a minimum of one nurse to one patient. High dependency

patients in a critical care unit may have a lesser nurse patient ratio. Some patients receiving complex

therapies in certain critical care environments may require more than one nurse to one patient.

• When calculating nurse-to-patient ratios and roster requirements in critical care, consideration and care must be given to the skill sets and attributes of nursing and support colleagues within the nursing shift team as they vary and require re-evaluation with fluctuations in patient care requirements.
• Adequate nursing staff positions must also be in place to assist with nursing education, inservice training, quality assurance and research programs, management and leadership activities, and where institutionally required, external liaison and support services beyond the confines of the critical care unit.
• Critical care nurses should focus their labor on roles and tasks that require advanced skill, expertise and knowledge of best practice in patient care. Therefore, adequate numbers of support staff should be employed to preserve the talents of critical care nurses for patient care and professional responsibilities wherever possible.
• Flexible workforce strategies and incentives should be employed by management to recruit, retain and remunerate expert critical care nurses at the patient bedside, and to ensure appropriate succession planning for future leadership needs. Additionally, contingencies should also be in place to respond to fluctuating and unexpected demands on the critical care service.

Recommendations for Critical Care Nursing Workforce Requirements

As a minimum, the critical care unit should maintain or strive to achieve the following nursing workforce requirements:

• Critically ill patients (clinically determined) require one registered nurse at all times.
• High dependency patients (clinically determined) in a critical care unit require no less than one registered nurse for two patients at all times.
• Where necessary extra registered nurses may provide additional Assistance, Coordination, Contingency (for late admission, sick staff), Education, Supervision, and Support to a sub-set of patients and nurses in a critical care unit. (some times referred to as ACCESS nurse)
• A critical care unit must have a dedicated head nurse (otherwise called Charge Nurse or similar title) to manage and lead the unit. This person must have a recognised post-registration critical care nursing qualification. It is also recommended the Head Nurse/Nurse in Charge have management qualifications.
• Each shift must have a designated nurse in charge to deputise for the head nurse and to ensure direction and

supervision of the unit activities throughout the shift. This person must have a recognised post-registration

critical care nursing qualification.

• A critical care unit must have a dedicated nurse educator to provide education, training and quality improvement activities for the unit nursing staff. This person (s) must have a recognised post-registration critical care nursing qualification.
• Resources must be allocated to support nursing time and costs associated with quality assurance activities, nursing and team research initiatives, education and attendance at seminars and conferences.
• Adequate support staff within the critical care area including: administrative staff, support staff to assist with manual handling, cleaning and domestic duty staff and other personnel exist to allow nursing staff to focus on direct patient care and associated professional requirements.
• Appropriately skilled and qualified medical staff are appointed and accessible to the unit for decision making and advice at all times. A medical director is appointed to work collaboratively with the head nurse in order to provide policy/protocol, direction and collaborative support.
• Remuneration levels for nursing staff are such that they are competitive with similar professions in the country and are scaled in such away as to reward and retain qualified, experienced and senior critical care nurses.
• Appropriate, accessible and functional levels of equipment and technology are available and maintained to meet the demands of the expected patient load at any given time and nursing staff are adequately trained and skilled in the application of such equipment and technology.
• Adequate occupational health and safety regulations should be in place and enforced to protect nurses from hazards of manual handling and occupational exposure.
• Organised and structured peer support and debriefing procedures are in place to ensure nursing staff support and wellbeing following critical incident exposure.
• Australian College of Critical Care Nurses Position Statement on Intensive Care Nursing Staffing. www.acccn.com.au 
• British Association of Critical Care Nursing. Position Statement. Nurse-patient ratios in critical care. Nursing in Critical Care.2001. Vol No2.P59-63 
• Williams, G.F. & Clarke, T. 2001. “A Consensus Driven method to measure the Required Number of Intensive Care Nurses in Australia”. Aust.Critical Care. 14(3):106-115. 

  Position Statement on the Rights of the Critically Ill Patient - Declaration of Manila, August 2007

At the 1st World Federation of Critical Care Nurses (WFCCN) meeting in Cambridge in 2004 the WFCCN chose to develop a position statement on Rights of the Critically Ill Patient. The existing situation was considered and similar documents from other organisations were examined. This was then discussed further at the 2nd Congress of WFCCN in Buenos Aires, August 2005.

The current position statement aims to inform and assist critical care nursing associations, health services, educational facilities and other interested parties in the development of patient’s rights for the critically ill.

I. Preamble

In 1948 the United Nations proclaimed the Universal Declaration of Human Rights. The rights of individuals have been proclaimed and expanded since then in many statements and nations. The specific rights in health care have been stated by many nations and some health care groups.

Critical care nursing is specialised nursing care of critically ill patients who have manifest or potential disturbance of vital organ functions.

The World Federation of Critical Care Nurses (WFCCN) has considered the rights of critically ill patients. WFCCN have agreed that the statement on patient’s rights from the International Council of Nurses (ICN) covers the requirements for a position statement on the rights of the critically ill patient.

The WFCCN accept and support the ICN position statement on Nurses and Human Rights reproduced below.

II. Nurses and Human Rights

ICN Position:

The International Council of Nurses (ICN) views health care as a right of all individuals, regardless of financial, political, geographic, racial or religious considerations. This right includes the right to choose or decline care, including the right to accept or refuse treatment or nourishment; informed consent; confidentiality, and dignity, including the right to die with dignity. It involves both the rights of those seeking care and the providers.

Human Rights and the Nurse’s Role

Nurses have an obligation to safeguard and actively promote people’s health rights at all times and in all places. This includes assuring that adequate care is provided within the resources available and in accordance with nursing ethics. As well, the nurse is obliged to ensure that patients receive appropriate information in understandable language prior to consenting to treatment or procedures, including participation in research.

Nurses are accountable for their own actions and inactions in safeguarding human rights, while National Nurses Associations (NNAs) have a responsibility to participate in the development of health and social legislation related to patient rights.

Where nurses face a “dual loyalty” involving conflict between their professional duties and their obligations to their employer or other authority, the nurse’s primary responsibility is to those who require care.

Nurses’ Rights

Nurses have the right to practice in accordance with the nursing legislation of the country in which they work and to adopt the ICN Code of Ethics for Nurses or their own national ethical code.  They also have a right to practice in an environment that provides personal safety, freedom from abuse and violence, threats or intimidation. Nurses individually and collectively through their national nurses associations have a duty to speak up when there are violations of human rights, particularly those related to access to essential health care and patient safety.

National nurses’ associations need to ensure an effective mechanism through which nurses can seek confidential advice, counsel, support and assistance in dealing with difficult human rights situations.

