Critical care nurses provide highly skilled, expert care for the most severely ill or injured patients. This introduction - part one of a six-part series – provides an overview of their role
Abstract
In this first article of a six-part series on critical care nursing, we introduce the role and what it involves, as well as looking at how critical care nurses can support the whole patient, from a physical and psychosocial perspective. The importance of rehabilitation, assessment of risk of ongoing morbidity and delirium are also discussed. Part 2 describes the assessment of the critically ill patient.
Citation: Credland N et al (2021) Essential critical care skills 1: what is critical care nursing? Nursing Times [online]; 117: 11, 18-21.
Authors: Nicki Credland is reader in critical care, University of Hull; Louise Stayt is senior lecturer, Oxford Brookes University; Catherine Plowright is professional adviser, British Association of Critical Care Nurses; David Waters is associate professor, Birmingham City University.
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Introduction
Critical care nurses provide expert, specialist care to the most severely ill or injured patients in intensive care units and the wider hospital. They are highly trained and skilled safety-critical professionals working as part of a multidisciplinary team. Critical care is classified using four levels of patient acuity, as outlined in Table1. Updated guidelines for the provision of intensive care services (Faculty of Intensive Care Medicine, 2019) recommend that level-3 patients should have a minimum registered nurse–patient ratio of 1:1 and level-2 patients must have a minimum nurse–patient ratio of 1:2.
To deliver highly skilled care, critical care nurses undertake postgraduate study and ongoing training. The Step Competency Framework underpins critical care nurse education; it recognises that, to be able to deliver high-quality care to patients, staff need the knowledge and skills so they can work at the highest level, with standardisation across all critical care units. Step 1 for adult critical care begins when a nurse with no previous experience of the specialty starts working in intensive care medicine. Steps 2 and 3 should be incorporated into academic intensive care programmes.
Critical care nurses also lead many outreach teams that identify, monitor and initiate timely treatment to prevent clinical deterioration, and support ward nurses (Department of Health, 2000). They offer advanced system assessment and rescue before irretrievable deterioration and cardiac arrest takes place.
This article is the first in a six-part series on essential critical care skills, which aims to explore essential critical care nursing competencies.
Managing organ dysfunction
Admission to a critical care unit is usually because of organ dysfunction or organ failure. Respiratory failure alone leads to around 100,000 annual admissions to critical care in the UK (FICM, 2019). The goal is to correct or provide support to these dysfunctional organs. Technological and medical advances over the past few decades have meant significant growth in treatments and interventions, and more-effective management of patients who need organ support.
The interventions most commonly used include mechanical ventilators, infusion devices and renal replacement therapy. Table2 outlines the interventions used for different physiological systems.
Patient monitoring and documentation
It is crucial to gather accurate data on physiological parameters – such as oxygen saturation (SpO2), heart rate and fluid balance – at the bedside of the patient who is critically ill. Typically, each patient will have their own monitor that will display a range of clinical factors (Box 1) and provide real-time feedback to help evaluate critical care interventions, and detect any deterioration or emergency situations promptly.
Box 1. Clinical factors recorded by bedside monitors
- Heart rhythm
- Heart rate
- Oxygen saturation
- Respiratory rate
- Exhaled carbon dioxide concentration/partial pressure
- Non-invasive blood pressure
- Arterial blood pressure
- Central venous pressure
- Temperature
Critical care nurses need technical skill and knowledge to effectively use and interpret bedside monitors. A further common technical resource is the clinical information system (CIS), which can record and process large amounts of data, such as:
- Patient physiological observations;
- Care or interventions delivered;
- Medication plans.
The FICM (2019) highlights how a CIS can not only improve efficiency, but also reduce errors and improve compliance with standards or guidelines.
Psychosocial care
Holistic patient-centred care – as outlined by Jasemi et al (2017) – is vital in critical care, with effective psychosocial care, and cultural, spiritual and family care being of particular significance. Immediately on admission to a critical care setting, patients are subjected to an onslaught of physical and psychosocial stressors including:
- Physical pain;
- An unfamiliar environment; equipment and treatments;
- Sensory disturbances;
- Isolation from family;
- Loss of autonomy;
- Impaired communication;
- Fear for their life (Kiekkas et al, 2010).
