ABOUT CRITICAL CARE NURSING

Definition of Critical Care Nursing Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care. Definition of a Critically Ill Patient Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care. Number of Critical Care Nurses in the United States According to "The Registered Nurse Population" study conducted in March 2004 by the Department of Health and Human Services, there are 503,124 nurses in the U.S. who care for critically ill patients in a hospital setting. Of these, 229,914 spend at least half their time in an intensive care unit (ICU); 92,826 spend at least half their time in step-down or transitional care units; 117,637 spend at least half their time in emergency departments; and 62,747 spend at least half their time in post-operative recovery. Critical care nurses account for an estimated 37% of the total number of nurses who work in a hospital setting. Where Critical Care Nurses Work According to "The Registered Nurse Population" study, 56.2% of all nurses work in a hospital setting, and critical care nurses work wherever critically ill patients are found intensive care units, pediatric ICUs, neonatal ICUs, cardiac care units, cardiac catheter labs, telemetry units, progressive care units, emergency departments and recovery rooms. Increasingly, critical care nurses work in home healthcare, managed care organizations, nursing schools, outpatient surgery centers and clinics. What Critical Care Nurses Do Critical care nurses practice in settings where patients require complex assessment, high-intensity therapies and interventions, and continuous nursing vigilance. Critical care nurses rely upon a specialized body of

knowledge, skills and experience to provide care to patients and families and create environments that are healing, humane and caring. Foremost, the critical care nurse is a patient advocate. AACN defines advocacy as respecting and supporting the basic values, rights and beliefs of the critically ill patient. In this role, critical care nurses:

Respect and support the right of the patient or the patient's designated surrogate to autonomous informed decision making. Intervene when the best interest of the patient is in question. Help the patient obtain necessary care. Respect the values, beliefs and rights of the patient. Provide education and support to help the patient or the patient's designated surrogate make decisions. Represent the patient in accordance with the patient's choices. Support the decisions of the patient or designated surrogate, or transfer care to an equally qualified critical care nurse. Intercede for patients who cannot speak for themselves in situations that require immediate action. Monitor and safeguard the quality of care the patient receives. Act as a liaison between the patient, the patient's family and other healthcare professionals. The Roles of Critical Care Nurses Critical care nurses work in a wide variety of settings, filling many roles including bedside clinicians, nurse educators, nurse researchers, nurse managers, clinical nurse specialists and nurse practitioners. With the onset of managed care and the resulting migration of patients to alternative settings, critical care nurses are caring for patients who are more ill than ever before. Managed care has also fueled a growing demand for advanced practice nurses in the acute care setting. Advanced practice nurses are those who have received advanced education at the master's or doctoral level. In the critical care setting, they are most frequently clinical nurse specialists (CNS) or acute care nurse practitioners (ACNP). A CNS is an expert clinician in a particular specialty critical care in this case. The CNS is responsible for the identification, intervention and management of clinical problems to improve care for patients and families. They provide direct patient care, including assessing, diagnosing, planning and prescribing pharmacological and

nonpharmacological treatment of health problems. ACNPs in the critical care setting focus on making clinical decisions related to complex patient care. Their activities include risk appraisal, interpretation of diagnostic tests and providing treatment, which may include prescribing medication. Level of Education for Critical Care Nurses To become a registered nurse (RN), an individual must earn a diploma in nursing, an associate's degree in nursing (ADN) or a bachelor's degree in nursing (BSN) and pass a national licensing exam. Requirements vary as dictated by each state's Board of Nursing. Many nursing schools offer students exposure to critical care, but most of a critical care nurse's specialty education and orientation is provided by the employer. Advanced practice nurses must earn a degree at the master's or doctoral level. Critical Care Nurse Certification Although certification is not mandatory for practice in a specialty like critical care, many nurses choose to become certified. Some employers prefer to hire certified nurses because they have demonstrated acquisition of a specific high level of knowledge in their specialty through successful completion of a rigorous, psychometrically valid, job-related examination. For example, a critical care nurse must care for critically ill patients for a minimum of two years to be eligible for the CCRN certification exam offered by AACN, one of many credentials the association offers. Because of the availability of Medicare and managed care reimbursement to clinical nurse specialists, a growing number of employers are requiring advanced practice certification. Additionally, as state boards of nursing attain statutory authority to issue advanced practice nursing licenses, nurses are often being required to pass a nationally recognized certification examination. Certified nurses validate their continuing knowledge of current practices in acute/critical care nursing through a renewal process that includes meeting continuing education and clinical experience requirements. Nursing Shortage More Pronounced for Critical Care Nurses The nursing shortage is especially acute in the specialty areas of nursing, as noted in the skyrocketing number of requests for temporary and traveling critical care nurses to fill staffing gaps in every part of the U.S.