Background:

Nurses deal with human rights issues daily, in all aspects of their professional role. As such, they may be pressured to apply their knowledge and skills in ways that are detrimental to patients and others. There is a need for increased vigilance, and a requirement to be well informed, about how new technology and experimentation can violate human rights. Furthermore

nurses are increasingly facing complex human rights issues, arising from conflict situations within jurisdictions, political upheaval and wars. The application of human rights protection should emphasise vulnerable groups such as women, children, elderly, refugees and stigmatised groups.To prepare nurses to adequately address human rights, human rights issues and the nurses’ role

need to be included in all levels of nursing education programmes.

ICN endorses the Universal Declaration of Human Rights[1]and ICN addresses human rights issues through a number of mechanisms including advocacy and lobbying, position statements, fact sheets, and other means.

Adopted in 1998

Revised in 2006

(Replaces previous ICN Position: “The Nurse’s Role in Safeguarding Human Rights”, adopted 1983, updated 1993).

1 Universal Declaration of Human Rights (1948), New York: United Nations

• International Council of Nurses Position Statement on Nurses and Human Rights, Adopted in 1998,revised in 2006. Accessed on December 2008, at. http://www.icn.ch/pshumrights.htm

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Critical Care Nursing

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• Rick Yiu Cho Kwan 3 ,
• Vico Chiang 4 &
• Kitty Chan 3  

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Emergency care nursing ; High-acuity care nursing ; Intensive care nursing

Critical care is defined by the US Department of Health and Human Services as the direct delivery of care for people who are critically ill, which means that an illness or injury has acutely impaired one or more vital organ system to a degree that there is a high probability of life-threatening deterioration (Duke 2006 ). According to the Association of American Critical Care Nurses, critical care nursing is a specialty that deals specifically with human responses to life-threatening problems; a critical care nurse is a licensed professional nurse who is responsible for ensuring that critically ill patients and their families receive optimal care (Burns 2014 ).

Critical care nursing emerged from the early 1950s. At that time, the use of mechanical ventilation and cardiopulmonary resuscitation began, and there was a great demand for providing efficient care to gravely ill patients (Perrin...

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Abella Alvarez A, Torrejon Perez I, Enciso Calderon V, Hermosa Gelbard C, Sicilia Urban JJ, Ruiz Grinspan M, … Gordo Vidal F (2013) ICU without walls project. Effect of the early detection of patients at risk. Med Intensiva 37(1):12–18. https://doi.org/10.1016/j.medin.2012.08.006

Akgun KM, Kapo JM, Siegel MD (2015) Critical care at the end of life. Semin Respir Crit Care Med 36(6):921–933. https://doi.org/10.1055/s-0035-1565254

Article   Google Scholar  

Bell L (2015) AACN scope and standards for acute and critical care nursing practice. Retrieved from http://www.dphu.org/uploads/attachements/books/books_5310_0.pdf

Biel M, Eastwood J-A, Muenzen P, Greenberg S (1999) Evolving trends in critical care nursing practice: results of a certification role delineation study. Am J Crit Care 8(5):285

Google Scholar  

Burns SM (2014) AACN essentials of critical care nursing. McGraw-Hill Education, Chicago, IL

Burns KE, Misak C, Herridge M, Meade MO, Oczkowski S (2018) Patient and family engagement in the ICU. Untapped opportunities and underrecognized challenges. Am J Respir Crit Care Med 198(3):310–319

Calhoun A (2018) ECMO: nursing care of adult patients on ECMO. Crit Care Nurs Q 41(4):394–398. https://doi.org/10.1097/CNQ.0000000000000226

Chamberlain D, Pollock W, Fulbrook P (2018) ACCCN workforce standards for intensive care nursing: systematic and evidence review, development, and appraisal. Aust Crit Care 31(5):292–302. https://doi.org/10.1016/j.aucc.2017.08.007

Chaudhuri D, Tanuseputro P, Herritt B, D’Egidio G, Chalifoux M, Kyeremanteng K (2017) Critical care at the end of life: a population-level cohort study of cost and outcomes. Crit Care 21(1):124. https://doi.org/10.1186/s13054-017-1711-4

Critical care services Ontario (2012) Standards for critical care nursing in Ontario. Critical Care Services Ontario, Ontario

Duke EM (2006) The critical care workforce: a study of the supply and demand for critical care physicians. US Department of Health and Human Services, Rockville, p 34

European Federation of Critical Care Nursing associations. Clinical Practice. Retrieved from http://www.efccna.org/clinical-practice

Fairman J, Lynaugh J, Lewensgn SB (2000) Critical care nursing: a history. University of Pennsylvania Press, Philadelphia

Flannery L, Ramjan LM, Peters K (2016) End-of-life decisions in the Intensive Care Unit (ICU) – exploring the experiences of ICU nurses and doctors – a critical literature review. Aust Crit Care 29(2):97–103. https://doi.org/10.1016/j.aucc.2015.07.004

Foreman MD, Milisen K, Fulmer TT (2010) Critical care nursing of older adults best practices, 3rd edn. Springer, New York

Gordo F, Abella A (2014) Intensive care unit without walls: seeking patient safety by improving the efficiency of the system. Med Intensiva 38(7):438–443. https://doi.org/10.1016/j.medin.2014.02.001

Hardin, S. R. (2005). Introduction to the AACN synergy model for patient care. In S. R. Hardin & R. Kaplow, Synergy for clinical excellence: the AACN synergy model for patient care (pp 3–10). Burlington, MA: Jones & Bartlett Learning.

Kelly D, Kutney-Lee A, Lake ET, Aiken LH (2013) The critical care work environment and nurse-reported health care-associated infections. Am J Crit Care 22(6):482. https://doi.org/10.4037/ajcc2013298

Kelly DM, Kutney-Lee A, McHugh MD, Sloane DM, Aiken LH (2014) Impact of critical care nursing on 30-day mortality of mechanically ventilated older adults. Crit Care Med 42(5):1089

Kleinpell R, Heyland DK, Lipman J, Sprung CL, Levy M, Mer M, … Curtis JR (2018) Patient and family engagement in the ICU: report from the task force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care 48:251–256. https://doi.org/10.1016/j.jcrc.2018.09.006

Laporte L, Hermetet C, Jouan Y, Gaborit C, Rouve E, Shea KM, … Guillon A (2018) Ten-year trends in intensive care admissions for respiratory infections in the elderly. Ann Intensive Care 8(1):84

Lavallee JF, Gray TA, Dumville J, Russell W, Cullum N (2017) The effects of care bundles on patient outcomes: a systematic review and meta-analysis. Implement Sci 12(1):142. https://doi.org/10.1186/s13012-017-0670-0

Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M (2008) Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med 148(11):801–809

Lilly CM, Swami S, Liu X, Riker RR, Badawi O (2017) Five-year trends of critical care practice and outcomes. Chest 152(4):723–735

Mick DJ, Ackerman MH (2004) Critical care nursing for older adults: pathophysiological and functional considerations. Nurs Clin N Am 39(3):473–493. https://doi.org/10.1016/j.cnur.2004.02.007

Minton C, Batten L, Huntington A (2019) A multicase study of prolonged critical illness in the intensive care unit: families’ experiences. Intensive Crit Care Nurs 50:21–27. https://doi.org/10.1016/j.iccn.2018.08.010

Montgomery H, Grocott M, Mythen M (2017) Critical care at the end of life: balancing technology with compassion and agreeing when to stop. Br J Anaesth 119(Suppl 1):i85–i89. https://doi.org/10.1093/bja/aex324

Murphy P, Kreling B, Kathryn E, Stevens M, Lynn J, Dulac J (2000) Description of the SUPPORT intervention. Study to understand prognoses and preferences for outcomes and risks of treatments. J Am Geriatr Soc 48(5 Suppl):S154

Nurses AA o C-C, Corporation AC (2003) Safeguarding the patient and the profession: the value of critical care nurse certification. Am J Crit Care 12(2):154–164

Perrin KO, MacLeod CE (2012) Understanding the essentials of critical care nursing. Pearson Higher Ed, London

Saito S, Nakatani T, Kobayashi J, Tagusari O, Bando K, Niwaya K, … Kitamura S (2007) Is extracorporeal life support contraindicated in elderly patients? Ann Thorac Surg 83(1):140–145

Schofield-Robinson OJ, Lewis SR, Smith AF, McPeake J, Alderson P (2018) Follow-up services for improving long-term outcomes in intensive care unit (ICU) survivors. Cochrane Database Syst Rev 11:Cd012701. https://doi.org/10.1002/14651858.CD012701.pub2

The Canadian Association of Critical Care Nurses (2009) Standards for critical care nursing practice: Canadian Association of Critical Care Nurses. Retrieved from https://www.caccn.ca/pdfs/CACCN%20STND%20CRIT%20CARE%202009.pdf

Ward NS, Chong DH (2015) Critical care beds and resource utilization: current trends and controversies. Semin Respir Crit Care Med 36(6):914–920. https://doi.org/10.1055/s-0035-1564876

World Federation of Critical Care Nurses (2017) WFCCN resources for clinical guidelines. Retrieved from http://wfccn.org/clinical-guidelines/

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Critical Care Nursing

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Critical care nursing is a field of nursing that practices predominantly in intensive care and emergency units. Critical care nurses are equipped to handle critically ill patients, often specializing in a particular aspect of critical illness, such as cardiac care, to provide the best care for patients who are seriously ill or injured.

In addition to caring for the physical health of patients, critical care nurses must deal with the emotional health of patients as they cope with their conditions, as well as working with family members to make the best health care decisions for the patients. The nurses usually work with a team of health care professionals to develop a patient’s care plan. Communication is imperative in critical care nursing; in addition, a nurse must be prepared for adapting a patient’s care quickly based on the patient’s health.

Critical Care Nursing Theories and Models

• Erickson’s Modeling and Role Modeling Theory
• King’s Theory of Goal Attainment
• Neuman’s Systems Model
• Orem’s Self-Care Deficit Nursing Theory
• Orlando’s Nursing Process Discipline Theory
• Peplau’s Theory of Interpersonal Relations
• Parse’s Human Becoming Theory
• Rogers’ Theory of Unitary Human Beings
• Roy’s Adaptation Model of Nursing
• Kolcaba’s Theory of Comfort
• Watson’s Philosophy and Science of Caring
• Nightingale’s Environment Theory
• Pender’s Health Promotion Model
• Roper-Logan-Tierney’s Model for Nursing Based on a Model of Living
• Henderson’s Nursing Need Theory

For more information on Critical Care Nursing, try the following sources:

AACN Synergy Model for Patient Care

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When the AACN Synergy Model for Patient Care debuted more than 20 years ago, it embodied a fundamental shift in thinking about nursing skills and how to assess them through certification. Today, the Synergy Model not only continues to serve as the basis for AACN certification programs, its use has expanded to other nursing applications in a variety of organizational types.

We understand many of you have questions about the Synergy Model, and wanted to answer some of your most frequently asked questions.

What is the Synergy Model?

At its core, the AACN Synergy Model for Patient Care is a conceptual framework that aligns patient needs with nurse competencies. Originally developed in 1996 as a new framework for AACN’s certification programs, the Synergy Model shifted the assessment of nursing skills from the then-prevalent body systems/medical model — which didn’t consistently match actual practice — to a “nurse competencies” framework.

The central idea of the model is that a patient’s needs drive the nurse competencies required for patient care. When nurse competencies stem from patient needs, and the characteristics of the nurse and patient match, synergy occurs. This synergy enables optimal outcomes.

The model identifies eight patient characteristics and eight nurse competencies. More detailed information about these needs and competencies is available here .

Where is the Synergy Model used?

While development of the Synergy Model initially focused on critical care nursing certification, the model’s architects also acknowledged its potential for broader application to nursing practice. Why? Because the patient needs identified in the model can be applied to any patient/nurse interaction.

Currently, you’ll find the Synergy Model at work not only as the keystone of AACN certifications, but as a professional practice model, a foundation for nursing school curricula and a model for professional advancement. More information about each of these applications follows.

How is the Synergy Model integrated into AACN certification programs?

The Synergy Model influences AACN certifications in three ways.

• Developing Nurse Competencies AACN Certification Corporation uses the nurse competencies of the Synergy Model as the conceptual framework for the research — called job analyses or “studies of practice”— underpinning development of its certification exams. The organization conducts national job analysis surveys at least every five years to ensure its certification exams reflect current nursing practice. The nurse competencies in the model guide the questions on these surveys, and the results serve as the foundation for certification test plans. You can access the job analysis report from each AACN certification .
• Developing Certification Test Plans Test plans for AACN Certification Corporation exams are organized by the nurse competencies in the Synergy Model and can be accessed in the exam handbook for each certification program. When preparing for an AACN certification exam, you are not expected to memorize all components of the model. However, you may benefit from studying the nurse competencies of the model and are encouraged to use your certification’s test plan as a primary study resource.
• Supporting Certification Renewal Renewal of many AACN Certification Corporation credentials requires earning Continuing Education Recognition Points (CERPs) in categories corresponding to the eight nurse competencies in the Synergy Model. For example, one category focuses on collaboration and systems thinking, encompassing topics such as communication and healthy work environments. When it’s time to renew your certification, you may find it beneficial to familiarize yourself with these nurse competencies. Access details about CERP categories in the CCRN/PCCN Renewal brochure .

