critical care nursing education standards

Consensus forum: worldwide guidelines on the critical care nursing workforce and education standards

Affiliation.

• 1 School of Nursing, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Level 1, 723 Swanston Street, Carton Vic 3053, and Maroondah Hospital, PO Box 3135, East Ringwood, Victoria 3135, Australia. [email protected]
• PMID: 16893727
• DOI: 10.1016/j.ccc.2006.03.010

This article explores the key themes, evidence, and arguments that inform the current position statements. It is acknowledged that future research, evidence, and practice experience may create the need to review and change these guidelines. Reform and refinement of the guidelines are inevitable; however, the current guidelines represent the best attempt yet to reach international consensus on what are appropriate standards to guide critical care nursing education and workforce requirements.

Publication types

• Clinical Competence / standards
• Critical Care / standards*
• Education, Nursing, Graduate / organization & administration
• Education, Nursing, Graduate / standards
• Global Health
• Practice Guidelines as Topic*
• Specialties, Nursing / education*

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Global standards for professional nursing education: The time is now

Cynthia baker.

a Canadian Association of Schools of Nursing (CASN), Queens University, Canadian Association of Schools of Nursing, 1145 Hunt Club Rd, Suite 450, Ottawa K1V 0Y3, Canada

Ann H. Cary

b Marieb College of Health & Human Services, Florida Gulf Coast University, American Association of Colleges of Nursing, United States of America

Maria da Conceicao Bento

c Vocal de Desarrollo Institucional - Assocoación Latino Americana Escuelas y Faculadade de Enfermeria (ALADEFE), Portugal

A well-educated, professional nursing workforce is essential to good health care outcomes. Although nursing education is being strengthened globally, considerable diversity persists in the level and standards of nursing education both within and across countries. An international framework of guidelines for nursing education has, therefore, been developed to promote greater international consistency and high-quality nursing education globally.

The purpose of this paper is to discuss the multinational methodology used to develop a global framework for professional nursing education and the policy implications of this framework in guiding the harmonization of nursing education demanded by the State of the World's Nursing 2020 (WHO, 2020a) call to action. The framework includes the underpinning assumption that nurses be prepared at the baccalaureate level and three pillars of global expectations targeting: a) learning outcomes for graduating preservice nursing students; b) standards for nursing programs, and c) standards for educational institutions delivering nursing programs.

The Global Pillars Framework reflects international best practices, but the guidelines are adaptable across socio-cultural contexts facilitating the integration of locally relevant education. As 2020 has been declared the Year of the Nurse and Midwife globally, the ground has been laid for the next evolution in the education of the nursing workforce globally.

Introduction

The proportion of professionally prepared, baccalaureate nurses is significantly correlated with better health outcomes ( AACN, 2019 ; Aiken et al., 2017 ; Blegen et al., 2013 ). Globally 91% of countries report that standards for duration and content of nursing education exist and 89% of countries indicate they possess accreditation for education institutions ( WHO, 2020a ). However, considerable variation persists in the level and quality of education for registered nurses within the six World Health Organization (WHO) regions. Moreover, often variation exists within a single country ( Shaffer, 2013 ; WHO, 2020a ). The current complexity of health care demands that nursing education respond to a shift to higher levels of decision making, clinical judgement, team leadership, and political acumen enabling nurses to manage care in complex environments and across health care and social sector boundaries. In addition, nurses are an increasingly mobile workforce with one in eight not practicing in the country where they were born or educated ( WHO, 2020b ). Thus, there is an urgent international need for high quality guidelines to direct nursing education and for greater harmonization of entry level nursing education globally.

The Global Alliance for Nursing Education and Sciences (GANES) undertook a multinational methodology to develop global educational guidelines for preservice baccalaureate nursing education. This methodological approach will be described, and the policy implications of the Global Pillars Framework that emerged will be discussed.

Despite advances in health care, the global disease burden has increased. There are more people over 60 than children under five worldwide, which has been associated with a global increase in the prevalence of non-communicable chronic illnesses ( WHO, 2014 ). Communicable diseases however, including the current COVID-19 pandemic, once considered to have been vanquished by medical science, continue to take a devastating toll on communities. In addition, population mobility, armed conflict, and climate change are creating major health crises worldwide ( WHO, 2016 ).

Because nurses fulfill multiple roles in diverse settings and care for all age groups, the quality of their education is crucial to ensure health systems respond effectively to current health challenges ( All-Party Parliamentary Group on Global Health, 2016 ). Nurses are front line responders in health crises and disasters such as the COVID-19 pandemic, provide palliative and end-of-life care, educate and support individuals with chronic illness and their families, monitor patients who are acutely ill, and manage and respond to population health indicators and life threatening conditions in high acuity care settings. In addition, nurses promote population health, and prevent illness and injury among individuals, families, and communities ( GANES, 2019 ).

Level and quality of nursing education

Governments in several countries have undertaken measures to improve health services by enhancing the quality of nursing education. The global challenge facing nursing education programs resides in delivering transformed undergraduate curricula and practice learning opportunities to meet the new paradigms emerging in healthcare.

In response to these demands, an international trend in nursing education has been a shift from vocational training to professional education ( Collins & Hewer, 2014 ). Although some countries continue to provide only vocational training for nurses, an increasing number have instituted the baccalaureate degree as an entry-to-practice requirement for registered nurses ( WHO, 2020a ). For example, China has three entry levels for registered nurses - diploma, advanced diploma, and baccalaureate degree. Chinese policy and regulations recognize that high standards of nursing education are essential to meet the health demands of the population and the numbers of baccalaureate prepared nurses and nurses with graduate degrees have therefore increased ( Wang et al., 2016 ). While a number of countries in the European Union have considered a shift from vocational training to be unnecessary ( Collins & Hewer, 2014 ), the Bologna Accord, prompted a harmonization of educational processes to facilitate the mobility of nurses ( Shaffer, 2013 ), spurring a move to professional education as the requirement for nurses. Further, a national study of nursing education between 2011 and 2013 in South Africa, concluded that top-up, baccalaureate nursing degrees for diploma educated nurses needed to be developed to meet health care demands ( Comiskey et al., 2015 ). A Nursing Qualifications Framework was, therefore, created ( Blauw et al., 2014 ).

The most recent recommendations from the World Health Organization (WHO) and its partners assert that countries must modernize regulatory rules by harmonizing education requirements and standardizing nurses' credentials globally ( WHO, 2020b ). Undoubtedly, the preponderance of evidence demonstrates that the quality of nursing education affects health outcomes. Over the past decade international development aid to optimize health crises outcomes has been directed to nursing education. For example, in 2008 the US Congress made a commitment to enhance nursing education in Africa to achieve UNAIDS 90–90 goals that 90% of HIV positive people know their status, 90% diagnosed are on treatment and 90% on treatment are virally suppressed ( Michaels-Strasser et al., 2018 ). As a result, schools of nursing in the Democratic Republic of the Congo, Ethiopia, Lesotho, Malawi, South Africa, and Zambia were supported with infrastructure improvement, curricular revisions, clinical skill development, in- service training, and faculty development. However, the ground-breaking international study by the Lancet Commission on health professional education for the 21st century, called for curricula that are locally relevant as well as reflective of international best practices ( Frenk et al., 2010 ). Achieving successful implementation of high-quality standards internationally, therefore, is dependent upon ensuring that the standards not only represent best practices but are adaptable to local contexts and cultures.

The aim in creating the Global Pillars Framework was to provide guidelines for professional nursing education that are adaptable to differing sociocultural contexts while representing best practices ( GANES, 2019 ). It is important to recognize that 2020 has been declared by the WHO as the Year of the Nurse and Midwife; therefore the debut of the recommendations in the GANES document is a fitting tribute to enrich the quality of nursing education globally.

International standards for nursing education

Given the diversity in the level and quality of nursing education globally and the importance of well-educated nurses for optimum health care outcomes, strengthened international guidelines for nursing education are essential. As a result, the Global Alliance for Leadership in Nursing Education and Sciences (GANES) developed a Global Framework for Nursing Education to promote high quality, entry-level education for registered nurses worldwide ( GANES, 2019 ). This Global Framework offers guidance for executing recommendations in the State of the World's Nursing 2020 report ( WHO, 2020a )

The global framework specifies expectations for three interrelated pillars ( GANES, 2019 ).

• • Pillar I: Competency expectations for new graduates that are formulated as learning outcomes
• • Pillar II: Expectations for professional nursing education programs that are formulated as guidelines
• • Pillar III: Expectations for educational institutions that provide nursing education programs formulated as guidelines ( GANES, 2019 ).

Methodology

The modified Delphi methodology for developing national, consensus-based guidelines, standards, and competencies ( Schofield et al., 2018 ) was expanded to integrate multi-national engagement. This methodology involves a multi-step, iterative process of formulating and reformulating a knowledge product through input obtained from a wide variety of sources, including multiple stakeholders. This process is led by a panel of experts who come to a final consensus about the knowledge product.