These requests are most pronounced for adult critical care units, pediatric and neonatal ICUs and emergency departments. Recruitment advertising for critical care nurses in AACN's publications continues to grow, especially in the annual Career Guide. Hospitals are offering critical care nurses ever more attractive incentives, including sign-on bonuses, relocation bonuses, and reimbursement for continuing education and certification. In addition, many hospitals are launching critical care orientation and internship programs, such as the Web-based Essentials of Critical Care Orientation (ECCO) program, to attract and prepare experienced and newly licensed nurses to work in critical care and the Essentials of Nurse Manager Orientation program. History of Critical Care Nursing Although there have always been very ill and severely injured patients, the concept of critical care is relatively modern. As advances have been made in medicine and technology, patient care has become more complex. To provide appropriate care, nurses needed specialized knowledge and skills, and the care delivery mechanisms needed to evolve to support the patients' needs for continuous monitoring and treatment. The first intensive care units emerged in the 1950s to provide care to very ill patients who needed one-to-one care from a nurse. From this environment the specialty of critical care nursing emerged. Future of Critical Care Nursing Rapid advances in healthcare and technology have contributed to keeping more people out of the hospital. However, patients in critical care units are more ill than ever. Many patients who would have been cared for in a critical care unit five years ago are now being cared for on medical floors or at home. Many patients in today's critical care units would not have survived in the past. It has been proposed that hospitals of the future will be large critical care units, and other types of care will be provided in alternative locations or at home. Critical care nurses will need to keep pace with the latest information and develop skills to manage new treatment methods and technologies. As issues relating to patient care become increasingly complex and new technologies and treatments are introduced, critical care nurses will need to become ever more knowledgeable.
A. General information

1. Critical care nursing deals with human responses to life-threatening problems and includes the critically ill patient, the critical care nurse, and the critical care environment. 2. It is the field of nursing with a focus on the care of the critically ill or unstable patients. 3. Care is provided to patients of all ages with alterations in physical or emotional health. 4. The critical care nurse coordinates interventions aimed at resolving life-threatening problems. 5. Critical care nurses can be found working in a wide variety of environments and specialties, such as emergency departments and the intensive care units. B. Critically Ill Patient 1. Critically ill patients are defined as those patients who are at high risk for actual or potential life-threatening health problems. 2. The critically ill patient is at high risk for developing life-threatening problems and requires constant, intensive, multidisciplinary assessment and intervention to restore stability, prevent complications, and achieve and maintain optimal responses 3. The more critically ill the patient is, the more likely he or she is to be highly vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care. C. History of Critical Care Nursing 1. Critical care began as a component of recovery rooms before expanding into coronary care units in the 1960s 2. The American Association of Critical-Care Nurses (AACN) was organized in 1969 3. A competency-based examination was developed in 1975 to provide certification in critical care nursing; certification is valid for 3 years; available for adult, neonatal, and pediatric certification 4.The AACN developed Standards for Nursing Care of the Critically Ill in 1981 to explain the role of the critical care nurse in ensuring quality care for critically ill patients and their families C. Critical care environment 1. Units may be specially designated as medical, surgical, coronary, pediatric, neonatal, recovery, or postanesthesia or may encompass other areas in some institutions 2. Adequate resources (emergency equipment, supplies, and support systems) are necessary for safe care 3. A management and administrative structure is required to ensure effective care through all phases of the patients hospital stay, from emergency department to discharge 4. Legal, regulatory, social, economic, and political trends must be monitored to promote the early recognition of problems and a timely response 5. Specialized electronic technology and techniques are used to monitor patient status

continuously; these may create safety hazards for patients, such as possible exposure to electric shock D. Roles of the critical care nurse 1. Care provider: provides comprehensiveand at times highly technicaldirect care to the patient and family in response to life-threatening health problems 2. Educator: provides patient and family with education based on their learning needs and the severity of the situation and allows the patient to assume more responsibility for meeting health care needs as health condition stabilizes or improves 3. Manager: coordinates the care provided by various health care workers to achieve the specific goal of providing optimal nursing care to critically ill patients 4. Advocate: protects the patients rights E. Functions of the critical care nurse 1. Assesses and implements treatment for patient responses to life-threatening health problems 2. Provides direct measures to resuscitate, if necessary 3. Uses independent, dependent, and interdependent interventions to restore stability, prevent complications, and achieve and maintain optimal patient responses 4. Provides health education to the patient and family 5. Supervises patient care and ancillary personnel 6. Supports patient adaptation, restores health, and preserves the patients rights, including the right to refuse treatment F. Legal issues affecting the provision of critical care nursing 1. Negligence 2. MALPRACTICE 3. INFORMED CONSENT 4. Implied consent 5. Advanced directives, including DURABLE POWER OF ATTORNEY and living wills G. Qualifications of a Critical Care Nurse 1. To become a registered nurse (RN), an individual must earn a diploma in nursing, an associates degree in nursing (ADN) or a bachelors degree in nursing (BSN) and pass a national licensing exam. 2. Requirements vary and are dictated by each states Board of Nursing. Many nursing schoolsoffer students exposure to critical care, but most of a critical care nurses specialty education and orientation is provided by the employer. Advanced practice nurses must earn a degree at the masters or doctoral level. 3. Although certification is not mandatory for practice in a specialty like critical care, many nurses choose to become certified. Some employers prefer to hire certified nurses because

they have demonstrated acquisition of a specific high level of knowledge in their specialty through successful completion of a rigorous, psychometrically valid, job-related examination. 4. Certification examinations test critical care knowledge primarily at the application/analysis level, which indicates strong critical thinking abilities. 5. A required number of clinical hours in the specialty are also an examination prerequisite. Certified nurses validate their continuing knowledge of current practices in critical care nursingthrough a renewal process every three years, which includes meeting extensive continuing education and clinical experience requirements. 6. Certified critical care nurses (CCRN) must have been in critical care practice for a minimum of two years to be eligible for the examination.