Where can I find Synergy Model source materials and references for research projects?

Over the years, a number of national nursing experts have authored materials that describe and expand on the AACN Synergy Model for Patient Care.

• “ Synergy: The Unique Relationship Between Nurses and Patients ” — Edited by Martha A.Q. Curley in 2007, this book remains a seminal publication on the Synergy Model. It is available for purchase in the AACN Store.
• “ Synergy for Clinical Excellence – The AACN Synergy Model for Patient Care ,” 2nd ed. — Sonya Hardin and Roberta Kaplow’s 2017 book provides a detailed analysis with case examples for each of the Synergy Model’s eight patient characteristics and eight nurse competencies, as well as examples of the model’s broader applications.
• Critical Care Nurse and the American Journal of Critical Care — These two AACN peer-reviewed journals have published numerous articles on applications of the Synergy Model since 1996.

Is the Synergy Model useful in developing frameworks for nursing practice?

The Synergy Model emphasizes the importance of alignment between patient needs and nurse competencies in achieving optimal outcomes and nurse satisfaction. With its focus on context and the patient/nurse relationship, the model lends itself to broader application within the world of nursing practice.

Hardin and Kaplow dedicate an entire section of their book “Synergy for Clinical Excellence – The AACN Synergy Model for Patient Care,” 2nd ed. to various applications of the model within nursing practice, in situations from the bedside to the boardroom, and from academic education to professional development.

Many organizations across the United States draw on the Synergy Model as a basis for their work. For example, the Department of Nursing at the University of California, San Francisco Medical Center and Baylor Health Care System Professional Nursing use it as their professional practice model. Duquesne University employs it as their model for nursing education and publishes their Synergy Model-based graduate curriculum model online.

Can the Synergy Model be used to develop viable staffing models?

As a guiding framework, the Synergy Model matches nurse knowledge, skills and abilities with patient needs. Matching nurse competencies with patient needs promotes optimal outcomes and nurse well-being. Using this framework enables organizations to implement the “Appropriate Staffing” standard of the “ AACN Standards for Establishing and Sustaining Healthy Work Environments .”

Appropriate staffing ensures an effective alignment between the unique characteristics of both the nurse and the patient. The Synergy Model moves staffing practices beyond potential mismatches that result from rigid solutions — such as fixed staffing ratios — toward staffing plans that acknowledge the dynamic variability among acutely and critically ill patients.

For additional information on appropriate staffing, visit our Staffing Resources .

Inspire ideas with the potential to impact how care is delivered.

Gain access to a variety of educational content that meets the needs of health care educators, clinicians and the community., unlock new possibilities through immersive learning at jump simulation, discover how data can be used to empower knowledge creation, insights and decision-making to optimize and transform health care., take your idea from exploration to implementation or commercialization., start the process towards testing or piloting your promising solution within osf., build the future of health care with us., attend a steam or medical education event at the jump trading simulation & education center., from jump steam courses to simulation facilitation classes., essentials of critical care concepts.

Critical care nursing is a complex, challenging area of nursing, wherein clinical expertise is developed over time by integrating critical care knowledge, clinical skills, and caring practices. This curriculum succinctly presents essential information about how best to safely and competently care for critically ill patients and their families. This curriculum recognizes the learners’ needs to assimilate foundational knowledge provided by this course before attempting to master more complex critical care nursing concepts.

In an effort to standardize competency and confidence of the care for critically ill patients, the Essentials of Critical Care Concepts are to be introduced to all OSF ministry novice nurses. Standardized critical care education will ensure that all critical nurses at every facility have the training and confidence to care for higher acuity patients and provide advanced, evidence-based interventions.

Course Description

Utilizing the modalities of self-study, new concept didactic, high fidelity simulation, and skills practice this course aligns with the students current learning patterns while providing an opportunity for novice nurses to experience the critical care concepts and environment in a supportive group setting.

Curricular Goals

• Improved Critical Care Nurse Competency test results pre to post.
• Positive shift percentage in Evidence-Based Nursing Practice Self-Efficacy Scale Confidence Mark.
• To standardize a critical care curriculum across OSF.

Assessment & Outcomes Measurement

Critical Care Nurse Competency Exam will be assigned after attending Essentials of Critical Care Concepts. Evidence-Based Practice Self-Efficacy Scale pre class and 6 months after class. We aim to standardize curriculum and improve educational outcomes. We will track ministry participation in the classes. Critical Care Nurse Competency exam scores reviewed annually.

TARGET LEARNERS

Registered Nurses

Lacey Reed Clinical Educator OSF HealthCare

Samantha Marotta Clinical Education Specialist OSF HealthCare

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Toward Precision in Critical Care Research: Methods for Observational and Interventional Studies

Graham Linck, Emma J. MSc 1 ; Goligher, Ewan C. MD, PhD, FRCPC 2,3,4 ; Semler, Matthew W. MD, MSc 5,6 ; Churpek, Matthew M. MD, MPH, PhD, ATSF 1,7

1 Department of Biostatistics and Medical Informatics, UW-Madison, Madison, WI.

2 Interdepartmental Division of Critical Care Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.

3 Department of Physiology, University of Toronto, Toronto, ON, Canada.

4 Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada.

5 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN.

6 Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN.

7 Division of Pulmonary and Critical Care, Department of Medicine, University of Wisconsin-Madison, Madison, WI.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website ( http://journals.lww.com/ccmjournal ).

Dr. Graham Linck was supported, in part, by the National Institutes of Health (NIH)/the National Library of Medicine (NLM) training grant (T15LM007359). Dr. Goligher is supported by grants from the Canadian Institutes of Health Research and the National Sanitarium Association; he received consulting fees from Lungpacer Medical, Stimit LLC, and Bioage; honoraria for lectures from Vyaire, Draeger, and Getinge; advisory board participation for Getinge (current) and Lungpacer (previous); and receipt of equipment for research from Timpel and Lungpacer. Dr. Semler was supported, in part, by a grant from the NIH/National Center for Advancing Translational Sciences (5UL1TR002243), a grant from the NIH/National Heart, Lung, and Blood Institute (NHLBI) (K23HL143053), and a grant from the U.S. Department of Defense. Dr. Semler reports having received compensation from Baxter Healthcare Corporation for having delivered two virtual lectures at conferences; an honorarium from the University of Pittsburgh; compensation from Baxter Healthcare Corporation for having served on a medical advisory board; compensation for continuing medical education lectures from Northwest Anesthesia Seminars; and an honorarium from the Cleveland Clinic. Dr. Churpek was supported by a grant from NIH/NHLBI (R01HL157262) and NLM; he is a named inventor on a patent (No. 11,410,777) for electronic Cardiac Arrest Risk Triage score, a risk stratification tool for ward patients, and receives royalties from this IP from the University of Chicago. Dr. Semler has disclosed that he does not have any potential conflicts of interest.