It can lead to severe emotional distress and the development of delirium, anxiety, depression and post-traumatic stress disorder (PTSD) (Hatch et al, 2018) – all of which may persist long after the patient’s physical recovery and discharge from hospital (Ewens et al, 2018).
Psychosocial care is often considered the touchstone to person-centred care and, in this setting, refers to supportive interventions that may mitigate the stressors associated with critical illness. Evidence-based measures that may all help include:
- Providing information and explanations;
- Regularly orientating the patient to date, time and place;
- Reassurance;
- Empathetic touch;
- Early mobilisation;
- Family visits;
- Maintaining clear night and day routines;
- Minimising noise (Bani Younis et al, 2021; Alaparthi et al, 2020; Parsons and Walters, 2019).
Delirium is of particular concern in patients who are critically ill, and has an incidence range of 45-87% (Cavallazzi et al, 2012). It is characterised by the acute onset of cerebral dysfunction, with a change or fluctuation in baseline mental status, inattention, disorganised thinking or an altered level of consciousness (NICE, 2019). Delirium is associated with significant increases in mortality, morbidity and hospital stay, as well as having long-term ramifications such as cognitive impairment, PTSD, anxiety and depression (Cavallazzi et al, 2012) so the prevention, early recognition and effective management of it is of paramount importance. The ABCDEF bundle of care may help:
- Assessment, prevention and management of pain;
- Awakening the patient and doing a spontaneous Breathing trial;
- Choice of sedation and analgesia;
- Assessment, prevention and management of Delirium;
- Early mobilisation;
- Family engagement (Marra et al, 2017) .
Cultural and spiritual care
A patient’s cultural and spiritual background influences many aspects of nursing in critical care, such as patient and family roles, communication, nutrition, values and beliefs towards health, care and treatments, and end-of-life care. Careful assessment of the patients’ health beliefs, communication needs, social networks and family dynamics, dietary requirements, religious practices and values, is essential to plan and deliver culturally sensitive and spiritual care that contributes to the quality of life, care and satisfaction of patients as well as their families (Willemse et al, 2020).
Family care
Family members of patients who are critically ill can play an important part – often acting as surrogate decision makers – and be essential in providing emotional and social support. However, relatives may experience extreme stress, fear and anxiety, both during and after the patient’s admission. Relatives are also vulnerable to ongoing psychological illnesses such as PTSD, anxiety and depression (Johnson et al, 2019). Nurses need to develop a collaborative relationship with them to effectively identify and address their immediate needs, as well as prepare them to cope with their loved one’s discharge and ongoing rehabilitation. Families need honest and timely information, assurance, proximity, comfort and support (Scott et al, 2019).
Rehabilitation
Critical illness can cause significant long-term physical and non-physical problems for patients, and rehabilitation is important to improve recovery. National guidelines, such as those by the FICM (2019) and the National Institute for Health and Care Excellence (2017), have supported this, with the aim of improving these patients’ physical, psychological and cognitive outcomes.
Patients should be assessed at the following key stages:
- Within four days of admission to a critical care unit, or earlier if being discharged;
- Just before discharge to ward-based care;
- When receiving ward-based care;
- Before discharge to their home or community care;
- Two to three months after discharge from the critical care unit.
Rehabilitation should be patient centred, involve the whole multidisciplinary team and occur throughout the patient pathway, with plans updated as the patient’s condition changes (FICM, 2019). Physiotherapists, occupational therapists, dieticians, speech and language therapists, critical care nurses and doctors, as well as patients and their families, all have a role.
Short clinical assessments should be done with all patients in critical care to identify their risk of physical and non- physical morbidity. A short clinical assessment is applicable for patients who are expected to recover quickly, despite requiring initial level-3 care, and should assess a range of factors (Box 2). If the patient is deemed at risk, a comprehensive clinical assessment should be undertaken; this will also assess physical and non-physical risk (Box 3).
