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Critical Care Nurse

What Is a Critical Care Nurse?

• Western Governors University. Critical Care Nurse Career .
• Maryville University. How to Become a Critical Care Nurse .
• CareRev. The Vital Role of Critical Care Nursing .
• Lippincott NursingCenter. Critical Care Nursing . 

What Does a Critical Care Nurse Do?

Critical Care Nurses work in high-stress environments where patients require constant attention and complex care. They must be able to make quick decisions, handle emergencies calmly, and provide compassionate care to critically ill patients and their families.

Key Responsibilities

• Perform comprehensive patient assessments, including physical examinations and evaluation of vital signs
• Monitor and interpret complex physiological data from various medical devices and equipment
• Administer medications, including intravenous drugs, and manage drug therapies
• Operate and troubleshoot life support equipment such as ventilators, cardiac monitors, and dialysis machines
• Respond quickly to changes in patient condition and initiate appropriate interventions
• Assist with or perform invasive procedures like intubation, central line placement, and arterial line insertion
• Provide advanced cardiac life support (ACLS) during emergencies and participate in code blue situations
• Manage pain and sedation levels for critically ill patients
• Assess and manage wounds, including complex dressings and wound vacs
• Implement infection control measures to prevent hospital-acquired infections
• Collaborate with physicians and multidisciplinary teams to develop and adjust patient care plans
• Coordinate patient care across various hospital departments and specialties
• Provide emotional support and education to patients and their families
• Advocate for patients’ needs and preferences within the healthcare team
• Document patient care, including assessments, interventions, and responses to treatment

How to Become a Critical Care Nurse

Becoming a Critical Care Nurse requires dedication, advanced training, and a strong commitment to patient care. The journey involves earning a nursing degree, gaining experience, and obtaining specialized certifications. The following steps outline the path to becoming a Critical Care Nurse.

1. Earn a Bachelor of Science in Nursing (BSN)

Begin your journey to becoming a critical care nurse by obtaining a Bachelor of Science in Nursing (BSN) degree from an accredited nursing program. This four-year degree provides a comprehensive education in nursing theory, practice, and clinical skills essential for critical care. While an Associate Degree in Nursing (ADN) can lead to RN licensure, a BSN is increasingly preferred or required by employers in critical care settings due to the complex nature of the work.

2. Obtain RN Licensure

3. gain general nursing experience, 4. acquire specialized certifications, 5. pursue critical care nursing education, 6. gain experience in critical care, 7. obtain critical care nursing certification.

After gaining experience, pursue professional certification in critical care nursing. The American Association of Critical-Care Nurses (AACN) offers the CCRN certification, which validates your expertise in critical care nursing. This certification can enhance your career prospects and demonstrate your commitment to excellence in the field.

8. Continue Professional Development

Commit to lifelong learning and stay updated on the latest advancements in critical care nursing. Attend conferences, participate in research, and pursue advanced degrees such as a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) to further your career and potentially move into leadership roles in critical care.

Benefits of Becoming a CCN

Opportunity for specialized skills and knowledge, lower nurse-to-patient ratios, career advancement and specialization opportunities, collaborative and dynamic work environment, critical care nurse salary.

Critical Care Nurses in the United States earn competitive salaries, with an average annual income of approximately $94,610, though estimates vary slightly between sources. The typical salary range falls between $74,000 and $101,500, with top earners potentially making up to $119,500 annually. Factors influencing salary include location, experience, education, and specialized certifications.

Critical Care Nurses generally earn more than general RNs but less than advanced practice nurses. The field offers opportunities for salary growth through career advancement, such as moving into administrative roles or pursuing advanced degrees.

Job Outlook

The job outlook for critical care nurses is very positive. According to the U.S. Bureau of Labor Statistics, employment of registered nurses, including those in critical care, is projected to grow 6% from 2022 to 2032. This growth is driven by several factors, including an aging population requiring more healthcare services, increased demand for critical care services due to complex health conditions, and a shortage of critical care physicians leading to expanded roles for nurses.

The COVID-19 pandemic has further highlighted the essential role of critical care nurses, intensifying the demand. Additionally, with up to 27% of critical care nurses estimated to be planning to exit the profession in the near future, there will likely be numerous job openings to fill these vacancies.

• Salary.com. Critical Care Nurse Salary in the United States . 
• Host Healthcare. 8 Factors That Play Into ICU Nurse Salary .
• ShiftMed. How Much Do Critical Care Nurse (ICU Nurse) Make?