For information regarding this article, E-mail: [email protected]

Critical care trials evaluate the effect of interventions in patients with diverse personal histories and causes of illness, often under the umbrella of heterogeneous clinical syndromes, such as sepsis or acute respiratory distress syndrome. Given this variation, it is reasonable to expect that the effect of treatment on outcomes may differ for individuals with variable characteristics. However, in randomized controlled trials, efficacy is typically assessed by the average treatment effect (ATE), which quantifies the average effect of the intervention on the outcome in the study population. Importantly, the ATE may hide variations of the treatment’s effect on a clinical outcome across levels of patient characteristics, which may erroneously lead to the conclusion that an intervention does not work overall when it may in fact benefit certain patients. In this review, we describe methodological approaches for assessing heterogeneity of treatment effect (HTE), including expert-derived subgrouping, data-driven subgrouping, baseline risk modeling, treatment effect modeling, and individual treatment rule estimation. Next, we outline how insights from HTE analyses can be incorporated into the design of clinical trials. Finally, we propose a research agenda for advancing the field and bringing HTE approaches to the bedside.

• There are many methodological approaches for assessing heterogeneity of treatment effect (HTE) in completed randomized and observational studies, including expert-derived subgrouping, data-driven subgrouping, baseline risk modeling, treatment effect modeling, and individual treatment rule estimation.
• Trial designs that can facilitate the identification of HTE in planned or ongoing trials include predictive enrichment trials, response-adaptive randomization trials, and pragmatic trials.
• Future research should include determining when assessment of HTE in completed trials is most likely to succeed, how to validate HTE when identified, and approaches for bringing recognition of HTE to the bedside.

Most randomized clinical trials (RCTs) in critical care have not identified a statistically significant effect of the treatment on patient outcomes, leading researchers and clinicians to wonder whether these interventions are ineffective or whether existing trial designs and analyses are inadequate to assess treatment effects in critically ill patients. In RCTs, efficacy is typically assessed by the average treatment effect (ATE), which quantifies the overall effect of the intervention on the study population. The ATE is often interpreted as the treatment effect everyone should expect to experience; in reality, some individuals in a trial may benefit more than the ATE, and some may benefit less. For example, a null ATE could result from half of the trial participants experiencing benefit and half experiencing harm. Thus, assuming that other common causes of null trials are sufficiently addressed, including insufficient power, failure to address a clinically useful question, and poor calibration between primary statistical and clinical outcomes of interest, a null ATE could be caused by heterogeneous treatment effects (HTE), defined as nonrandom variation in the magnitude or direction of a treatment effect on a clinical outcome across levels of covariates ( 1–4 ).

Critical care trials often evaluate the effect of interventions on outcomes for individuals with diverse histories and causes of illness, often under the umbrella of heterogeneous clinical syndromes, such as sepsis, acute respiratory distress syndrome (ARDS), acute kidney injury, delirium, and cardiogenic shock. Given this variation, it is reasonable to expect that the effect of treatment on outcomes may differ for individuals with variable characteristics. For example, individuals with sepsis from viral pneumonia may respond differently to an intervention than individuals with sepsis from bacterial cellulitis. Accounting for interindividual variability could distinguish between ineffective interventions and those with HTE that are beneficial to some patients, enabling precise targeting of treatments.

Two major guidelines for HTE analyses have been published. The Instrument for Assessing the Credibility of Effect Modification (ICEMAN) recommends assessing subgroup credibility through a qualitative assessment of the strength of prior evidence and the likelihood that the result could be seen by chance ( 5 ). The Predictive Approach to Treatment Heterogeneity (PATH) statement provides guidance on when to look for HTE, how to evaluate predictive HTE models, and the evidence required for translation to patient care ( 1 , 6 ).

In this review, we describe methodological approaches for assessing HTE, including expert-derived subgroup analysis (the “traditional” approach), data-driven subgrouping, baseline risk modeling, treatment effect modeling, and individual treatment rule estimation ( Fig. 1 ; and eTable 1 , https://links.lww.com/CCM/H568 ). Next, we outline how insights from HTE analyses can be incorporated into clinical trial design. Finally, we propose a research agenda for advancing the field and bringing HTE approaches to the bedside.

METHODS FOR ASSESSING HTE

Expert-derived subgroup analysis.

Expert-derived subgroup analyses seek to compare treatment effects in predefined subgroups, typically one characteristic at a time. Subgroup analysis should be guided by the ICEMAN criteria, with groups prespecified before the analysis and determined based on prior literature, preliminary data, basic and translational preclinical models, or standard groupings in the field (e.g., age, sex, race) ( 5 ). The presence of HTE is established by an interaction test between the variable of interest and treatment in a regression model ( 7 ). For example, a single-characteristic HTE analysis found that the effect of low tidal volume ventilation on mortality varied according to respiratory system elastance ( 8 ). Expert-derived subgrouping can be an intuitive approach to testing a well-supported clinical hypothesis. However, in practice, these methods have important limitations. Typically, only one variable is investigated at a time, ignoring complex interactions between treatment and other baseline variables on the outcome. In addition, prior knowledge is needed to rationalize a proposed subgroup, which may not be available. Consequently, these analyses are generally exploratory and hypothesis-generating. Nonetheless, expert-derived subgroup analysis can be a valuable tool for investigating HTE for a small number of subgroups with strong biological or mechanistic rationale.