In this initiative, the 12-member, doctoral prepared nursing education leaders of the GANES Board of Directors served as the international panel of experts guiding the development of the Global Pillars Framework. GANES members represented nursing education in South, Central, and North America, Spain, Portugal, and South Africa.

The development process involved 4 phases: 1) environmental scan and literature review; 2) stakeholder consultations; 3) validation survey; and 4) survey analysis and final revisions. The steps of the development process were carried out by a smaller working group of nurse educators in leadership positions from Canada, the United States, and Portugal ( GANES, 2019 ). Each step is described in greater detail.

Phase 1: environmental scan/literature review

The process began with a review of the grey literature on international and national guidelines for nursing education. Grey literature refers to information produced outside dedicated publishing channels such as journals. It includes policy papers, reports, newsletters, government documents, conference proceedings and so on. The following search terms guided the process: nursing education guidelines, and nursing education standards. Documents were retained if they were published by a national or international organization involved in nursing, health care or nursing education. Eighteen documents were reviewed and were supplemented by peer reviewed articles on nursing competencies. This literature informed a first draft of the Global Pillars Framework.

Following draft revisions, peer reviewed literature was retrieved using Medline and CINAHL to examine the research question: “How does the quality of nursing education affect health?” The key words guiding the search strategy were nursing education, global health, and, nursing education standards. The search was restricted to articles published between 2014 and 2019, which yielded 110 articles. We focused on the national and international literature written in English to gain insights. If a review of the abstract indicated a publication was concerned with voluntourism (a form of tourism in which students participate in voluntary work, typically for a charity), graduate level nursing education, or student exchange it was excluded. As a result, 31 articles were retained for analysis.

Drafts of the Global Pillars Framework were created based on the environmental scan and literature review and an initial consensus was reached by the panel of experts on the expectations of the three pillars.

Phase 2: stakeholder consultations

A series of face-to-face consultations with nursing educators were conducted by members of the working group at three international nursing conferences: the first in Miami, United States, the second in Barcelona, Spain, and the third in Lima, Peru ( GANES, 2019 ). At each of these sessions, from 35 to 50 educators who were present reviewed drafts of the pillars and provided feedback. The session in Lima Peru was conducted in Spanish and translated into English by a bilingual research assistant. Each consultation led to further revisions by the working group which were reviewed and, in some cases, modified by the panel of experts. Following the last consultation, a second draft version was adopted by the GANES panel of experts to be validated by an international sample of stakeholders ( GANES, 2019 ).

Phase 3: validation survey

Each of the GANES member organizations sent out a survey electronically to their respective networks in English, French, Spanish, and Portuguese, and a snowball sampling approach was used to reach a wide base of stakeholders ( GANES, 2019 ).

Survey respondents were asked to indicate their level of agreement with:

• a) the two assumptions underpinning the framework (entry-level nursing education must be at the baccalaureate level; and expectations of the framework must be adaptable to local contexts and support local population needs).
• b) each expectation stated in each of the global pillars.

Respondents were also invited to provide input on each of these as well as on the framework in general.

Survey sample

There were 357 respondents of the validation survey from Africa, Asia, Europe, the Middle East, and South, Central, and North America. As displayed in Table 1 , respondents self-identified as educators ( n  = 278), employed in not-for-profit nursing roles ( n  = 15), engaged in public sector employment (n = 27) or other types of nursing employment ( n  = 37) ( GANES, 2019 ).

Respondents by region and type of employment.

Phase 4: survey analysis and final revisions

It was predetermined that if there was less than 75% agreement with any assumption or expectation it would be removed. A descriptive statistical analysis was conducted of the level of agreement with each assumption and each expectation in the framework, and a content analysis of the written, open-ended feedback was carried out. Any further modifications of the framework were to be based on a systematic content analysis of stakeholders' comments.

Level of agreement

There was a very high level of agreement with all components of the framework with none reaching the <75% threshold for removal. More than 90% of respondents indicated that they either strongly agreed or agreed with 39 out of the 42 expectations, and with 1 of the 2 assumptions. Over 80% strongly agreed or agreed with the remaining three expectations in the pillars, and 77% agreed or strongly agreed with the second assumption ( GANES, 2019 ).

Content analysis of feedback

Ninety-nine (28%) of the respondents provided detailed open-ended feedback. All feedback was provided in English despite the diverse sample with native speakers of Spanish, Portuguese, and French who could select to respond to the survey in these languages.

The first step in analyzing their input was to extract all recommendations and categorize them into the following three groups ( GANES, 2019 ):

• 1) Convergent: recommendations from more than one person (20)
• 2) Single participant: recommendations from one person only (25)
• 3) Divergent: contradictory recommendations (5).

The next step was to further sub-categorize comments into the following 4 types of recommendation ( GANES, 2019 ):

• 1) clarify or specify an expectation;
• 2) add an expectation or add to an existing expectation;
• 3) remov e a concept/assumption;
• 4) change an expectation.

For convergent and single participant recommendations, 9 recommended clarification, 28 recommended additions, 3 recommended removal, and 5 recommended modifications. Three of the divergent recommendations were about changing an expectation albeit in opposing directions. Two were about removing or retaining a concept or assumption ( GANES, 2019 ).

Method to address recommendations

Although the application of a given rationale was subjective, an audit trail was kept that included the initial categorizations of the recommendation, whether and how it was addressed, and the specific rationale for the decision. This was submitted to the panel of experts to review along with the proposed modifications made by the working group.

A predetermined set of rationales provided the guidelines for the recommendations. Once the classification and sub-classification of respondents' feedback was completed, the recommendations to either add, clarify, remove, or change an expectation in each of the three categories ( convergent , single participant , divergent ) were reviewed and a decision made as to whether or not the input should be addressed. These were as follows: a) all convergent recommendations to clarify should be addressed; b) recommendations to add an expectation should be addressed if it refers to a broad area of nursing and is supported in current nursing education literature –it should not be addressed if the scope is narrow, the expectation is context dependent, or it applies to medicine rather than nursing; c) recommendations to remove a concept/assumption should be addressed if broadly supported in current nursing education literature; d) recommendations to make a change should be addressed if broadly supported in current nursing education literature ( GANES, 2019 ).

Revisions of convergent recommendations

Based on the guidelines, all convergent comments to clarify were addressed. All but one of the recommendations to add an expectation were addressed. This recommendation was not integrated into the framework because it was judged to be context dependent. In contrast, however, although several respondents recommended that simulation be removed from one expectation because not all countries have the technological capabilities to provide this, it was retained. The group rationalized that the retention of simulation includes non-computerized low fidelity simulation and globally available role-play and therefore, is not context dependent. There was only one convergent recommendation of a minor change: It was to replace knowledge , skills and abilities with knowledge , skills , and attitudes and this modification was made ( GANES, 2019 ).

Single participant recommendations

There were 20 single participant recommendations to add an expectation to standards or learning outcomes. Of these, 11 (55%) were addressed as broad areas of nursing supported by current nursing literature. The remaining 45% were either judged to be a) a narrow and specific concept/theme, b) focused on medicine rather than nursing, or c) not typically found in current nursing literature ( GANES, 2019 ).

Divergent recommendations

Finally, there were five divergent recommendations with contradictory recommendations about changing or removing an assumption or expectation ( GANES, 2019 ):

• 1) Increase level of research expectations/Reduce level of research expectations “Participating” in research was reduced to “using” research to inform practice. The rationale was based on current literature on nursing research and evidence-based practice ( GANES, 2019 ).
• 2) More on nursing theory/remove nursing theory

The term nursing theory was changed to nursing knowledge and the rationale based on current literature related to the discipline of nursing ( GANES, 2019 ).

• 3) Increase level of leadership expectations/reduce level of leadership expectations of students

The expectations related to nursing leadership skills were lowered and the rationale was based on current nursing literature regarding leadership ( GANES, 2019 ).

• 4) Baccalaureate Nursing (BN) unrealistic/BN should be the entry-to-practice qualification (an assumption of the pillars).

With over 75% agreement, the BN as entry-to-practice was retained. In addition, it was specifically supported by all stakeholders at each of the earlier face-to-face consultations ( GANES, 2019 ).

• 5) Internet and library use necessary and important/internet and library access unrealistic

– remove.

Internet and library access were retained despite the influence of context because evidence-informed practice is a key international best practice in nursing education ( GANES, 2019 ).

Rigor, trustworthiness, and limitations

The multilingual and multinational composition of the expert panel and stakeholders who provided input, the expertise and leadership roles of panel members, and the triangulation of data and methods represented integral components of the methodology supporting the credibility and trustworthiness of the findings. Adding to its confirmability and dependability, an audit trail was maintained detailing each step in the process and each revision of the Global Pillars Framework. The audit trail included the documentation of all coding steps, coding decisions, and the rationale for revisions. However, transferability, would have been strengthened if representatives of more linguistic and national groups had been members of the expert panel, and if the validation survey had involved a purposeful sample rather than a snowball sample of respondents. Despite the national diversity of the input obtained, some parts of the world were overrepresented, and others underrepresented or not represented. Similarly, while anglophones, francophones, Spanish and Portuguese speakers contributed to the development of the framework, major linguistic groups such as Mandarin and Arabic were unrepresented.