Box 2. Short clinical assessment
The following may indicate that the patient is at risk of physical/non-physical morbidity and needs further assessment:
Physical
- Unable to get out of bed independently
- Anticipated long duration of critical care stay
- Obvious significant physical or neurological injury
- Lack of cognitive functioning to continue exercise independently
- Unable to self-ventilate on 35% of oxygen or less
- Presence of pre-morbid respiratory or mobility problems
- Unable to mobilise independently over short distances
Non-physical
- Recurrent nightmares, particularly if the patient reports trying to stay awake to avoid them
- Intrusive memories of traumatic events that occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks)
- New or recurrent anxiety or panic attacks
- Expressing a wish not to talk about their illness or changing the subject quickly
Box 3. Comprehensive clinical assessment
This assessment should be undertaken for all patients identified as being at risk of physical or non-physical morbidity.
Physical issues
- Physical
- Fatigue
- Breathlessness
- Tracheostomy
- Ventilated
- Artificial airway
- Swallowing issues
- Poor nutritional state
- Activities of daily living
- Minor assistance needed
- Major assistance needed
- Full assistance needed
- Sensory
- Visual changes
- Hearing changes
- Altered sensations
- Sedated/pain
- Communication
- Difficulties in speech
- Changes in voice quality
- Difficulty writing
- Miscellaneous
- Hair loss
- Poor wound healing
Non-physical issues
- Anxiety or depression (new or recurrent symptoms)
- Palpitations, irritability or sweating
- Nightmares
- Hallucinations, delusions
- Flashbacks, withdrawal, traumatic memories of critical care
- Cognitive
- Loss of memory
- Attention deficit
- Sequencing problems
- Lack of organisational skills
- Confusion
- Disinhibition
- Miscellaneous
- Low self-esteem
- Low self-image
- Relationship difficulties
- Difficulty sleeping
During the assessment of these patients, a range of tools may be used including the following:
- Hospital Anxiety and Depression Score (Zigmond and Snaith, 1983);
- Barthel Activities of Daily Living Index (Wade and Colin, 1988);
- Chelsea Critical Care Physical Assessment Tool (Corner et al, 2013).
Many critical care units provide follow-up services for patients after discharge, giving them access to a range of health professionals, including critical care nurses, to assess physical and non-physical recovery (NICE, 2017). If these are not available, patients can be directed to ICU Steps (www.icusteps.org), which can help to support patients and families affected by critical illness.
Conclusion
This article aims to provide an overview of critical care and the critical care nurse role. The following articles in this series will explore in more detail key issues relating to the management of patients who are critically ill.
Key points
- Critical care nursing is highly skilled, and requires postgraduate study and training
- Critical care nurses provide outreach to support ward nurses who are caring for patients at risk of deterioration
- Care of patients on critical care units often involves organ system support and close monitoring is needed
- A holistic view of the patient – which takes into account physical and psychosocial matters – is vital, as is supporting families
Also in this series
- Essential critical care skills 2: assessing the patient
- Essential critical care skills 3: arterial line care
- Essential critical care skills 4: airway assessment and management
- Essential critical care skills 5: management of fluid balance
- Essential critical care skills 6: arterial blood gas analysis
References
Alaparthi GK et al (2020) Effectiveness, safety, and barriers to early mobilization in the intensive care unit. Critical Care Research and Practice; 2020: 7840743.
Bani Younis M et al (2021) Effect of noise and light levels on sleep of intensive care unit patients. Nursing in Critical Care; 26: 2, 73–78.
Cavallazzi R et al (2012) Delirium in the ICU: an overview. Annals of Intensive Care; 2: 49.
Corner EJ et al (2013) The Chelsea Critical Care Physical Assessment Tool (CPAx): validation of an innovative new tool to measure physical morbidity in the general adult critical care population; an observational proof-of-concept pilot study. Physiotherapy; 99: 1, 33-41.
Department of Health (2000) Comprehensive Critical Care: A Review of Adult Critical Care Services. London: DH.
Ewens BA et al (2018) Surviving ICU: stories of recovery. Journal of Advanced Nursing; 74: 7, 1554–1563.