Data-Driven Subgrouping

Data-driven subgroup analyses compare treatment effects across groupings of individuals identified by supervised or unsupervised modeling approaches, rather than predefined subgroups determined by experts. Supervised approaches find subgroups based on baseline characteristics, treatment assignment, and the outcome of interest, and include methods such as Virtual Twins, model-based recursive partitioning, subgroup identification based on differential effect search, and various Bayesian methods ( 9–15 ). The output of these methods is data-driven subgroups that exhibit differential responses to a treatment. However, a review of 13 supervised data-driven subgrouping methods found that most suffer high rates of false discovery due to multiple testing, produce subgroups of varying stability, and often lead to biased treatment effect estimates ( 16–18 ). In contrast to supervised approaches, unsupervised approaches find subgroups based only on baseline characteristics (ignoring treatment assignment and outcomes) and include “soft” clustering methods, such as latent class analysis (LCA), and “hard” clustering methods, such as K-means clustering. For example, Calfee et al ( 19 ) applied LCA to clinical and biomarker data in patients with ARDS, identifying “hyperinflammatory” and “hypoinflammatory” subgroups that had differential responses to treatment. These ARDS subgroups have since been validated in multiple other studies ( 20–23 ). Clinical critical care syndromes, which often have overlapping pathophysiologic mechanisms, may be more suited to analysis with probabilistic “soft” clustering methods, which output the probability of an individual belonging to each cluster rather than their optimal cluster assignment; however, more research is needed ( 18 , 24 ). Although some unsupervised subgrouping methods have been found to be predictive of treatment effect, there is no guarantee that this will universally be the case. Even when HTE is identified across subgroups, treatment effects can vary within a subgroup, limiting a single subgroup’s ability to predict treatment response for individual patients. Nonetheless, unsupervised clustering methods may unravel heterogeneity in underlying pathways involved in treatment response ( 25 ). Overall, data-driven subgroup identification methods are useful exploratory tools when it is hypothesized that treatment response may be influenced by a combination of factors, but high false discovery and low replicability necessitate thorough validation.

Predictive Approaches for Assessing HTE

Predictive approaches for identifying HTE use multivariable models that directly predict individualized risk, treatment effect, or optimal treatment (depending on the approach). These models capture complex interactions between characteristics, leading to more precise estimates for individual patients. There are three approaches to building a predictive model to identify HTE: risk modeling, treatment effect modeling, and individualized treatment rule (ITR) modeling. Each of these approaches has distinct assumptions and outputs, making it important to consider prior knowledge about the nature of expected heterogeneity when choosing a modeling approach.

Risk Modeling

Risk-based approaches involve assessing treatment effect as a function of baseline risk of the study outcome (e.g., 90-d mortality). This can involve using previously published risk scores in critical care (e.g., Acute Physiology and Chronic Health Evaluation). However, the accuracy of these models in the trial population should be evaluated first ( 26 ). Alternatively, this approach can involve developing a new model using baseline characteristics from the trial. An analysis of 32 RCTs found that risk-based HTE on the absolute scale is common, with simulations suggesting that it is plausible in many critical care trials ( 27 , 28 ). Whether to identify risk-based HTE on the absolute or relative scale remains controversial, as heterogeneity can be present on either or both scales, and either scale could be of clinical interest depending on the intervention and use case ( 1 , 29–34 ). The relationship between absolute predicted outcome risk and treatment effect is variable; treatment benefit may increase with increasing or decreasing absolute outcome risk ( 35 , 36 ). For example, Goligher et al ( 36 ) found that patients at the low absolute risk of requiring organ support benefited most from therapeutic-dose heparin, while those at the highest risk benefited the least. Risk-based HTE is intuitive and easy to implement to guide treatment decisions. However, risk-based modeling can miss important interactions between the treatment and baseline characteristics unrelated to the risk of the outcome that drives HTE. Furthermore, a model with poor accuracy will not reliably detect HTE, even when it is present across levels of severity of illness. Overall, risk modeling is an intuitive approach for identifying HTE, but may fail in cases where HTE is not related to outcome risk, or when using an inaccurate risk model.

Treatment Effect Modeling

Individualized treatment effect models predict personalized treatment effect estimates based on individual-level baseline characteristics. This output is known as the individualized treatment effect (ITE), or the conditional average treatment effect (CATE; note that CATE is a general term that can also refer to the output of any subgrouping method). To estimate ITE, distinct frameworks are paired with supervised machine learning algorithms. The simplest framework is the S-learner, which first trains a single outcome model that incorporates baseline characteristics, treatment assignment, and their interactions and then estimates ITE as the difference in predicted outcome when the treatment variable is set to 1 versus 0. The T-learner predicts ITE as the difference in predicted outcomes between a model built in the treatment group and a second model built in the control group. The X-learner predicts ITE as a combination of several outcome models ( 37 ). Other frameworks include the R-learner, Uplift-RF, Causal Forests, Bayesian Causal Forests, and modified covariate regression ( 9 , 38–42 ). These methods have been used to identify HTE in critical care trials, including Bougie or Stylet in Patients Undergoing Intubation Emergently, ICU Randomized Trial Comparing Two Approaches to Oxygen Therapy (ICU-ROX), Pragmatic Investigation of Optimal Oxygen Targets, Antithrombotic Therapy to Ameliorate Complications of COVID-19, Accelerating COVID-19 Therapeutic Interventions and Vaccines Acute, Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP), and REST ( 8 , 36 , 43 , 44 ). As a semantic aside, ITE models described here are distinct from individual treatment effect models ( 45 , 46 ).

The primary advantage of treatment effect modeling is the ability to predict a personalized estimate of a treatment’s effect given an individual’s characteristics, resulting in a single treatment effect prediction for an individual. The primary downside is the large amount of data needed. Although some work has been done to explore the relationship between sample size, treatment effect, and power, further work exploring the power of treatment effect models to detect HTE is needed ( 47 ). Larger samples are more common in observational studies, where the application of treatment effect models is more challenging due to the lack of randomization (see below). Despite this limitation, ITE modeling has the potential to enable precision medicine in critical care. For example, in a study recently published in Journal of the American Medical Association , investigators developed a treatment effect model using the R-learner in the PILOT study of oxygenation targets and validated the model in the ICU-ROX trial. They found that the ITE predictions ranged from 27.2% absolute reduction to a 34.4% absolute increase in 28-day mortality, and that individual assignment based on their model would have improved overall mortality by 6.4% compared with random assignment ( 44 ).

Individualized Treatment Rules

Methods for learning ITRs predict the optimal treatment for an individual given their baseline characteristics. ITR methods can be direct or indirect ( 48 ). Direct methods identify a treatment that maximizes the expected positive outcome given an individual’s characteristics. Indirect ITR methods learn the optimal treatment by trial and error, a process called reinforcement learning. ITR modeling can account for multiple treatments across time, making it well-suited for the management of conditions that require multiple timely interventions. For example, Komoroski et al used reinforcement learning to predict personalized recommendations for vasopressor and fluid use for patients with sepsis ( 49 ). However, ITR methods may not be appropriate when the treatment has benefit and harm profiles that individual patients may value differently. For example, a treatment that may increase survival while increasing the likelihood of acute kidney injury requiring dialysis. In this case, a uniform rule regarding which treatment would be most effective for an individual may produce suboptimal decisions if different individuals have varying preferences for survival versus avoiding dialysis. In addition, ITR methods output a single treatment recommendation (“treatment A” or “treatment B”), rather than a continuous ITE estimate, ignoring granularity that could be useful for treatment decision-making.