Global pillars

The collective experience and wisdom of the panel of experts and international stakeholders are reflected in the three pillars with quality expectations for nursing education that emerged from this process (See appendix A). Before discussing policy implications of the framework an overview of each pillar is presented,

Pillar 1: learning outcomes for graduates

The learning outcomes for graduates specified in Pillar l are classified under the following areas: 1) Knowledge and Practice Skills; 2) Communication and Collaboration; 3) Critical Thinking, Clinical Reasoning and Clinical Judgement; and 4) Professionalism and Leadership.

The specific learning outcomes encompassing Knowledge and Practice Skills target cognitive understanding of health sciences, mastery of locally relevant competencies, care of individuals across the life span, care of families and communities, care of clients in stable and unstable conditions, comfort care, pain and symptom management, end-of-life care, psycho- social and spiritual care; social determinants of health; culturally sensitive and culturally safe care; human rights, health equity, social justice and global awareness ( GANES, 2019 ).

The specific learning outcomes focused on Communication and Collaboration incorporate relational skills including empathy and reflection, effective interaction with individuals and families, accurate and timely care documentation, counseling and health education, and interprofessional and intersectoral collaboration ( GANES, 2019 ).

The Clinical Reasoning and Judgement learning outcomes address cognitive skills related to the use of evidence in practice, abilities to identify and interpret observations, and to recognize and respond to rapidly changing situations. Finally, the expectations under Professionalism and Leadership emphasize advocacy, ethical and professional behaviors, leadership, and the ability to influence public policy ( GANES, 2019 ).

Pillar ll: guidelines for educational programs

The guidelines of pillar II are directed at the educational program under the auspices of 1) Curriculum; 2) Admissions; and 3) Learning Experiences. Standards targeting the Curriculum include responsiveness to the local context and to the particular health needs of the population. They also include that key stakeholders provide input into the curriculum and that the curriculum is monitored and updated on a regular basis.

The Admissions construct directs attention to the alignment of student admission standards with resources as well as with academic and practice demands. In addition, it includes that admission policies be reviewed on a regular basis ( GANES, 2019 ).

Learning Experience guidelines include providing nursing students with increasingly complex learning opportunities, interprofessional education, practice through simulation and clinical placements in a variety of settings. They also include that gender and cultural influences be considered.

Pillar lll: guidelines for educational institutions

The guidelines for educational institutions that deliver nursing education programs are classified as: 1) Faculty, Instructors and Preceptors; 2) Resources; 3) Leadership and Administration; and 4) Outcomes.

The guidelines for Faculty, Instructors and Preceptors specify that faculty possess a graduate degree and expertise in the areas in which they teach. Similarly, they also specify that clinical instructors and preceptors possess expertise and experience in the area in which they are teaching and/or mentoring students. In addition, these guidelines specify that the number of students a faculty member, clinical instructor or preceptor is teaching in each classroom or online course, a laboratory course, or a clinical placement fosters optimum learning in accordance with evidence-based quality educational activities ( GANES, 2019 ).

Guidelines targeting the Resources of the educational institution include the need for library and internet resources for students to learn to use evidence to inform their practice and develop critical thinking skills. The institutional expectation necessitating possession of resources (material, pedagogical, and andragogical) needed to support optimum learning is explicit. In addition, the guidelines specify that the institution must have the financial resources to cover both the human and material expenses needed to sustain the educational program ( GANES, 2019 ).

In terms of the Leadership and Administration of the institution, the guidelines specify that the governance and administrative structure must be clearly defined and support a high- quality nursing education program. They also specify that the person responsible for the program must be a registered nurse who has a graduate degree. Guidelines also include that the leadership and administration collaborate effectively with health services to ensure optimum practice opportunities for student learning ( GANES, 2019 ).

The guidelines related to Outcomes focus on the implementation of an ongoing evaluation of the education program, the analysis of evaluation data, and the use of this data analysis to improve the institution, the program, and the student outcomes ( GANES, 2019 ).

Implications for nursing and health policy

Because the quality of nursing education is a critical determinant of the quality of nursing practice, the guidelines for nursing education in the Global Pillars Framework have the potential to execute the call to action to enhance nursing education, nursing care, and nursing services as illustrated in the State of the World's Nursing 2020 report ( WHO, 2020a ). At the policy level, the Global Pillars Framework offers direction to Ministries of Education, Labor, Health and Finance; educational institutions, accreditors, private sector and other funders who have been called to action by the WHO, International Council of Nurses, and Nursing Now to invest in nursing education that produces modernized graduates. The complexity of medicine, science, culture, and delivery systems needed to address population health undergird the tremendous responsibility of nursing education to graduate a well-prepared workforce globally. Policy makers across the globe can be responsive to their constituent and country values by incorporating the voices of nurses and place nurses in policy positions to support the application of this educational standards framework. It is well documented that nurses migrate across regions; therefore, the use of the Global Pillars and research-informed standards can harmonize the education and ultimately practice standards to recognize nurses' credentials globally.

Countries that seek to utilize nurses in specialties, advanced practice, as faculty, and as policy influencers and policy makers will benefit from focusing entry level nursing at the baccalaureate level using the Global Pillars as the initial direction. These Global Pillars ground the preparation of a baccalaureate prepared global workforce- a workforce that has been shown to reduce mortality and length of stay and lower health care costs in countries, predominately in acute care settings where the most expensive resource consumption exists. The science of nursing and nursing care demands clarity in the vision of nurses for the advocacy and policy influence expectations for their roles as they create, educate and influence legislative agenda for health in a country. Well educated nurses reflecting the Global Pillars competency outcomes will play pivotal roles in systems delivery improvements for nursing education globally.

Conclusions

The Global Pillars Framework provides guidelines to strengthen nursing education internationally and is in concert with the WHO State of the World's Nursing 2020 report. “Significant investment in education and training is required to match current and anticipated needs of health systems and meet national and subnational standards” ( WHO, 2020a , recommendation 101). These Pillars are based on a systematic, multinational methodology, reflect an international consensus among national leaders in nursing education, and build on the evidence in support of baccalaureate prepared nurses. They represent, therefore, a first step towards greater harmonization in nursing education internationally through generating discussion and execution among policy makers, nurses, and funders. The State of the World's Nursing 2020 report ( WHO, 2020a ) asserts the imminent challenge to the discipline of professional nursing: we must start now to create a harmonized and modernized nursing education approach to optimize nursing outcomes globally.

CRediT authorship contribution statement

Project design: CB., AC., MdaCB.

Data collection: CB., AC/. MdaCB.

Data analysis: CB.

Manuscript writing: CB., AC.

Critical revisions for important intellectual content: AC., MdaCB.

Declaration of competing interest

Acknowledgment.

The authors acknowledge the editorial review assistance of Dr. Krista Casazza, Associate Dean for Research at Florida Gulf Coast University, Marieb College of Health and Human Services as well as the GANES Board of Directors and the respondents whose input resulted in the final Global Pillars Framework.

Appendix A. 

