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The standardization of critical care nursing education and training: strategies for advancing clinical practice in Ontario's adult ICUs.


Concerns about the delivery of critical care services are not a new development. A general understanding of ICU care as expensive and, at times, difficult to access is well-entrenched in the vernacular of most acute care institutions (Bell & Robinson, 2005). However, when as few as 80 critically ill patients overwhelmed available ICU resources during Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, the fault lines in the existing models of critical care delivery were illuminated.

Recognizing the potential implications of unmet demands for adult critical care services and concerned with demographics and also recent global events leading to sudden surges in the demand for ICU care, a critical care transformation strategy was launched by the Ontario Ministry of Health and Long-Term Care (MOHLTC) as part of the broader Access to Services and Wait Times Strategy. A critical care steering committee was charged with reviewing the current situation and making recommendations for greater efficiencies and quality improvements in the delivery of adult critical care services in Ontario (Bell & Robinson, 2005). While the number of critical care beds was an obvious item for consideration, the need to improve access, quality and resource management was also recognized as a priority.

Nurse training standards task group

A comprehensive plan to address human resource issues (nursing) in critical care led to the establishment of a Critical Care Nurse Training Standards Task Group. The mandate of this group was to identify and articulate critical care core competencies for nurses working in adult ICUs to reflect achievable expectations, to which actual nursing performance can be compared. A secondary objective was to propose methods of determining that training programs and graduates of those programs meet the identified standards.

Of note, other jurisdictions have also recognized the importance of investing in critical care nursing resource management. In Britain, for example, efforts to develop a planned approach to ICU nursing workforce development and the delivery of critical care nursing services were initiated based on recommendations in a document called Comprehensive Critical Care (Department of Health, 2000). A published report followed a year later, in which a nursing expert group responded with a series of considerations necessary to maximize the nursing contribution to a more effective critical care delivery model, including access to competency-based education and training to ensure that nurses are appropriately skilled to meet the needs of patients and families in their care (Department of Health, 2001). The World Federation of Critical Care Nurses (WFCCN) has recently employed an evidence-informed, consultative process to develop a position statement and guidelines for appropriate critical care nursing education. Key recommendations include the preparation of critical care nurses at the post-graduate or post-registration level and the articulation of common standards and outcomes that critical care nursing course curricula must meet when preparing graduates (Williams, Schmollgruber, & Alberto, 2006).

In preparation for the development of a standardized core competency document for Ontario ICU nurses, we accessed a number of resources including a snapshot survey on the current practices of Ontario ICUs as they pertain to nurse training and competency assessment, communications with professional associations and a review of the literature. This next section will provide an overview of findings that we found useful to our discussions and that subsequently informed our recommendations for a standardized competency document.

Survey of Ontario ICUs

In November of 2005, a survey was e-mailed to Ontario hospitals known to have critical care units (n = 84) with a goal to capture information about 1) existing standards of practice, and 2) the training programs currently used to prepare nurses new to critical care for practice in that setting. We were interested in knowing whether written standards of practice were available to nursing staff and, if so, which national or provincial standards they most reflected. We asked about competency statements and the frequency of evaluation of the standards document and, also, evaluation of nurses, including whether documentation was provided, both from the nurse manager and as a peer review component of the process.

With respect to training, we inquired as to whether nurses were educated by an external higher-education provider, resulting in the awarding of a critical care certificate on successful completion of the program, or through an in-house program. The duration of the course, expressed as the total number of didactic and clinical weeks, was also requested.

Results. Results based on responses from 68 Ontario ICUs, mostly medical-surgical (Figure One), showed that the majority of units (85%) do have written standards of practice (Figure Two). Most ICUs (93%) referred to the published standards of the Canadian Association of Critical Care Nurses (CACCN) and also incorporated those of the College of Nurses of Ontario (CNO) (86%). In-house programs appear to be most widely used for training nurses new to critical care (89%), followed next in frequency by preceptorship (64%) and, lastly, college certificate programs (33%). The frequency with which unit standards were updated varied, with most responses (55%) falling within two categories encompassing the one- to five-year range (43% missing data). Many, but not all of the ICUs, reported inclusion of competency statements and a documented nurse evaluation component (70%). Nurses were evaluated every one to two years and, in most cases, there was not a required peer review component.