Faculty of Intensive Care Medicine (2019) Guidelines for the Provision of Intensive Care Services. London: FCIM.
Hatch R et al (2018) Anxiety, depression and post traumatic stress disorder after critical illness: a UK-wide prospective cohort study. Critical Care; 22: 310.
Jasemi M et al (2017) A concept analysis of holistic care by hybrid model. Indian Journal of Palliative Care; 23: 1, 71-80.
Johnson CC et al (2019) Psychological sequelae in family caregivers of critically iII intensive care unit patients. a systematic review. Annals of the American Thoracic Society; 16: 7, 894-909.
Kiekkas P et al (2010) Psychological distress and delusional memories after critical care: a literature review. International Nursing Review; 57: 3, 288–296.
Marra A et al (2017) The ABCDEF bundle in critical care. Critical Care Clinics; 33: 2, 225-243.
National Institute for Health and Care Excellence (2019) Delirium: Prevention, Diagnosis and Management. London: NICE.
National Institute for Health and Care Excellence (2017) Rehabilitation after Critical Illness in Adults. London: NICE..
Parsons LC, Walters MA (2019) Management strategies in the intensive care unit to improve psychosocial outcomes. Critical Care Nursing Clinics of North America; 31: 4, 537-545.
Scott P et al (2019) Families of patients in ICU: a scoping review of their needs and satisfaction with care. Nursing Open; 6: 3, 698-712.
Wade DT, Collin C (1988) The Barthel ADL Index: a standard measure of physical disability? International Disability Studies; 10: 2, 64-67.
Willemse S et al (2020) Spiritual care in the intensive care unit: an integrative literature research. Journal of Critical Care; 57: 55-78.
Zigmond AS, Snaith RP (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica; 67: 6, 361–370.
FAQs
What is a critical care nurse? ›
What Does A Critical Care Nurse Do? Critical care nursing involves working with doctors and specialists to assess, treat, and monitor critically ill patients while also providing their basic care.
What is defined as critical care? ›Critical care is medical care for people who have life-threatening injuries and illnesses. It usually takes place in an intensive care unit (ICU). A team of specially-trained health care providers gives you 24-hour care. This includes using machines to constantly monitor your vital signs.
What is level 1 critical care? ›Level 1 Suitable for patients at risk of their condition deteriorating, those recently relocated from higher levels of care, and those whose needs can be met on an acute ward with additional advice and support from the critical care team.
What do you learn in critical care nursing? ›Critical care nurses need a thorough understanding of medicine, biology, chemistry, anatomy, medical technology, and patient care. Critical care nurses rely on their detailed technical knowledge to respond to crisis situations and unforeseen complications.
Why do you want to be a critical care nurse? ›Being a critical care nurse offers me the opportunity to make a difference in a vulnerable moment of someone else's life. I can help the patient feel better and recover to a higher state of health. With deep respect for the human being we can go beyond the probable and make others see what is possible only through us.
What makes a good critical care nurse? ›“A PICU nurse needs to be strong to get through tough situations but have a caring heart.” That balance of emotional fortitude and empathy is a hard ICU nursing skill to come by, but the best ICU nurses strive to find that kind of professional and personal harmony.
What are examples of critical care? ›Examples of patients who need critical care includes those who undergo very invasive surgery or who have poor outcomes after surgery, those who are severely injured in an accident, people with serious infections, or people who have trouble breathing on their own and require a ventilator to breathe for them.
What is the difference between ICU and critical care? ›There's no difference between intensive care and critical care units. They both specialize in monitoring and treating patients who need 24-hour care. Hospitals with ICUs may or may not have a separate cardiac care unit.
How do you take care of a critical patient? ›- early recognition of sepsis.
- appropriate balanced resuscitation.
- rapid identification of the source of infection.
- timely source control.
- early and effective antimicrobial therapy.
- haemodynamic support, consideration of adjunctive therapies and high-quality supportive care.
A Level II Trauma Center is able to initiate definitive care for all injured patients. Elements of Level II Trauma Centers Include: 24-hour immediate coverage by general surgeons, as well as coverage by the specialties of orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology and critical care.