• 1.1.1 Apply nursing knowledge, health sciences including genetics, genomics and epigenetics, behavioral and social sciences, across the continuum of care.
• 1.1.2 Master locally relevant entry-to-practice competencies that reflect evidence-based international best practices.
• 1.1.3 Care for individuals across the lifespan, families, communities, and populations.
• 1.1.4 Manage and monitor complex care of clients in stable and unstable contexts to improve health outcomes.
• 1.1.5 Provide comfort care that addresses pain, symptom management, and psycho-social and spiritual needs throughout the illness trajectory including end-of-life.
• 1.1.6 Provide culturally sensitive, culturally safe, holistic, and person-centered care that integrates the social determinants of health.
• 1.1.7 Apply a global education perspective of human rights, health equity, social justice, global awareness, and the interconnectedness of systems.
• 1.2.1 Implement relational skills including listening, questioning, empathy, reflection, and sensitivity to emotional contexts when providing care.
• 1.2.2 Provide clear, accurate, timely, and appropriate documentation of care.
• 1.2.3 Communicate with empathy and respect in interactions with clients, families, members of the health care team, and others.
• 1.2.4 Counsel and provide information and health teaching to the client, family, and community.
• 1.2.5 Communicate effectively with members of the health care team.
• 1.2.6 Collaborate interprofessionally and intersectorally in the best interest of the client.
• 1.3.1 Systematically seek, interpret, and critically evaluate information, evidence, and practice observations.
• 1.3.2 Use research evidence in providing care.
• 1.3.3 Use clinical reasoning and problem solving to inform decision-making and caregiving in diverse practice settings.
• 1.3.4 Recognize and respond to rapidly changing client conditions and contexts including disasters.
• 1.4.1 Demonstrate a reflective understanding of ethical codes and ethical principles in providing care.
• 1.4.2 Practice within regulatory, legal, and ethical standards and contribute to a culture of patient safety.
• 1.4.3 Demonstrate the ability to analyze and influence public policy related to health.
• 1.4.4 Respond professionally to the needs of the individual, family, and community.
• 1.4.5 Demonstrate leadership skills in promoting health and influencing change.
• • Pillar ll Expectations for professional nursing education programs ( GANES, 2019 , p. 9–10)
• 2.1.1 Faculty teaching and student learning are guided by a curriculum that is systematically developed and reviewed.
• 2.1.2 The curriculum is responsive to the changing health care needs of the local population and the health care system.
• 2.1.3 Key stakeholders including employers, faculty, students, and alumni are consulted and provide input into curriculum development and review.
• 2.1.4 There is a systematic process for ongoing monitoring and improvement of the quality and relevance of the curriculum.
• 2.1.5 There is a systematic process for updating the curriculum as health needs, knowledge, and technology change.
• 2.2.1 Student enrollments are aligned with faculty resources to ensure high-quality education and responsiveness to the health care needs of the community.
• 2.2.2 Admission standards are set in relation to academic and practice demands, communicated clearly to applicants, and are respected.
• 2.2.3 Admission standards are reviewed regularly to ensure they meet current needs.
• 2.3.1 The education program includes practice experience through simulation and placements in a variety of clinical settings and with diverse populations.
• 2.3.2 Practice experiences are organized to provide students with increasingly complex learning opportunities.
• 2.3.3 Gender and cultural influences that may have an impact on learning are considered.
• • Pillar lll: Expectations for educational institutions that provide nursing education programs ( GANES, 2019 , p. 11–12)
• 3.1.1 Nursing faculty with graduate-level education and expertise in the areas in which they teach, ensure optimum delivery of the program in classroom, distance, laboratory, and clinical courses.
• 3.1.2 Nursing instructors and/or preceptors in practice settings possess clinical experience and expertise in the area in which they are instructing or mentoring students.
• 3.1.3 The number of students, in classroom, online/distance, laboratory, and clinical courses fosters optimum learning outcomes.
• 3.2.1 Library and internet resources support the development of evidence-informed practice and critical thinking among students.
• 3.2.2 Material, pedagogical, and andragogical resources support optimum learning outcomes.
• 3.2.3 Financial resources covering the human and material resources needed to deliver the program are sufficient to allow for the continuity of the program.
• 3.3.1 The governance structure is clearly defined and the administration actively supports the delivery of high-quality nursing education.
• 3.3.2 A registered nurse with a graduate degree is responsible for the nursing education program.
• 3.3.3 The leadership and administration of the nursing education program collaborate effectively with health service agencies to provide students with optimum practice learning opportunities.
• 3.4.1 An evaluation plan guides the assessment of the program, the educational institution, and the program outcomes.
• 3.4.2 There is ongoing implementation of the evaluation process and analysis of the evaluation data collected.
• 3.4.3 Evaluation data are used to improve the educational institution, the nursing education program, and student outcomes.
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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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Standards for Critical Care Nursing Practice

View:     Standards for Critical Care Nursing Practice (5th Edition) 

The 5th edition of the CACCN Standards for Critical Care Nursing Practice was completed in Summer 2017.  CACCN Members receive a copy of the Standards as a benefit of CACCN membership (a $30.00 value) ( while supplies last )!  

• New CACCN Members receive a copy of the standards with the welcome package.
• Members who were active members in November 2017 received a copy of the standards by mail.
• Hard copies of the Standards are available for purchase through CACCN National Office at a cost of  $30.00 per copy plus 13% HST.    
• Standards may be purchased using a Visa, MasterCard, AMEX, EFT, Etransfer or cheque.  If paying by EFT, Etransfer or cheque, the publication will be sent once payment is received.  
• Purchase a copy of the Standards: Publications Order Form – return the form to [email protected] or Order Online

Copyright Notification:    The CACCN Standards for Critical Care Nursing Practice is protected by copyright.  Personal use of the information is acceptable.   Distribution and/or commercial use is  prohibited  without the express written permission of CACCN.  Please contact National Office at [email protected], providing your name, contact telephone, contact email, and the purpose for redistribution of the materials. CACCN will review the request and provide a written response.

• Open access
• Published: 23 May 2024

Pass or fail: Teachers’ experience of assessment of postgraduate critical care nursing students’ competence in placement. A qualitative study

• Line J. Øvrebø   ORCID: orcid.org/0000-0002-9191-6465 1 ,
• Dagrunn Nåden Dyrstad 2 &
• Britt Sætre Hansen 2  

BMC Nursing volume  23 , Article number:  348 ( 2024 ) Cite this article

37 Accesses

Metrics details

Learning in placement is essential to postgraduate critical care nursing students’ education. Assessment of students’ competence in placement is important to ensure highly qualified postgraduate critical care nurses. The placement model applied in Norway involves students being assessed by a preceptor in practice and a teacher from the university. The teacher has a more distant role in placement, and the aim of this study was to explore how the teachers experience the assessment of postgraduate critical care nursing students’ competence in placement. Additionally, to explore the content of assessment documents used for postgraduate critical care nursing placement education in Norway.

This study has a qualitative design with main data collection from individual interviews with 10 teachers from eight universities and colleges in Norway. Additionally, we performed a document analysis of assessment documents from all 10 universities and colleges providing postgraduate critical care nursing education in Norway. We followed the Consolidated Criteria for Reporting Qualitative Research.

The teachers experienced the assessment of postgraduate critical care nursing students’ competence in placement as important but complex, and some found it difficult to determine what critical care nursing competence is at advanced level. A thematic analysis resulted in one main theme: “Teacher facilitates the bridging between education and practice.” Furthermore, three themes were identified: “Assessment based on trust and shared responsibility”; “The teacher’s dual role as judge and supervisor”; and “A need for common, clear and relevant assessment criteria”.

Conclusions

Teachers have a key role in placement as they contribute to the bridging between education and practice by providing valuable pedagogical and academic input to the assessment process. We suggest that more teachers should be employed in joint university and clinical positions to enhance the collaboration between practice and education. Clear and relevant assessment criteria are essential for providing assessment support for both students and educators. Education and practice should collaborate on developing assessment criteria. Further, there is a need to collaborate on developing, both nationally and internationally, common, clear, relevant and user-friendly assessment tools.

Peer Review reports

Nurses’ competence is crucial to provide high-quality care to patients, and nurses with advanced and specialized expertise, like postgraduate critical care nurses (CCNs), can affect the treatment capacity of the health service, reduce intensive care unit length of stay, time to treatment and ameliorate costs [ 1 , 2 , 3 , 4 , 5 ]. CCNs need to integrate advanced theoretical knowledge with interpersonal and practical skills to take care of critically ill patients [ 6 , 7 ]. Learning in placement is essential to nursing education, however research confirms that there are concerns regarding the educational quality of placements and nursing students’ fitness for practice upon graduation [ 8 , 9 ]. To ensure a certain level of knowledge and skills, assessment of student competence is an important part of the education in placement [ 10 , 11 , 12 , 13 , 14 ]. Nurse educators play a key role in the assessment approaches [ 15 ], but the complexity of assessment can be challenging for educators [ 13 , 16 , 17 ]. Moreover, as postgraduate students are already qualified nurses, it can be difficult to assess which nursing competency is at a more advanced level [ 18 ]. According to Mårtensson et al. [ 19 ] postgraduate education programmes in health professions need to assess their students in relation to the expected standards and criteria upon programme completion, and the importance of having valid and reliable assessment is clear.

A common definition of competence is what individuals know or can do in terms of knowledge, skills, and attitude. A more holistic approach also involves the student’s ability to use theory, judgment, critical thinking, and professionalism [ 19 ]. Ääri et al. [ 20 ] presented competence in critical care nursing (CCN) in two domains; clinical competence and professional competence where the clinical competence included the knowledge- and skill base. The professional competence in CCN is perceived as difficult to describe, but terms like: teamwork, decision-making, being able to manage situations and care for the patients beyond the technical aspects, in addition to personal maturity and having a good attitude, are used to describe core competencies [ 2 , 5 , 7 , 11 , 20 ]. In this article the term competence will be used as a collective term for clinical and professional competence.

The purpose of assessment is to provide feedback to the students on their ability to perform the required skills and competencies. Assessment can be formative to monitor and give feedback on progress, or summative to indicate a final level of achievement [ 10 , 21 ]. Assessment methods and requirements probably have a strong influence on what students learn, thus there should be a constructive alignment between assessment criteria and functional ability [ 22 , 23 ]. As the concept of assessment contains different perspectives, the assessment of student`s competence in placement should contain both the student`s self-assessment and preceptor and teacher`s assessment [ 19 , 24 , 25 ]. The student`s self-assessment can be a consciousness-raising exercise for the students to become aware of their competence level and behavior. Assessment can also be done by grading practical, oral or written coursework against a set of specified criteria or in relation to the achievements of a group of people. Assessment that involves discussing performance with the student, may better reveal the student’s competence level [ 21 ].