Professional associations

In the interest of remaining within the scope of this paper, the following discussion will be limited to an overview of the two key documents that we relied on as primary resources, those being the CACCN Standards for Critical Care Nursing Practice (CACCN, 2004) and the CNO Competency Review Tool (CRT) for Nurses in Direct Practice (CNO, 2003). There are other excellent resources available through organizations such as the American Association of Critical Care Nurses (AACN), the WFCCN, and the Australian College of Critical Care Nurses (ACCCN). All are worthy of a full review and are available on-line in full-text format or can be purchased for a nominal fee.

CACCN Standards for Critical Care Nursing Practice According to the CACCN, critical care nursing practice is a research-based, holistic patient- and family-centred model of care that is committed to optimal outcomes, best achieved through partnerships and the appropriate use of resources (CACCN, 2004). The CACCN published standards provide a means by which professional accountability and adherence to these goals can be demonstrated. They are classified according to two broad categories: 1) the structure of the critical care unit including the physical layout, but also processes for unit governance and opportunities for professional development (see Table One), and 2) the critical care nursing process (see Table Two).

As the CACCN document was referenced by most Ontario ICUs represented in our survey findings, these standards were distributed to members of the Critical Care Nurse Training Standards Task Group for consideration as a proposed working template. We were aware also that the competency basis for the Canadian Nurses' Association (CNA) critical care certification exam was congruent with the competencies outlined in the CACCN document. On review, we concluded that the document is sound and agreed it would form one of the pillars of our recommendations.

CNO Competency Review Tool (CRT) for Nurses in Direct Practice

CNO Mission

"To protect the public's right to quality nursing services by providing leadership to the nursing profession in self-regulation" (College of Nurses of Ontario, 2005)

The Regulated Health Professionals Act (RHPA) requires all regulatory colleges in Ontario to have an established quality assurance (QA) program for ensuring that its members maintain ongoing competence. The CNO QA program supports nurses to maintain competency through lifelong learning and continuous improvement activities. The CRT for Nurses in Direct Practice is available to assist nurses in assessing their knowledge of the competencies essential for safe, effective, and ethical nursing care (CNO, 2003). Importantly, the identified competencies in the CRT are consistent with those on which the CNO QA program is based. In the event that individual nurses are randomly selected for the practice review component of the QA program, they will be better prepared as a result of their knowledge of the CRT.

For the above reasons, and because the CNO QA program has been in place since the late 1990s and is, therefore, familiar to Ontario nurses province-wide, the CRT was a logical choice for a generalist document to partner with the specialized CACCN standards. Further, the CRT is organized with nursing competencies eloquently articulated in five categories. They are: 1) professional behaviour/ethics, 2) critical thinking, research and leadership, 3) client and nurse safety/illness and injury prevention, 4) relationship/caring, and 5) clinical skills. Figure Three is meant to illustrate the relevance of these categories and their presence in the day-to-day work of nurses in direct practice.

CNO Vision

"Excellence in nursing practice everywhere in Ontario" (College of Nurses of Ontario, 2005)


The CACCN and CNO documents will provide the foundation for the articulation of standards and core competencies for critical care nurses who practise in Ontario's adult ICUs. However, these documents do not explicitly outline a format for how practice standards can be implemented and otherwise integrated into the practice of critical care nurses, and then evaluated. The Ontario document will be unique in this respect. It was developed with training and evaluation options considered and in consultation with a nurse in direct practice (HB), also a member of the Ontario Nurse Training Standards Task Group. We believe that nurses involved in the provision of direct patient care are ideally positioned to ensure the applicability of such a document to nurses' work.