INVESTIGATING HTE IN RANDOMIZED VERSUS OBSERVATIONAL SETTINGS

RCTs are the gold standard for causal effect estimation due to the use of randomization. However, they can be expensive to run, often recruit a small number of patients, typically occur in specialized settings, and frequently do not represent the full diversity of patients seen in critical care, limiting generalizability. Observational studies, therefore, may have an important role in addressing these limitations. However, the lack of randomization induces several barriers to extracting causal relationships from observational data: nonrandom variation in factors that affect both the likelihood of treatment and the outcome of interest (confounders), and the fundamental challenge of confounding by indication. Rigorous study design and thorough identification of potential confounding variables allow methodologists to make several assumptions that facilitate causal analysis in observational data. The most important of these assumptions is “strong ignorability:” that an individual’s potential outcomes if treated or untreated are independent of the treatment assignment given their baseline characteristics. In other words, the baseline characteristics collected should completely explain an individual’s likelihood of receiving the treatment, so that adjusting for treatment propensity induces independence between the treatment assignment and outcome. Adjusting for treatment propensity is accomplished through multivariable models or the use of direct estimates of the probability of receiving treatment (i.e., the “propensity score”) for matching, weighting, etc. Additionally, we must assume “no unmeasured confounding:” that all confounders have been measured; “positivity:” that all individuals have a non-zero probability of being treated; and “no interference:” that an individual’s treatment status does not influence another individual’s potential outcomes. In critical care, the direction of ATE estimated through propensity score analyses has largely agreed with RCTs, although specific effect measures can vary ( 50–52 ).

Confounding by indication occurs when the allocation of treatment varies by patient characteristics, which in critical care applications is often related to mortality risk (e.g., a person with high mortality risk due to shock is more likely to be prescribed a higher dose of a vasopressor). Simulations have demonstrated that methods used to adjust for the presence of confounders such as propensity score and weighting-based methods, may be ineffective at addressing confounding by indication ( 53 ). Instrumental variable-based approaches show promise, but further research is needed ( 54 ).

Expanding on methodology for assessing ATE, several methods have been developed for estimating ITE and subgroups in observational data ( 37 , 40 , 41 , 55 , 56 ). Simulations demonstrate that the accuracy of ITE estimates is sensitive to the presence of unmeasured confounding due to the violation of the “strong ignorability” assumption ( 45 ). As methods for assessing HTE in observational data are further validated, and granular EHR data that increase the feasibility of adjusting for important confounders becomes available, further applications to EHR data are likely. However, the fundamental challenge will remain developing and validating methods that reliably address confounding sufficiently to convince patients, clinicians, and policymakers to rely on estimates of ATE and ITE from observational studies.

APPLICATIONS TO CLINICAL TRIAL PLANNING AND DESIGN

In previous sections, we discussed how completed trials and observational data can be analyzed retrospectively to identify HTE. In this section, we focus on how HTE methods can be used to plan future clinical trials and guide ongoing trials to better capture HTE.

Planning Confirmatory Trials

HTE methods can inform future trials by identifying subpopulations that may benefit from a treatment. If the target subpopulation can be identified based on specific baseline characteristics, such as in expert-derived subgrouping, recruiting a trial population may be straightforward. Notably, however, many RCTs have failed to confirm the findings of a prespecified subgroup analysis identified in prior trials ( 57–59 ). Given the costs and time involved in confirmatory trials, it is critical that potential subpopulations are identified using methodologically rigorous approaches.

Adaptive Trials

Adaptive trials have been developed to address some of the limitations of traditional RCTs, including limited statistical power and possible harm to those not receiving the superior treatment. In adaptive trials, sample size, eligibility, or treatment allocation ratios can be modified throughout a trial. Two features of adaptive trial design can incorporate analysis of HTE: predictive enrichment and response-adaptive randomization (RAR).

Predictive Enrichment Trials

Predictive enrichment trial designs modify recruitment during a trial to enrich recruits for characteristics that may confer treatment benefits based on interim results. In fixed enrichment, the subpopulations of interest are defined before the trial starts and removed from trial recruitment if accrued data shows no benefit ( 60–63 ). In adaptive enrichment, a predictive model trained using accrued data is used to predict whether a person is likely to experience a positive outcome and therefore should be enrolled ( 64–69 ). Notably, several designs also incorporate interim analyses for futility, superiority, and sample size reestimation ( 68 , 69 ). Despite the plethora of predictive enrichment trial designs, few have been used in practice ( 70 , 71 ). This may be due to statistical and logistical issues with some designs, including potentially biased estimates of treatment effect, and the increased cost and time needed to collect data to appropriately group patients ( 72 , 73 ). Predictive enrichment trials could facilitate ITE-guided enrollment, but care should be taken to choose designs that minimize treatment effect estimation bias and allow sample size reestimation.

Response-Adaptive Randomization

Rather than changing eligibility criteria based on accrued data, RAR designs employ a Bayesian framework to adaptively update treatment allocation ratios toward the most effective treatment based on accrued data. RAR may be applied to different subgroups identified in HTE analysis. There are many variations of RAR trial designs ( 74 ). RAR trials have been used to evaluate cancer therapies (Investigation of Serial Studies to Predict Your Therapeutic Response with Imaging and Molecular Analysis [I-SPY], I-SPY 2, and Biomarker-integrated Approaches of Targeted Therapy for Lung Cancer Elimination [BATTLE]), treatments for community-acquired pneumonia (REMAP-CAP), as well as sepsis (Rapid Administration of Carnitine in Sepsis and Selepressin Evaluation Programme for Sepsis-induced Shock Adaptive Clinical Trial [SEPSIS-ACT]) ( 75–80 ). Recently, covariate-adapted RAR (CARA) was proposed as a way to adapt randomization ratios based on baseline covariates ( 81 , 82 ). A CARA design could be used when it is hypothesized that heterogeneity in baseline characteristics may affect the optimal treatment. There is substantial debate regarding whether RAR results in fewer individuals being randomized to an ineffective treatment, with simulations showing conflicting results depending on the RAR design used ( 74 , 83–86 ). In addition, operating RAR trial designs can be challenging, potentially limiting their use to academic medical centers ( 74 , 87 ). Overall, RAR trial designs are a promising approach for incorporating treatment effect heterogeneity into a trial, but careful consideration of the trial design, hypothesized treatment effect and realistic enrollment remain paramount.