Postgraduate nursing education can be organized either as a hospital-based specialization program, residency programs offered by healthcare institutions or as a university-based program [ 26 , 27 , 28 , 29 ]. Both theoretical and practical preparation are key components of nursing education [ 13 ]. However, CCN education programs vary worldwide from weeks to years with a master’s degree [ 2 , 30 ], and it is difficult to establish the exact time and level when nurses are considered qualified CCNs [ 31 ]. Students of postgraduate courses are registered nurses with various professional background and work experiences [ 27 ]. Some students may have work experience from intensive care units prior to starting CCN education, whereas other students have no experience working with critically ill patients. Universities and colleges are responsible for graduating CCN students with high theoretical and practical competencies, nevertheless a review study by Øvrebø et al. [ 24 ] found great variation as to how the postgraduate CCN students’ competence in placement are assessed and variation in assessment requirements.

This study was conducted in Norway where CCN education is a postgraduate university or college program of optional 90 or 120 credits (master’s degree). Attendance requires a bachelor’s degree in nursing and at least two years ‘clinical experience. The program consists of at least 28 weeks supervised placement in intensive care unit (ICU) and theoretical education following a national curriculum. Assessment of CCN students’ competence during placement includes a partnership where CCN students, teachers, and preceptors collaborate on confirming the students’ achieved competence. The CCN students are supervised and assessed by a preceptor who is working as a CCN in practice and followed up by a teacher from the university or college. The teacher is responsible for the assessment process and provides information and support to preceptors and CCN students without engaging directly in patient care. During a placement period there should be at least three formal meetings between the CCN student, preceptor, and teacher. The first meeting is to clarify expectations, at mid-term the meeting focuses on formative assessment, and the last meeting is a summative assessment of the students’ competence. Although the teacher does not observe student skills in practice, the teacher will meet the students in reflection groups, simulation- and skills training in addition to the three planned meetings. Prior to the assessment meetings the students send a written self-assessment to the preceptor and teacher.

Helminen et al. [ 32 ] described the teacher’s role in Finland as similar to the Norwegian context. However, according to Immonen et al. [ 13 ] the role of nurse educators in the assessment of nursing students’ competence in placement varies internationally. In some countries, teachers from universities and colleges take the role of clinical facilitators and actively guide students during the placement period, but in several European countries the role of teachers in placement has decreased. Löfmark et al. [ 33 ] states that the role of nursing teachers in placement has changed from the traditional role of clinically skilled practitioner to a more distant, multifaceted and unclear role in the placement context. The transfer of education from hospitals to universities and colleges has led to an academization of teachers who are to a greater extent distant from practice [ 33 , 34 , 35 ]. Hence, there is a need to investigate the teachers’ role in relation to assessment of students in placement.

Challenges concerning the assessment of nursing students during placements have been reported previously [ 10 , 12 , 13 , 24 , 36 ], however to our knowledge few studies have investigated the assessment of postgraduate CCN students from the perspectives of the nursing teachers and content of assessment documents. Assessment of postgraduate students’ competence is different from that of pre-registration student nurses, and there is a need for research on how the teachers experience their role in the assessment of postgraduate student`s competence in placement. Further it is necessary to examine the content of assessment documents as there are no national or international common criteria, and the assessment documents are essential for the assessment process.

For the rest of this article postgraduate CCN students are referred to as CCN students, CCN supervisors in placement as preceptors, and nursing teachers as teachers.

The aim of this study was to explore how teachers experience the assessment of postgraduate CCN students’ competence in placement. Furthermore, we wanted to explore the content of assessment documents used for placement courses. The following research questions were developed:

What is the teacher’s assessment of CCN students’ competence in placement based on?

How do teachers experience their role in the assessment of CCN students’ competence in placement?

How do teachers experience the use of assessment documents, and what is the content of assessment documents for placement courses?

We used a qualitative research design with individual interviews and document analysis. This design was suitable because we wanted to gain a deeper understanding of the teachers experiences on the assessment of students’ competence and content of the assessment documents [ 37 ]. The consolidated criteria for reporting qualitative research (COREQ) checklist were used to report the findings [ 38 ].

Setting and sample

In Norway, CCN teachers must be registered CCNs with a completed master’s or PhD-level degree. Additionally, it is required that they have completed pedagogical studies within two years of employment. Teachers are mainly employed by the universities and colleges. However, a few teachers are employed in joint positions between hospitals and universities/ colleges.

We conducted a purposive sampling of teachers to participate in the interviews with the aim to obtain variation regarding workplace and experience [ 37 ]. The inclusion criteria were teachers with experience of assessing CCN students in placement, no specific exclusion criteria were set. To recruit participants, we contacted the managers of all the 10 postgraduate/master’s CCN programs in Norway. The managers were asked to communicate the request to participate in the study to possible participants. We received contact information from the managers to 18 teachers working at eight different universities and colleges. All the 18 teachers were invited to participate, and 13 agreed to be interviewed. However, three of the teachers withdrew before the interviews took place, and explained it was due to workload. This left us with 10 teachers participating in the study from eight different universities and colleges. Participants in the interviews were teachers experienced in assessment of CCN students in placement. Details of the participants are listed in Table  1 .

The managers of the postgraduate/master’s CCN programs in Norway were also requested to send the assessment documents for placement courses. We received assessment documents from all 10 universities and colleges by email.

Data collection

The main data collection was from individual interviews with 10 teachers from eight different universities/ colleges, supplemented by assessment documents from all 10 universities/ colleges providing postgraduate CCN education in Norway. The interviews were conducted digitally (Zoom) from December 2021 to January 2022 due to Covid-19 pandemic restrictions. Individual interviews are considered well-suited to provide insight into the participants’ own experiences and perceptions [ 39 , 40 ]. The interviews were audio recorded, had a semi-structured approach, and lasted between 44 and 69 min (average 54 min). The interview guide (Table  2 ) was based on themes agreed in the research group.

The first author conducted the interviews, made field notes, and transcribed the interviews verbatim. The third author assisted during the first two interviews that originally were pilot interviews. The quality of the pilot interviews was sufficient for them to be included in the data set. According to Malterud [ 41 ] information power is dependent on aim and design, and a larger sample size is needed for studies with broader aims. However, this study had a specific aim and the interviews provided rich data to answer the research questions, and information power was evident [ 41 ].

As a supplementary data collection, assessment documents from 10 universities/ colleges in Norway were collected between January 2021 and December 2022. The first author made a summary of the assessment documents as presented in Table  3 .

Data analysis

Data from the interview transcriptions were the main data source and were analyzed using thematic analysis, which is a method for identifying, analyzing and reporting patterns in qualitative data [ 42 ]. This method is suitable to describe and show patterns in the semantic content. We used a modified version of Braun and Clarke`s [ 42 , 43 ] step by step thematic analysis: (1) familiarizing, (2) coding, (3) generating initial themes, (4) reviewing and developing themes, refining, (5) defining and naming themes, and (6) writing the report. Step 1: The audio tapes were listened to, after which the interviews were transcribed by the first author. Step 2: Coding was performed focusing on the research questions to sort the data. The first author made codes by color-marking important features in the text transcripts and sorting data relevant to each code. Step 3: Initial themes subsequently emerged, as a back-and-forth approach was applied when the research team met several times to discuss the codes and identify themes. Step 4: We used an inductive approach, as we identified themes that were explicit, or recognized the surface meaning of the data. Step 5: Finally, these themes were reviewed to determine whether there were any new themes. An extract of the data analysis process is presented in Table  4 .

Findings from the assessment documents (Table  3 ) were discussed by the research team and provided a supplement to the analysis of the main data collection. Verbatim quotations from the interviews exemplified our interpretations as reflected in the findings. Thematic analysis was considered the most appropriate method as it is descriptive and flexible [ 42 , 43 ].

Ethical considerations

The study was approved by the Norwegian Centre for Research Data on 30.09.21 (case No. 949,642). The teachers’ participation was voluntary, and written informed consent was obtained from all participants. Confidentiality, anonymity, and the right to withdraw from the study without any consequences was guaranteed. The data were recorded using an approved digital tool. Furthermore, the data material was kept secure throughout the research process in accordance with the university’s laws and regulations.

Analysis of the interviews and documents led to the identification of one main theme: “Teacher facilitates the bridging between education and practice”. Placement in postgraduate nursing education is the bridge between education and practice, and we found that teachers contribute to facilitate this bridging. Further three themes were identified describing the assessment of CCN students’ competence from the teachers’ perspective and content of assessment forms: “Assessment based on trust and shared responsibility “The teacher’s dual role as judge and supervisor,” and “A need for common, clear and relevant assessment criteria”. An overview of the themes is presented in Fig.  1 .