Which of the following describes a level 1 critically ill patient? ›
Level 1—Ward based care where the patient does not require organ support (for example, they may need an IV, or oxygen by face mask)
How many levels of care are there? ›Health care is described as different levels of care: primary, secondary, tertiary, and quaternary.
Why critical care is important? ›Emergency and critical care focuses on resuscitating unstable patients and allowing time for recovery or the effect of specific therapies to improve outcomes and prevent death. We use emergency and critical care in the broad sense of care provided to all critically ill patients.
What is unique about critical care nursing? ›Intensive Care or Critical care nursing is a nursing specialization that caters patients facing life-threatening. Patients admitted in the ICU requires close monitoring, round the clock medications and high-quality nursing care to be delivered 24 hours a day to improve health.
Is Critical Care Nursing hard? ›The life of a critical care nurse, or intensive care unit (ICU) nurse, can be incredibly challenging. ICU nursing jobs require both emotional and physical stamina, and the ability to juggle different variables as they relate to the condition of critically ill patients.
How do I prepare for a critical care nursing interview? ›- Talk about a time you worked in a fast-paced setting. ...
- Describe your experience with a very ill patient who required a lot of your time. ...
- Talk about a time when you felt overwhelmed with your work or patient load. ...
- Give an example of an important goal you set for yourself.
Having empathy to interact with the patient and their family and helping them to cope with problems is very important in a nursing position. Having the ability to understand and share those feelings with the patient and their loved ones is an essential strength for a nurse.
Are ICU nurses smart? ›Although ICU and ER nurses alike are superheroes. They are incredibly smart, quick-thinking, and save lives every single day.
What is an example of critical thinking in nursing? ›Williams gives an example of this by saying, "a critically thinking nurse will hold a patient's blood pressure medicines and contact the physician when he or she notes that the patient's blood pressure is below an acceptable level." In this case, lack of critical thinking skills could put the patient in jeopardy by ...
What type of nursing is the hardest? ›- Intensive Care Unit nurses (ICU) ICU is an extremely high-pressure environment and these nurses work with patients who have significant injuries and disease with added morbidity risks. ...
- Emergency Department nurses. ...
- Neonatal ICU. ...
- OR nursing. ...
- Oncology Nursing. ...
- Psychiatric Nursing.
How do you identify critically ill patients? ›
Assessment of the critically ill patient should be undertaken by an appropriately trained clinician and follow a structured ABCDE (airway, breathing, circulation, disability and exposure) format.
What is a critical care unit in a hospital? ›Intensive Care Units. Intensive care units (ICUs) are areas of the hospital where seriously ill patients receive specialized care such as intensive monitoring and advanced life support. These units are also called critical care units, intensive therapy units, or intensive treatment units.
What are some of the common problems of critical care patients? ›Common examples include unexpected bleeding, low blood pressure, problems with heart rhythm, or difficulty with breathing. Patients whose admission to ICU was planned in advance typically require a short period of monitoring in ICU before being transferred out.
What are the types of ICU? ›- Medical intensive care unit. ...
- Surgical intensive care unit. ...
- Pediatric intensive care unit. ...
- Neonatal intensive care unit.
...
Some common reasons include:
- a serious accident – such as a road accident, a severe head injury, a serious fall or severe burns.
- a serious short-term condition – such as a heart attack or stroke.
- a serious infection – such as sepsis or severe pneumonia.
Critical care units (CCUs) are specialist hospital wards that treat patients who are seriously ill and need constant monitoring. These patients might, for example, have problems with one or more vital organ or be unable to breathe without support.
What equipment is used in ICU? ›ICU equipment may be used to monitor the patient and/or help treat their illness. NET brand ICU Equipment have set new standards in intensive care. The ICU equipment we offer include Defibrillator, Patient Monitor, Ventilator, CPAP & BPAP systems etc.
What is ICU full form? ›ICU (Intensive Care Unit) is a special room for critical patients who needs intensive treatment and continuous observation.