Frequently Asked Questions

Caring for acutely or critically ill patients requires an advanced skill set. The complexity and demands of the job mean that nurses working in ICUs must have the education and clinical experience to qualify for their position. The minimum education for patient care roles in ICUs varies by location, but most states and employers require nurses to have a Bachelor of Science in Nursing degree with additional training in advanced nursing practices.

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Critical Care Nurse Career Overview

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Job outlook, average earning potential, what does a critical care nurse do.

Critical care nurses possess the same skills as a registered nurse and may undergo additional training to care for acute or critical illnesses. An average workday includes monitoring critical medical support equipment and tending to patients with life-threatening injuries. Critical care nurses require clear communication to interact with other nurses and interdisciplinary teams to stabilize emergency situations. Nurses also work with healthcare providers to administer medical treatments, and keep the patient’s family informed.

• Ability to access and treat patients swiftly and accurately
• Critical thinker in a fast-paced environment
• Good communicator between patients and families
• Physically fit for long, intensive shifts

Where Do Critical Care Nurses Work?

Critical care nurses apply their advanced training and expertise to various healthcare settings.

They typically work in intensive care units (ICU) but provide care in other healthcare facilities related to emergency injuries or long-term illness. Step-down units look after patients who don’t need as much immediate care as a patient in the ICU but aren’t stable enough to be sent to a medical floor or home. Some critical care nurses can even work from home by supporting other nurses from a teleICU.

• Stabilize patients’ health by assessing their condition, administering medicine, and monitoring life support machines
• Adapt and stay calm under high-stress situations where critical thinking is crucial
• Coordinate with the interdisciplinary team and the patient’s family on the best course of action for the patient

Step-down Units

• Help lower the number of patients in the ICU by providing an intermediate place for more stable patients to go
• Provide care for patients who have just gone through major surgery or continue to need medical support
• Comfort patients and families
• Quickly be able to respond to any changes in a patient’s condition
• Create a treatment plan for a patient with other nurses and specialists through videoconferencing
• Have an open mind to new ideas and ways to treat patients with teleICUs being a new development in healthcare
• Technologically capable
• Analytically minded

Why Become a Critical Care Nurse?

Critical care nurses bear high-risk, high-reward careers because of the incredible amount of responsibility they carry when caring for patients in life-threatening situations. Nurses have to assume the job of advocate for unconscious patients and form bonds with the patient’s family throughout the patient’s admission. These situations add emotional weight to nurses’ professional lives and can take a toll on their mental health.

Although they carry this heavy burden, there are many benefits to critical care nursing . When working at an ICU or other healthcare facilities, the critical care nurses have access to the most up-to-date medical equipment and get to work alongside veteran professionals. A critical care nurse also has many opportunities to specialize and gain a higher salary or seek higher-level positions.

Advantages to Becoming a Critical Care Nurse

Disadvantages to becoming a critical care nurse, how to become a critical care nurse, earn a bsn or adn ., pass the nclex-rn to receive rn licensure., gain experience in critical care nursing., consider earning a specialty certification in critical care nursing., critical care nurse certifications and specialty areas, pediatric critical care nurse (ccrn-p), neonatal critical care nurse (ccrn-p), how much do critical care nurses make.

A critical care nurse’s salary varies from geographical location, but they receive a national annual median pay of $74,991 . Los Angeles, California, boasts the highest salaries for critical care nurses, with nurses earning more than 51.7% above the national average. The more experience a nurse has plays a large part in their earnings with PayScale reporting that critical care nurses with 20 years of experience earn over $40 an hour.

The BLS projects that all registered nurses positions, including critical care nurse jobs, will grow by 7% from 2019 to 2029.

Frequently Asked Questions

How long does it take to become a critical care nurse.

A critical care nurse requires an associate or bachelor’s degree in nursing, which typically takes 2-4 years to complete. Along with this, a nurse needs to pass the NCLEX-RN exam to get their registered nurse license. Depending on the state or employer, healthcare facilities may also require certification from the AACN, which calls for a minimum of two years of professional experience.

Is a graduate degree required to become a critical care nurse?

A critical care nurse with a graduate degree has the ability to pick from a larger pool of job opportunities, but a graduate degree isn’t required to be a critical care nurse. A graduate degree, such as an MSN prepares nurses by providing them with additional education and training before starting their career.

What career advancement opportunities are available for critical care nurses?