Overview of themes

Assessment based on trust and shared responsibility

The teachers expressed that they mostly based their assessment of the students’ competence on the written documents and dialogue with the students and preceptors in the assessment meetings. The teachers felt highly dependent on feedback from the preceptors, and it was important that the preceptors did not dispute what the students conveyed. Sometimes the teachers experienced a great discrepancy between the assessment comments from the students and the preceptors. When this occurred, the teachers would take other elements into consideration, such as their own perception of the students gained from reflection group meetings, simulation training, and other meetings. Some of the teachers found it challenging to assess the students without having seen them much in action:

“ The organization and structure around it (…) is much more problematic than the assessment form itself. Personally, I could imagine seeing the students a lot more .” (T6).

To compensate for this drawback, the teachers talked about the importance of knowing their students well, and that they preferred to follow the students for several placement periods. The teachers expressed that it is necessary to have clear criteria and the students must always be assessed based on the learning outcomes. The teachers also described how dependent they were on having preceptors who documented what wasn’t a satisfactory level of competence. If the students were at risk of failing the placement course, the teachers explained that their role was to clarify what they expected the student to achieve. Furthermore, our findings suggest that some of the teachers felt responsible for the final assessment of the students:

“ It happens that we do not agree with the student’s level, and so on. But then it is quite clear in our documents (…) that it is the teacher who has the last word. ” (T5).

The teachers assumed that it could be more difficult for the preceptors to set strict requirements for the students because a teacher has a different and somewhat more distant perspective. However, the teachers experienced that most of the preceptors took their role seriously and did not refuse to fail students. They found that most of the preceptors took great pride in being CCNs and expected the CCN students to maintain a certain standard. The learning outcomes were very much governing, but the preceptors also had an inner pride to help their students perform as well as possible. They looked upon themselves as kind of gatekeepers, because the students will probably become their future colleagues and must be ready to function as competent CCNs when they start working.

There is great pressure to educate more CCNs, and the teachers were concerned about the preceptor’s lack of time to supervise and assess students properly. Sometimes the focus was more on quantity than quality in the guidance. Despite the teachers concern about the preceptors’ lack of time, some of the teachers expressed their deep respect for the preceptors as they considered them to have high moral and ethics, and they looked well after the students in placement.

The teacher’s dual role as judge and supervisor

We found that the teachers experienced a kind of duality in the role as teachers. They had to both look after the student and support their learning process, and at the same time ensure high quality of the future CCNs. The teachers also experienced having to guide and support the preceptors in their role. This was especially evident in the assessment of underachieving students because the preceptors felt it very unpleasant to be involved in failing a student:

“ We stand there and must be, in a way, the student’s lawyer and the preceptor’s lawyer or everyone’s support, so it is demanding .” (T3).

The teachers would then provide guidance on the assessment based on the learning outcome descriptions in the assessment documents. They would also make sure to adequately document the assessment of the student. Having a close collaboration with the preceptors and the nursing managers in the ICU made the duality of the role less demanding. There is a need for the teachers, students, and preceptors to collaborate closely, and we found that the pedagogical role of the teacher could influence the students’ learning process in placement:

“ I think it’s important for learning, that they are confident in me as a teacher and see that I want them well. That doesn’t mean all students should pass. But at least it gives a good relationship with the students, and it gives them a broad and fair assessment, and that’s important to me.” (T5) .

Furthermore, the teacher seemed to provide other elements to the assessment process than the preceptor because teachers have a different perspective.

The teachers in our study emphasized that it was essential to clarify expectations and to establish a close relationship where the threshold for communication with each other was low. One of the success factors for a good collaboration was that they agreed on what should be the student’s focus. On the other hand, the lack of continuity in follow-up in placement affected the learning and assessment process negatively. The teachers also described how some preceptors could make the students feel insecure if the students felt that they were constantly in an assessment situation. Further, several of the teachers found it important to be updated in practice:

“ The ideal would have been if, as a CCN teacher, you could have worked 50/50. This way you could both have been a part of the teaching staff and a part of the patient-oriented staff. Then you could have kept up to date .” (T8).

Two of the participants worked part-time as teachers and CCNs in practice. They appreciated that this dual role might be positive for the collaboration with the university and the hospital. In addition, the teachers felt more available to the students and preceptors, which seemed to be an advantage in the process of assessing the students’ competence.

A need for common, clear and relevant assessment criteria

We found that there is great variation in the assessment criteria for CCN placement education in Norway as shown in Table  3 . Some of the assessment documents were clear and relevant to practice, whereas others were indistinct. Most of the universities and colleges had developed their own assessment documents, and the content of the documents varied much depending on the different educational institutions (Table  3 ). The assessment form content was defined as “clear” if the learning outcomes were specified to different learning situations and activities and characterized as “vague” if the learning outcomes were scarcely described.

Accordingly, some of the teachers experienced that the assessment forms were reliable and helpful in the assessment situations:

“ The assessment criteria provided very good evaluation support, and assurance of quality so that there is not much room for subjective assessments. It becomes a bit more like we all speak the same language .” (T1).

If the goals were clear, it was easier to give example of how far the students had come in achieving their goals. However, other teachers experienced that the assessment form formulations were too unclear to reflect the defined standards. If both the students and preceptors failed to clearly set out what the expected level was, the teachers had to translate the learning outcomes to make them more manageable. The need for preceptors to be clear was especially important if the students were at risk of failing. The teachers emphasized that the assessment criteria were very important to clarify which competencies the students needed to improve:

“ I have to constantly work on making the conversation about the student, not about the situation and the patient and relatives and others .” (T7).

The use of clear competence descriptions with a focus on non-technical skills could be helpful in separating the student’s personality from the student’s skills. The teachers experienced that assessment documents could be decisive for what became the learning focus during placement. There is a need for a common understanding, and it was important that the preceptors read and familiarized themselves with the educational plan and the learning outcome descriptions.

How actively the preceptors and students used the assessment documents varied. The teachers were frustrated regarding the preceptors’ commitment and how much time they had to familiarize themselves with it. Sometimes the preceptors had a different opinion on what the student should learn, and this could then affect the assessment of the student:

“ It is important to have learning outcome descriptions that they can identify with, and where there is not too much of a difference between school and practice .” (T3).

Some of the teachers tried to make the assessment criteria from the university consistent with the expected level of functional ability and had operationalized the learning outcomes for placement courses in collaboration with CCNs at the hospital. Even though clear assessment criteria were highly appreciated by the teachers, some were worried about making things too specific. They found it important that the students should clarify their own goals to better see and understand what they needed to learn.

Our findings from the interviews and documents indicate that which competencies are emphasized vary. According to the teachers, the students found managing technical skills most important. Holistic nursing and non-technical skills such as communication and anticipate and stay ahead of the situation, was highly emphasized by the preceptors. These competencies were also regarded as important by the teachers. In addition, they regarded ethics and attitudes, knowledge, linking theory to practice, and working according to evidence-based practice as important competencies. The teachers also highlighted the need to strive for a balance between practicality and academic knowledge, and the importance of students’ self-reflection and self-assessment.

It is necessary to document the students’ competence level, but we found that there is a considerable variety regarding how and what is documented in relation to placement courses. Some of the teachers commented on the possibility of using a digital assessment tool. They presumed that the use of digital assessment tools would be a great improvement, because it would probably make the assessment documents more available and transparent for both students, preceptors and teachers. Further we found that the teachers were generally interested in new innovative methods to improve the assessment of CCN students’ competence in placement.

This study aimed to describe how teachers experienced the assessment of CCN students’ competence in placement. Additionally, to explore the content of assessment documents used for CCN placement education in Norway. Findings from the interviews indicate that teachers found it important but challenging to assess CCN students’ competence. The complexity of assessment of nursing students’ competence in placement is a matter of concern in nursing education and has been stated in several previous studies [ 10 , 12 , 13 , 32 ]. Additionally, it can be even more challenging to assess what nursing competence is at postgraduate level [ 18 , 19 , 24 ]. In Norway, the CCN students are experienced registered nurses, and some students have work experience from ICU prior to starting the CCN education. According to Solberg et al. [ 5 ] a master’s programme for nurses in critical care is intended to cultivate nurses who are able to integrate advanced theoretical knowledge with practical and interpersonal skills in caring for critically ill patients. Teamwork, decision-making, to manage situations and care for patients beyond the technical aspects, showing personal maturity and have a good attitude are terms used to describe professional competence in critical care nursing [ 5 , 7 , 11 ]. These competencies should be described in assessment documents to help distinguish the competence of a qualified nurse from a qualified CCN. According to Mårtensson et al. [ 19 ] a structured assessment tool that includes behavior cues could help teachers and preceptors improve the clarity of their assessment and feedback to students at postgraduate level.