What is meaning of critically ill patient? ›Critical illness is defined as any life-threatening condition that requires pharmacological and/or mechanical support of vital organ functions without which death would be imminent (Nates et al., 2016). From: Handbook of Clinical Neurology, 2021.
Is critical care the same as ICU? ›Critical care also is called intensive care. Critical care treatment takes place in an intensive care unit (ICU) in a hospital. Patients may have a serious illness or injury. In the ICU, patients get round-the-clock care by a specially trained team.
Is ER nursing considered critical care? ›
Critical care is just what it sounds like—critical. So nurses in these situations need to be ready for whatever comes through the doors. If you're up for the task, there are many roles that you can pursue as a critical care nurse, including working in the emergency room (ER) or intensive care unit (ICU).
Can critical care nurses intubate? ›Nurses may be trained to intubate in acute critical care settings. They care for the most serious patients, and there is a high risk they may need to intervene quickly. The RNs in critical care settings can complete special training which may qualify them to intubate in certain situations.
What is a critical care unit in a hospital? ›Intensive Care Units. Intensive care units (ICUs) are areas of the hospital where seriously ill patients receive specialized care such as intensive monitoring and advanced life support. These units are also called critical care units, intensive therapy units, or intensive treatment units.
How do I prepare for critical care? ›Mix one part of the powder with 2 parts of warm water. Please ensure Critical Care is fed at room temperature or warmer. Critical Care should ideally be prepared fresh for each feed. If necessary, the powder when premixed with water can be refrigerated up to 24 hours.
How do you identify critically ill patients? ›Assessment of the critically ill patient should be undertaken by an appropriately trained clinician and follow a structured ABCDE (airway, breathing, circulation, disability and exposure) format.
What is the difference between critical care and emergency medicine? ›The emergency department deals with immediately life-threatening injuries, medical conditions and situations that require sudden, emergent or immediate assistance. Critical Care medicine defines the ongoing care of a patient who is dangerously ill or requiring advanced care.
Who makes more money ICU nurse or ER nurse? ›The average salary of an ICU nurse nationwide according to ZipRecruiter is $95,000 per year. In contrast, the nationwide average annual salary for an ER nurse is $89,278 per year.
Are ICU nurses smart? ›Although ICU and ER nurses alike are superheroes. They are incredibly smart, quick-thinking, and save lives every single day.
Who makes more ER nurse or ICU nurse? ›This could be due to the fact that, while both work to save lives, Emergency Rooms Units tend to require a greater sense of urgency than Intensive Care Units. ER nurses can stand to make slightly over $100,000 a year, on average. This is about $5,000 more than the average yearly salary for ICU nurses.
Can nurses have tattoos? ›The resounding answer is yes. Nurses can have tattoos. However, some medical facilities may require you to cover tattoos when interacting with patients. Generally, most hospitals don't allow visible tattoos when the tats are obscene, derogatory, or offensive.
Why is ICU nursing so hard? ›
The life of a critical care nurse, or intensive care unit (ICU) nurse, can be incredibly challenging. ICU nursing jobs require both emotional and physical stamina, and the ability to juggle different variables as they relate to the condition of critically ill patients.
Do ICU nurses have special training? ›To work as an ICU nurse, you must first become an RN by graduating with an ADN or BSN from an accredited nursing program. You'll then get your licensure by passing the NCLEX-RN exam. Next, you'll need to gain at least two years of nursing experience in a position that specializes in intensive care nursing.
What are the common problems of critical care patients? ›Common examples include unexpected bleeding, low blood pressure, problems with heart rhythm, or difficulty with breathing. Patients whose admission to ICU was planned in advance typically require a short period of monitoring in ICU before being transferred out.
Who is a critically ill patient? ›Summary. Key features of the critically ill patient are severe respiratory, cardiovascular or neurological derangement, often in combination, reflected in abnormal physiological observations.
What type of patient are kept in ICU? ›ICU cares for people who have life-threatening conditions, such as a serious injury or illness, where they receive around-the-clock monitoring and life support. It differs from other hospital wards in that: ICU provides 24-hour care from a highly-trained team of specialists.