We would like to highlight the parallel between this initiative and the development of any document that espouses best practice standards. With the emergence of new evidence, changes in human resource strategies and in societal norms, there is a need for the content to be assessed, updated and/or retained as deemed appropriate. A scheduled review is one option, but there are circumstances in which this is not sufficient, such as when the benefits of a particular therapy are called into question or the potential for harm is identified (Shekelle, Eccles, Grimshaw, & Woolf, 2001). Upon considering the rate with which new information becomes available in the clinical setting, prudent professional practice would require that a pre-determined process is available and clearly communicated to all stakeholders.

We recognize that ICUs are complex environments and that some offer specialized therapies that are not available in all centres. For example, although high-frequency oscillation is an established therapy in the neonatal ICU setting, its use with adults is limited to patients with Acute Respiratory Distress Syndrome (ARDS) who are failing conventional ventilatory management and centres where the technology and expertise is available. Similarly, continuous renal replacement therapy (CRRT) is most appropriately available in ICUs where the volume of patients requiring the therapy is sufficient to support the ongoing competence of the nurses who initiate, monitor and otherwise administer the therapy. In advancing a framework for standardized competencies for Ontario nurses, we are not overlooking the important work that individual ICUs may undertake to ensure that the nurses they employ are assessed based on expectations that accurately reflect their day-to-day work. Where this means adding to the standardized document additional unit-specific competencies, we would support this as an appropriate application of the tool.

One of the strengths of our work is that it integrates provincial general nursing competencies with those published by the national critical care nurses' association, the CACCN. In adopting this approach, our intention was to portray critical care nursing practice within the context of a system resource. An additional strength was the task group's balance of university-based and community-based hospital nursing representatives and the varied perspectives that were represented as a result.

In this article, we have sought to share our work on the preparation and articulation of a standardized core competency document for Ontario nurses who are employed or seeking employment in adult ICUs. A process for determining appropriate training programs and that graduates of those programs meet the identified standards is still to be decided. We recognize the complexity of the task that this implies. It is an important area to consider and, like our work in preparation for the development of provincial standards, one that deserves to be examined in great depth.


The authors would like to acknowledge the following members of the Critical Care Nurse Training Standards Task Group: Heidi Barrett, Debra Carew, Lana Dunlop, Annette Ellenor, Maude Foss, Wendy Fucile, Glenda Hicks, Judy Kojlak, Brenda Lambert, Lina Rinaldi, Eleanor Rivoire, Sharon Slivar, Irene Travale and Brenda Weir.

The authors would like to acknowledge the leadership and support of the Ontario MOHLTC.


The authors would like to acknowledge the CACCN Board of Directors 2005-2006.

The authors would like to acknowledge Ged Williams of the WFCCN.


Bell, R., & Robinson, L. (2005). Final report of the Ontario critical care steering committee. Retrieved January 2006, from

Canadian Association of Critical Care Nurses. (2004). Standards for critical care nursing practice. London, ON: Author.

College of Nurses of Ontario. (2003). Competency review tool for nurses in direct practice. Retrieved December 2005, from www.cno-org

College of Nurses of Ontario. (2005). CNO's mission and vision. Retrieved January 2007, from

Department of Health. (2000). Comprehensive critical care: A review of adult critical care services. Retrieved December 2005, from

Department of Health. (2001). The nursing contribution to the provision of comprehensive critical care for adults: A strategic programme of action. Retrieved December 2005, from

Shekelle, P., Eccles, M., Grimshaw, J., & Woolf, S. (2001). When should clinical guidelines be updated? British Medical Journal, 323, 155-157.

Williams, G., Schmollgruber, S., & Alberto, L. (2006). Consensus forum: Worldwide guidelines on the critical care nursing workforce and education standards. Critical Care Clinics, 22, 393-406.