This study is the first to map the content of the assessment documents for CCN placement education in Norway. Even though there is a national framework for CCN education, we found that each educational institution had different assessment documents and there is great variation in the assessment criteria for placements as shown in Table  3 . Some of the assessment forms were indistinct, whereas others were clear and relevant to practice. Assessment instruments developed according to evidence-based practice and validated are not being used, as each educational institution make its own instruments. The inconsistency in assessment methods and instruments both between higher education institutions and between countries has been stated in previous research [ 2 , 13 , 30 ], and our study shows that even in a small country like Norway there is not a common national assessment form for CCN education.

Some of the teachers found that the assessment instruments provided good assessment support. In particular, the assessment criteria with a focus on the non-technical skills could be helpful in separating the students’ personality from the students’ skills. However, other teachers experienced that they had to translate the criteria to make them manageable. This made the teachers concerned about getting the preceptors to talk about the students’ competence rather than the situation. The purpose of assessment is to provide feedback to the students on their ability based on their learning outcomes [ 10 ], and the use of clear competence descriptions is both necessary and important to give the students a fair assessment [ 24 ].

The teachers in our study experienced that learning outcomes in assessment documents could be decisive for what became the learning focus during placement. However, focus varied depending on how actively the preceptors and students used the assessment documents. The teachers were frustrated about some of the preceptors’ lack of commitment, and sometimes the preceptors even had a different opinion on what the student should learn. This is in line with previous research on the formal assessment discussions in placement [ 14 ]. An interesting finding in our study was that some of the teachers had operationalized the learning outcomes for placement in collaboration with CCNs working at the hospital. Constructive alignment is important if there is a need for students to integrate and apply theory into practice [ 22 , 23 ]. The assessment criteria must be consistent with the expected level of functional ability and should be developed in collaboration with practice.

We found that the teachers based the assessment on different methods such as students’ self-assessment, the preceptors’ feedback, and the teachers’ perception of students from meetings and written assignments. Although they trusted the students’ and preceptors’ feedback, they preferred to get to know the students well to be able to form their own opinion about the students’ competence level. This finding is consistent with Helminen et al. [ 32 ] who highlighted that support from the teacher during the assessment process was relevant both for the students and the preceptors. Findings from our study indicate that the teachers’ presence in placement is important. This is an interesting finding since the role of nursing teachers has changed from a clinically skilled practitioner to a more distant role in the placement context [ 33 , 34 , 35 ]. Nevertheless, other studies support this finding and underline the value of teachers pedagogical and academic contributions by providing a different perspective in the assessment process [ 33 , 36 ].

Self-reflection, balancing practicality and theoretical knowledge, and working according to evidence-based practice were competencies highlighted by the teachers. Benner [ 44 ] states that these are among the core competencies in advanced critical care nursing. Even so, the teachers experienced that they emphasized different competencies than the students and preceptors in the assessment process. Nurse educators are positioned to facilitate opportunities for students and practicing nurses to be involved in evidence-based practice care initiatives. These competencies are important to make the students capable of further development in the field of critical care nursing [ 45 ]. Cant et al. [ 46 ] found that some students were more satisfied with the role of the teacher than preceptors because of their ability to integrate theory and practice and stimulate students’ critical thinking. A holistic approach to the term competence involves the student’s ability to use theory, judgment, critical thinking, and professionalism [ 7 , 19 , 47 ]. Thus, it’s important to assess both the student’s technical and non-technical skills in placement.

Most of the teachers in our study were employed by educational institutions, and some suggested that it would have been ideal if they could work 50/50 as teachers and CCNs in the patient-oriented staff to be updated in practice. Two of the participants in this study worked in joint positions at the university and the hospital. They could observe and meet the students more frequently, which was valuable in the assessment process. Also, the teachers appreciated how this could be positive for the collaboration between the university and hospital in general. This finding aligns with those of previous studies suggesting that educators in joint positions could strengthen the clinical learning environment for students [ 8 , 16 ]. Mathisen et al. [ 8 ] states that nurse educators who are insiders in both settings, are ideally placed to contribute to bridge the theory-practice gap. Further, partnerships between academia and practice can lead to improved patient care and health system innovations [ 45 ]. However, we found that there were some challenges related to having two employers. For one thing, they must be clear about when they are teachers and dedicated to taking care of the students, and when they are CNNs focused on taking care of patients.

Findings in our study suggest that the teachers looked upon themselves as responsible for the assessment process. However, the teachers also regarded the assessment as a shared responsibility. The teachers felt they had a common understanding with the preceptors regarding the importance of providing high-quality care to critically ill patients. Furthermore, the teachers experienced that the preceptors looked upon themselves as gatekeepers, and that they are in a position to shape and approve who is most likely to become their future colleagues. This finding is supported by other studies [ 10 , 12 , 13 ].

Further, we found that the teachers could experience a duality in their role. They had to support the students’ learning process and at the same time ensure an adequate competence level. This could sometimes be difficult, especially if the students were at risk of failing. The teachers cared for the students, and in nursing education, ethos and core values are important to become a professional and caring nurse. The term “failing to fail” is described as nursing faculty members struggling to assign failing grades to underperforming students in the clinical setting [ 48 ], and involves a difficult conversation that requires confidence and could cause emotional harm to both the student and educators. Thorup et al. [ 49 ] states that a nurse must have sensitivity in order to be able to relate to other people, and vulnerability is thus an important resource in nursing. Nevertheless, the teacher must ensure safe and high-quality care for the patients. The sense of care they have in relation to their students must not affect their professional responsibility as teachers. However, belief in students’ ability to grow is seen as central foundation and condition. This perspective is valuable, especially in the formative assessment of the students [ 21 ], and the teacher’s pedagogical competence is essential in this matter.

Findings in this study suggest that the teachers could provide guidance because they had a more distant perspective of the students and were more familiar with the assessment criteria. Moreover, the teachers could facilitate the bridging between the education and working life by linking theory and practice. Pedagogical competence is also important to guide the preceptors in their role, especially in the assessment of underachieving students. This is in line with previous research stating that the educational institutions contribute to the bridging between theory and practice [ 6 , 7 , 8 ].

The teachers in our study were concerned about the preceptor’s lack of time to supervise and assess students, which has also been stated in other studies [ 14 , 36 ]. The pressure to educate a growing number of students in placement can lead to additional strain on the CCNs [ 24 , 50 ]. According to Järvinen et al. [ 36 ] the lack of time and the increase in number of students affected the ability to assess the students properly during placement. Nurses’ competence is crucial to achieve the goal of providing safe and high-quality care [ 3 , 4 ]. Patient care must always be prioritized, but the increasing pressure to educate more CCNs may lead to placement periods of shorter duration and less follow-up, which could affect the qualifications of the future CCNs. We believe that teachers have a key role in providing educational quality in placement due to their responsibility for the assessment process of students.

Methodology considerations

Regarding data collection and analysis, the provision of trustworthiness, credibility, dependability, confirmability, and transferability must be ensured [ 23 , 28 ]. A pilot interview was thus performed to ensure credibility in data collection. The first steps of the analysis were mainly done by the first author, but to ensure credibility, the identified themes were discussed and approved by the research team. Credibility was also strengthened by ensuring that actual statements from the participants were represented in the manuscript. Transparency was maintained throughout the process, with a record being kept of all stages of data collection and analysis. Some of the text from the transcripts was read by the whole research team to assess comparability to the codes and themes derived by the first author. Transferability was attended to by conducting interviews with CCN teachers from eight different universities and colleges in Norway, and dependability was ensured by using the same interview questions for all participants. Dependability was also strengthened by the researcher’s experience as a CCN and preceptor, which provided a deep understanding of assessment of students’ competence. The authors who performed the interviews were teachers at the same university as two of the participants. This could be a limitation as this might have influenced the participants to speak less freely. But it can also be an advantage to have knowledge about the culture being studied, whereas it can be a challenge to create a distance when analyzing the material [ 23 , 28 ]. Confirmability was ensured by using representative quotations to illustrate information in relation to the findings. By providing descriptions of the participants and data collection, the transferability of our findings to another context was enhanced. A limitation of this study could be that the participants evaluated their own role. Further, the use of Zoom could be a limitation, as this may have affected the quality of the interviews. However, the researcher who conducted the interviews experienced few disturbances due to the use of Zoom. This study was carried out on a relatively small sample of teachers in Norway and may not reflect the teacher role in other countries. A strength of this study is that we included participants employed by different universities that were geographically spread out within the country. Additionally, we gathered assessment documents from all universities and colleges in Norway providing CCN education.

