LOGIN | SIGN UP

Open main menu

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 problems1.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 need3. 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 managers1.
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:

Level 1
 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.

Level 2
 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.

Level 3
 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
1. Neonatal
 2. Pediatric
3. Adult

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:
1. Medical
2. Surgical
3. Cardio-thoracic
4. Cardiac
5. Respiratory
6. Neurosurgical
7. Trauma

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 care4.
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
1. Detects and interprets indicators that signify the varying conditions of the critically ill
with the assistance of advanced technology and knowledge;
2. Plans and initiates nursing process to its full capacity in a need driven and proactive
manner;
3. Acts promptly and judiciously to prevent or halt deterioration of patients’ condition when
conditions warrant, and
4. 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
1. Understands family needs and provide information to allay fears and anxieties and
2. 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:
1. Provides health education to patient and family to promote understanding and
acceptance of the disease process thus facilitate recovery and
2. 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:
1. Acts in the best interests of the patient and
2. 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:
1. Performance of management and leadership skills in providing safe and quality care;
2. Accountability for safe critical care nursing practice;
3. Delivery of effective health programs and services to critically-ill patients in the acute
setting;
4. Management of the critical care nursing unit or acute care setting;
5. Taking the lead and supervision of nursing support staff, and
6. 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:
1. Engage self in nursing or other health – related research with or under the supervision
of an experienced researcher;
2. Utilization of guidelines in the evaluation of research study or report
3. 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
1. 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:

1. To develop, foster and maintain a level of knowledge about the norms, values, beliefs,
patterns of illness, health and care needs of the people;
2. To analyze and evaluate critical care nurses specialty skills and their evolving roles;
3. 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
4. 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:
1. 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)

1. 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 nurseutilizes 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.