By Patricia Hynes, RN, MA, CNCC(C), Nursing Unit Administrator, ICU, Mount Sinai Hospital, Toronto, ON, Marsha Pinto, MSc, Policy Analyst, Critical Care Secretariat, Ontario Ministry of Health & Long-Term Care, Wendy Fortier, RN, BScN, Clinical Director, Critical Care, The Ottawa Hospital, Ottawa, ON, and Jocelyn Bennett, RN, MScN, CON(C), Senior Director, Acute & Chronic Medicine & Nursing, Mount Sinai Hospital, Toronto, ON
Table One. Structure of the critical care unit

Outcome Standard 2

Opportunities for critical care nurses to maintain the knowledge and
skill necessary to deliver safe and knowledgeable nursing care,
within the context of the chosen conceptual model of nursing
practice, are provided by the health care facility


2.1 The health care facility develops criteria for hiring nurses
based on the knowledge and skill requirements of the job.

2.2 The health care facility provides an orientation program in which
the orientee is supernumerary and the orientation program:

2.2.1 Is based on a learning needs assessment

2.2.2 Includes specific unit philosophy, goals, policies and
procedures, as well as an organizational chart

2.2.3 Includes physical layout and instructions in the use of
unit equipment

2.2.4 Includes a clinical and theoretical component, the content and
length of which are based on the level and type of the unit.

2.3 The health care facility provides continuing education programs
on the following:

2.3.1 New or revised policies and procedures

2.3.2 The use of new or updated equipment

2.3.3 Roles and responsibilities of the critical care nurse,
including the role of charge nurse and preceptor

2.3.4 Role of the critical care nurse on the health care team

2.3.5 Theory pertinent to the patient population and needs of
critical care nurses

2.3.6 Critical incident stress management for all staff members

2.3.7 The use and fitting of personal protective equipment for all
staff involved in patient care

2.4 The health care facility evaluates the knowledge and competencies
of the critical care nurse

2.5 The health care facility establishes/maintains a current and
accessible library of reference materials relevant to the patient

Reproduced with permission: CACCN Board of Directors 2005-2006,
January 2006

Table Two: The Critical Care Nursing Process

Outcome Standard 7

The critical care nurse practises within the scope of professional,
legal and ethical standards


7.1 The critical care nurse contributes positively to the image of

7.2 The critical care nurse contributes positively to the image of
the critical care unit (e.g. education and ongoing information
about care).

7.3 The critical care nurse ensures confidentiality of the patient/
family information and reports infractions.

7.4 The critical care nurse maintains professional competence
through education.

7.5 The critical care nurse ensures patient and family privacy
within the limits of the environment.

7.6 The critical care nurse follows guidelines for notification of
reportable incidents (e.g. communicable diseases, abuse).

7.7 The critical care nurse follows guidelines for reporting data to
appropriate agencies (e.g. coroner, police).

7.8 The critical care nurse identifies potential candidates for
tissue and organ procurement.

7.9 The critical care nurse responds to environmental, physical and
psychosocial stress factors that impact interdisciplinary team
members in the critical care setting.

7.10 The critical care nurse participates in critical care nursing
research and incorporates research findings into practice.

7.11 The critical care nurse recognizes the delineation between the
practices of critical care nursing and the practice of critical
care medicine.

7.12 The critical care nurse responds to professional, legal and
ethical issues.

Reproduced with permission: CACCN Board of Directors 2005-2006,
January 2006

Figure One. Respondent ICUs by type.
Key: MICU = Medical ICU; SICU = Surgical ICU;
MSICU = Medical-Surgical ICU

 Type of ICU
ICU N=68

Burn 0
Trauma 0
Other 10

Note: Table made from bar graph.

Figure Two: Ontario ICUs with written standards of


Yes 58
No 10

Note: Table made from bar graph.
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Title Annotation:Intensive care units
Author:Hynes, Patricia; Pinto, Marsha; Fortier, Wendy; Bennett, Jocelyn
Geographic Code:1CANA
Date:Mar 22, 2007
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