More career opportunities open up for critical care nurses when they pursue higher education. Critical care nurses can specialize in specific fields like cardiac or neonatal. Critical care nurses who possess a master’s degree or doctorate have the option of working as a critical care nurse practitioner .

Resources for Critical Care Nurses

American association of critical-care nurses (aacn), aacn online courses, society of critical care medicine (sccm), world federation of critical care nurses (wfccn), related pages.

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Find out how to become a travel nurse, including education, experience, and licensure requirements.

Reviewed by:

Nicole Galan, RN, MSN

Nicole Galan is a registered nurse who earned a master’s degree in nursing education from Capella University and currently works as a full-time freelance writer. Throughout her nursing career, Galan worked in a general medical/surgical care unit and then in infertility care. She has also worked for over 13 years as a freelance writer specializing in consumer health sites and educational materials for nursing students.

Galan is a paid member of our Healthcare Review Partner Network. Learn more about our review partners .

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Critical Care Nurse

What is a critical care nurse critical care nurses (ccns) capably manage and coordinate the care of severely ill patients suffering from complicated medical or surgical illnesses. they possess high-level skills and balance multiple requirements as these patients are frequently intubated, on multiple iv drips, and have unstable cardiac or other organ failure risk. ccns quickly identify when a patient decompensates and alert the rest of the critical care team. critical care nurses also deliver emotional and psychological support to patients and their families.   patients are often unconscious, but critical care nurses must always pay attention to easing their and their loved one’s fears. in addition, critical care nurses are responsible for their patient’s recovery from life-threatening injuries or illnesses. they are the true masters of delivering lifesaving care.  intensive care units are often divided into different subunits, such as medical icu, surgical icu, pediatric icu, and neonatal icu. in some hospitals, there are additional divisions for cardiac care, trauma care, neurological treatment, and progressive or step-down units. critical care nurses encompass all those who deliver care in any of these designations, and they can further specialize based on their interests.  critical care nurses often receive advanced training to improve their skills. some become advanced practice registered nurses (aprns) or clinical nurse specialists (cnss) who specialize in an area of interest within critical care. { "@context": "https://schema.org", "@type": "faqpage", "mainentity": [{ "@type": "question", "name": "what is a critical care nurse", "acceptedanswer": { "@type": "answer", "text": "critical care nurses (ccns) capably manage and coordinate the care of severely ill patients suffering from complicated medical or surgical illnesses. they possess high-level skills and balance multiple requirements as these patients are frequently intubated, on multiple iv drips, and have unstable cardiac or other organ failure risk. ccns quickly identify when a patient decompensates and alert the rest of the critical care team. critical care nurses also deliver emotional and psychological support to patients and their families." } },{ "@type": "question", "name": "what does a critical care nurse do", "acceptedanswer": { "@type": "answer", "text": "critical care nurses perform some of the same activities as other nurses, but they focus on the life-sustaining treatment and recovery of critically ill patients. ccns typically care for one to two patients in the adult intensive care population and one to three patients in the pediatric or neonatal population." } },{ "@type": "question", "name": "what skills does a critical care nurse need", "acceptedanswer": { "@type": "answer", "text": "critical care nurses must be specifically trained in their specialty area. for example, an adult care ccn does not work with pediatric or neonatal critical care patients. ccns need advanced assessment skills and iv drug knowledge of drugs that need frequent adjustments based on the patient’s status, such as dopamine as well as resuscitation medications. they have knowledge to run sophisticated equipment to manage ventilators, arterial lines, ekg monitors, intracranial pressure monitors, and multiple infusion pumps. ccns must be able to anticipate all their patients’ needs as patients are either too young or not able to verbalize desires, concerns, or discomforts." } }] } what does a critical care nurse do critical care nurses perform some of the same activities as other nurses, but they focus on the life-sustaining treatment and recovery of critically ill patients. ccns typically care for one to two patients in the adult intensive care population and one to three patients in the pediatric or neonatal population.  general activities may include: • assess and monitor patients for changes in ventilation, cardiac and renal status • administer iv medications, dressing changes, catheter care, and prevent skin breakdown • manage cardiac monitors, ventilators, and other monitoring equipment • track and record patient progress, draw lab work, administer blood, maintain airways, provide wound care, and administer nutritional support • attend rounds with the care team, report on patient status, and assist physicians with patient treatments. • provide family and patient reassurance and teaching • provide comfort for end-of-life care what skills does a critical care nurse need.