We found that teachers have a key role in the assessment of students in placement, and it is important that they are present in the clinical setting. Teachers in our study experienced that the assessment of CNN students’ competence in placement can be challenging and complex. Nevertheless, they found their role in the assessment of students’ competence to be important to ensure high-quality care for patients. The teachers contributed valuable support and guidance to both the students and preceptors in the assessment meetings during placement. Collaboration in the education of CCNs is essential, and nursing teachers can facilitate the bridging between education and working life by linking theory to practice, promoting critical thinking, and working according to evidence-based practice. Assessment documents and criteria vary, and this study underpins the notion that common, clear and relevant assessment criteria are essential for learning focus and provide valuable assessment support. Teachers and preceptors must continue to work together, to improve and develop reliable and effective assessment strategies. CCN students need constructive feedback on their skills and performance to maintain high-quality nursing education in placement at advanced level.

Implications for practice and research

We believe that teachers employed in joint positions between education and practice could further enhance the collaboration between practice and education institutions regarding education of postgraduate CCNs. We further suggest the development of common national assessment documents for CCN education. The assessment documents should be developed as a collaboration between education and practice to meet the constant changes in critical nursing care and treatment, and the assessment documents should be constantly evaluated and improved. Research and innovation regarding development of user friendly and available assessment tools, like digital assessment tools, is also needed. Further research on assessment of CCN students’ competence from the students’ and preceptors’ perspective is recommended.

Data availability

The data from the audio-recorded interviews used to support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

• Critical care nursing

Critical care nurses

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Acknowledgements

The authors would like to thank the teachers who participated in this study. We would also like to thank the managers of the CCN education programs at universities and colleges in Norway for helping to recruit participants and provide access to the assessment documents.

Open access funding provided by University of Stavanger & Stavanger University Hospital. This study did not receive any external funding.

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Contributions

All authors contributed to the conception and design of the study. LJØ conducted the interviews, with assistance from BSH on two of the interviews. LJØ transcribed the interviews verbatim and interpreted and analysed the data, while DND and BSH provided critical input to all stages of the data analysis. LJØ wrote the first draft of the article and all authors contributed to critical revision and read and approved the final version of the manuscript.

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Correspondence to Line J. Øvrebø .

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Ethics approval and consent to participate in this study was performed in accordance with the checklist for qualitative research COREQ and followed the Helsinki Declaration. Ethical approval was obtained from SIKT – Norwegian Agency for Shared Services in Education and Research (formerly known as The Norwegian Centre for Research Data) (Project No. 949642). Further ethical approval from the clinical ethical committee was deemed unnecessary due to national regulations described in the Norwegian Health Research Act (Helseforskningsloven, 2008, § 4) regarding research not considered to be medical or health research. The participants received both written and oral information about confidentiality and voluntary participation and informed consent was obtained from all the participants before the interviews were recorded.

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Øvrebø, L.J., Dyrstad, D.N. & Hansen, B.S. Pass or fail: Teachers’ experience of assessment of postgraduate critical care nursing students’ competence in placement. A qualitative study. BMC Nurs 23 , 348 (2024). https://doi.org/10.1186/s12912-024-01951-8

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Received : 01 June 2023

Accepted : 19 April 2024

Published : 23 May 2024

DOI : https://doi.org/10.1186/s12912-024-01951-8

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CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings

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Core Infection Prevention and Control Practices for Healthcare

Introduction

Adherence to infection prevention and control practices is essential to providing safe and high quality patient care across all settings where healthcare is delivered

This document concisely describes a core set of infection prevention and control practices that are required in all healthcare settings, regardless of the type of healthcare provided. The practices were selected from among existing CDC recommendations and are the subset that represent fundamental standards of care that are not expected to change based on emerging evidence or to be regularly altered by changes in technology or practices, and are applicable across the continuum of healthcare settings. The practices outlined in this document are intended to serve as a standard reference and reduce the need to repeatedly evaluate practices that are considered basic and accepted as standards of medical care. Readers should consult the full texts of CDC healthcare infection control guidelines for background, rationale, and related infection prevention recommendations for more comprehensive information.

The core practices in this document should be implemented in all settings where healthcare is delivered. These venues include both inpatient settings (e.g., acute, long-term care) and outpatient settings (e.g., clinics, urgent care, ambulatory surgical centers, imaging centers, dialysis centers, physical therapy and rehabilitation centers, alternative medicine clinics). In addition, these practices apply to healthcare delivered in settings other than traditional healthcare facilities, such as homes, assisted living communities, pharmacies, and health fairs.

Healthcare personnel (HCP) referred to in this document include all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances, contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air.

CDC healthcare infection control guidelines 1-17 were reviewed, and recommendations included in more than one guideline were grouped into core infection prevention practice domains (e.g., education and training of HCP on infection prevention, injection and medication safety). Additional CDC materials aimed at providing general infection prevention guidance outside of the acute care setting 18-20 were also reviewed. HICPAC formed a workgroup led by HICPAC members and including representatives of professional organizations (see Contributors in archives for full list). The workgroup reviewed and discussed all of the practices, further refined the selection and description of the core practices and presented drafts to HICPAC at public meeting and recommendations were approved by the full Committee in July 2014. In October 2022, the Core Practices were reviewed and updated by subject matter experts within the Division of Healthcare Quality Promotion at CDC. The addition of new practices followed the same methodology employed by the Core Practices Workgroup but also included review of pathogen-specific guidance documents 21-22 that were created or updated after July 2014. These additions were presented to HICPAC at the November 3, 2022 meeting. Future updates to the Core Practices will be guided by the publication of new or updated CDC infection prevention and control guidelines.

Core Practices Table

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Standards Published for Critical Care Nurse Staffing

Apr 23, 2024

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ALISO VIEJO, Calif. — April 23, 2024 — The American Association of Critical-Care Nurses ( AACN ) has published " AACN Standards for Appropriate Staffing in Adult Critical Care ," the specialty's first, action-oriented staffing standards.

Appropriate staffing has long been one of the "AACN Standards for Establishing and Sustaining Healthy Work Environments" (HWE standards), first published in 2005. It has also been one of the most complex areas to address.

On every national survey conducted by AACN to measure the health of clinical work environments between 2005 and 2019, nurses consistently gave lower ratings for survey items related to the appropriate staffing standard than for items related to the other HWE standards . In the most recent national survey, conducted in 2021, the item labeled "ensuring an effective match between patient needs and nurse competencies" received the lowest mean rating of any element on any of these surveys conducted to date.

Besides the HWE standards, the new staffing-specific standards build on AACN's other influential resources related to nurse staffing, including AACN Synergy Model for Patient Care and its 2018 "Guiding Principles for Appropriate Staffing."

The standards also respond to recent recommendations from the Partners for Nurse Staffing Think Tank and the Nurse Staffing Task Force, both co-convened by AACN. Both groups called for specialty nursing organizations to define staffing standards for the patient populations they serve.

Developed by a work group with representatives from a variety of nursing roles, "AACN Standards for Appropriate Staffing in Adult Critical Care" outlines seven standards to incorporate appropriate staffing into everyday operations and patient care. Each standard includes actions for organizational leaders, clinical leaders and direct care nurses, as well as suggested exemplars, tools and resources.

"The link between healthy work environments and patient safety, nurse retention and recruitment, and an organization's bottom line is irrefutable," said Vicki Good, AACN chief clinical officer and co-editor of the staffing standards document. "These standards, coupled with a deep commitment to collaboration and change, provide an opportunity for evidence-based transformation that can profoundly improve the U.S. healthcare system's ability to meet patients' needs."

The seven standards are as follows:

• Direct care nurses participate in all aspects of staffing: planning, implementation and evaluation.
• Hospital patient care areas establish, evaluate and refine unit-specific staffing guidelines based upon their impact on patient and nurse outcomes.
• For every shift, patient assignments are based on an accurate assessment of the current nursing workload generated by each patient's needs and align nurse competency with patient characteristics.
• Clinical leaders such as charge nurses, educators and nurse managers are not included in patient assignments, except in rare crisis situations.
• Staffing plans and patient assignments support the unique needs of nurses who are new to the unit.
• Organizational staffing plans are designed to prioritize the health of the work environment and thus drive nurse retention and optimal patient outcomes.
• Organizational staffing plans anticipate that critically ill or injured patients generally require a ratio of one nurse to two patients.

The document also includes a section with answers to common questions that arose during development of the standards, a glossary and references.

"AACN Standards for Appropriate Staffing in Adult Critical Care" can be downloaded at no charge on the AACN website after signing in. A print version of the 42-page document can be purchased for $10 for AACN members and $25 for nonmembers from AACN's online store .

The document joins other AACN publications developed to describe the level of practice or performance expected by the nursing profession in order to provide excellent and compassionate care. In addition to the HWE standards and staffing standards, AACN has published guidelines specific to clinical nurse specialists, acute care nurse practitioners, tele-critical care nurses, and progressive care and critical care nurses.

About the American Association of Critical-Care Nurses : For more than 50 years, the American Association of Critical-Care Nurses (AACN) has been dedicated to acute and critical care nursing excellence. The organization's vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. AACN is the world's largest specialty nursing organization, with about 130,000 members and nearly 200 chapters in the United States.

American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656; 949-362-2000; www.aacn.org; facebook.com/aacnface; x.com/aacnme