Pragmatic Trials

In contrast with traditional RCTs, pragmatic trials seek to evaluate whether an intervention improves outcomes in practice, rather than in an idealized research environment ( 88 ). The primary feature of a pragmatic trial is broad eligibility criteria, which increases the diversity of baseline characteristics among participants, potentially increasing generalizability. Given increased heterogeneity in baseline characteristics, detecting HTE may be more likely. To fully use predictive modeling in the analysis of pragmatic trials, several aspects of trial infrastructure must be adapted. For example, approaches must be developed to systematically measure the broad range of baseline characteristics that may modify the treatment’s effect. In addition, protocols for prespecifying ITE analysis plans and validation strategies should be developed, decreasing the likelihood of identifying spurious HTE. If these aspects are addressed, predictive HTE methods could play a leading role in the interpretation of pragmatic trials, fueling further insights into HTE and leading to the availability of evidence-based estimates of ITE for a broad range of critically ill patients for commonly used treatments.

AGENDA FOR FUTURE RESEARCH

Determining when to investigate for hte.

It is unlikely that every intervention results in significant HTE, and repeated assessment of HTE when the likelihood of finding it is low will result in false positives that could lead to future costly, negative trials. Therefore, evidence is needed to determine when HTE analyses are most likely to succeed. The PATH statement advocates for HTE analyses to be motivated by preliminary data, theory, or mechanism-driven hypotheses. However, often little is known about the true drivers of HTE. Metrics that can suggest the presence of HTE have been proposed ( 27 , 89 , 90 ). However, these methods have not been widely adopted or validated. Large-scale studies of a wide selection of trials are needed to better understand the prevalence of HTE in critical care trials. Requiring prespecified analysis plans for HTE in RCTs could also help provide realistic estimates of the prevalence of significant HTE. Ultimately, the collaboration between trialists and HTE researchers is needed to establish guidelines for the analysis of HTE in RCTs.

Which Model to Choose?

There are over 10 established methods for data-driven subgrouping and over 20 methods each for ITE and ITR estimation. However, no guidelines exist on how to select a method for an HTE analysis. Although we have described the advantages and disadvantages of different approaches above, further research to support this guidance is necessary. One systematic comparison of treatment effect models identified several high-performing models on synthetic data, but new comparisons that include more recent methods are needed ( 91 ). Although there are examples of studies when nonparametric machine learning models are more accurate than traditional regression models, the improvements are not universal, and inappropriate use of machine learning without proper validation results in overfit models and optimistic findings ( 92 ). Further research should focus on comparing methodological approaches and providing guidelines for practitioners.

Translating HTE Models Into Practice

Identifying a clinically useful model.

A clinically useful model must satisfy several criteria. First, it must identify statistically significant HTE. Notably, what constitutes “statistically significant HTE” is an active field of research, with current HTE analyses defining it using various metrics, including Qini coefficients, Area Under the Target Operating Curve, and C-for-benefit ( 47 , 93 ). Alternatively, significance can be determined through a likelihood ratio test on the interaction between the treatment and predicted ITE in an unseen test set ( 29 , 43 ). Second, it must predict ITE larger than a clinically meaningful effect size for at least some individuals. A clinically meaningful effect size is typically defined by clinical experts in collaboration with statisticians and is dependent on the application. Third, it must predict ITEs that are concordant with observed ITE, a feature known as model calibration. Calibration can be visualized as the “slope” and “y-intercept” of a plot of observed versus predicted treatment effect ( 94 ). Fourth, it must perform better than standard practice and treatment guidelines. Finally, the variables used in the models must be available to clinicians at the time the prediction is made. Significant advances in the collection of real-time biomarker and physiologic data such as ECG waveform data and protein biomarkers are increasing the feasibility of incorporating these detailed predictors into models, further increasing our ability to detect HTE of clinical critical care syndromes ( 95 , 96 ).

When considering the above criteria, it is important to remember that predictive models are vulnerable to overfitting, where models fit both the true signal and noise. Therefore, it is essential to validate these models in patients not used for model development, preferably in external clinical trials. To date, validations have used either held-out data from the same trial(s) used to build the model ( 36 , 43 , 97–100 ), or data from other RCTs evaluating identical interventions in different populations ( 101 ). However, using randomized data to validate predictive HTE models fails to assess its generalizability to the general population, and limits the amount of data available for validation due to the small number of trials with identical interventions and outcomes. Recently, methods that combine observational and RCT data to improve ITE estimates have been proposed ( 102 ). Once a model has been validated in multiple health systems, the final component of validation of a model’s clinical utility could be conducted through an RCT where the interventions are treatment guided by the model itself compared with standard-of-care. Further discussions among the HTE research community are needed to establish guidelines for the validation of HTE models, including the minimum validation needed before clinical use. Although beyond the scope of this review, adherence to guidance from regulatory agencies, such as the Food and Drug Administration, is also important to consider before the broad implementation of these models in clinical practice.

Presenting HTE Predictions at the Bedside

A critical step to delivering precision medicine is determining the best approach to present predictive HTE analyses to clinicians. Determining the optimal way to present these models can be broken down into three lines of investigation: how to present the model’s prediction, how to present the uncertainty of the prediction, and how to explain the model’s reasoning. Clinical risk predictions are typically presented on the absolute scale; however, interfaces that allow interactive comparison with other metrics such as the average or median treatment effect may be useful ( 1 , 29 ). Additionally, there is growing recognition that quantifying prediction uncertainty aids clinical decision-making, but how to quantify this uncertainty is an active field of research. Several ITE models, such as Causal Forest and Bayesian Additive Regression Trees, have model-specific methods to estimate CIs or predictive intervals for individual predictions ( 40 , 41 ). More recently, conformal prediction has arisen as a generic method for forming predictive intervals for individual predictions ( 46 , 103 ). Finally, explaining a model’s reasoning is a vital step in translating predictive HTE tools. Some commonly used explainability tools have been modified to explain features that are most important for an individual’s prediction ( 43 ). Despite the perceived importance of explainability tools, the overall impact of these tools on the usefulness of predictive HTE models has not been evaluated.

CONCLUSIONS

Methods for discovering HTE have continued to proliferate and evolve. Increasing awareness of the advantages and limitations of each method will inform future applications to critical care. Future research aimed at providing evidence for when and how to search for HTE, what level of validation is required before using developed models in clinical practice, and how best to integrate validated tools at the bedside will increase the likelihood that these approaches will realize their potential of enhancing precision medicine in critically ill patients.

ACKNOWLEDGMENTS

The authors thank Alex Spicer, MS, for her thoughtful comments on this article.

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clinical trials; critical care; machine learning; precision medicine; treatment effect heterogeneity

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