Critical care nurses must be specifically trained in their specialty area. For example, an adult care CCN does not work with pediatric or neonatal critical care patients.

CCNs need advanced assessment skills and IV drug knowledge of drugs that need frequent adjustments based on the patient’s status, such as dopamine as well as resuscitation medications.  They have knowledge to run sophisticated equipment to manage ventilators, arterial lines, EKG monitors, intracranial pressure monitors, and multiple infusion pumps.  

CCNs must be able to anticipate all their patients’ needs as patients are either too young or not able to verbalize desires, concerns, or discomforts. 

What skills does a Critical Care Nurse need? Critical care nurses must be specifically trained in their specialty area. For example, an adult care CCN does not work with pediatric or neonatal critical care patients. CCNs need advanced assessment skills and IV drug knowledge of drugs that need frequent adjustments based on the patient’s status, such as dopamine as well as resuscitation medications.  They have knowledge to run sophisticated equipment to manage ventilators, arterial lines, EKG monitors, intracranial pressure monitors, and multiple infusion pumps.   CCNs must be able to anticipate all their patients’ needs as patients are either too young or not able to verbalize desires, concerns, or discomforts.  Learn More About Critical Care Nurses Work settings for Critical Care Nurses Critical care nurses usually work in hospitals or in emergency transport but also in outpatient surgical centers. Common Cases Critical Care Nurses Encounter Adult, pediatric, or neonatal settings all have different types of cases, as do surgical ICU or medical ICUs. Any patient with a life-threatening medical or surgical condition, regardless of age, is sent to an ICU. How to Become A Critical Care Nurse 1. Complete an Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) degree: takes two-to-four-years based on the program 2. Pass the NCLEX-RN exam and apply for your RN license after graduation 3. Apply as a new grad or from another nursing discipline such as Med-Surg or the ED 4. Become certified as a CCRN after meeting the prerequisites and gaining work experience. How to Advance Your Career As A Critical Care Nurse Critical care nurses must be BCLS certified but also need ACLS certification. Many places prefer you have at least one year of experience in Med/Surg or a similar setting to grow your skills. Apply for work in your critical care interest area. These units often offer internships and residencies to learn needed skills: Adult Intensive care unit (ICU) Pediatric ICU Neonatal ICU Other high acuity areas that are considered to be critical care: Emergency department, Step-down units, Cardiac care units, Telemetry units, or Progressive care units. You can apply for your CCRN in (Adult, Pediatric or Neonatal) from the AACN after completing the required clinical hours in either two or five years. You can also advance by getting an MSN or doctoral degree with a critical care focus as a Clinical Nurse Specialist (CNS) or an acute care nurse practitioner specializing in areas such as ED or ICU. Education Requirements & Helpful Certification Critical care nurses must be BCLS and ACLS certified. They are highly encouraged to become critical care registered nurse (CCRN) certified after gaining experience in their specialty area.  There are several certifications offered by the AACN.  Each is specifically geared towards either bedside nurses, advanced practice nurses, clinical specialists, educators, or managers.  The certifications are divided into adult, pediatric and neonatal care but also may be cardiac or gerontology focused. A CCRN needs to have worked either:  • 1750 hours directly caring for acute or critically ill patients for the last two years, with 875 of the hours accrued in the year before applying. • 2,000 hours directly caring for acute or critically ill patients for the last five years, with 144 of the hours accrued in the year before applying. Average Salary For Critical Care Nurses Critical care nurses typically make between $60,887- $103,872, with a median salary of $79,800, according to Salary.com . The May 2021 Bureau of Labor and Statistics report shows which states have the highest and lowest wages for nurses. They do not list by nurse specialty, but critical care nurse salaries would likely follow suit. The highest-paid states are California, Hawaii, and Oregon. The lowest-paid states are South Dakota, Alabama, and Mississippi. Specialty Organizations & Communities American Association of Critical-Care Nurses (AACN) Society of Critical Care Medicine Ideal Personality Traits Empathetic  Clear, calm communicator  Strong decision-maker Critical thinker Organized, meticulous Detailed planner Browse Jobs Let's start building the life you want.

Critical Care Nurses (CCNs), also known as ICU Nurses, care for patients with complex, life-threatening conditions in a variety of critical care settings. Many patients need oxygenation support and are receiving crucial continuous IV medication drips.

CCNs quickly identify when a patient decompensates and alerts the rest of the critical care team. They are experts at close monitoring and assist their patients progress from severe illness to stable health. CCNs also provide emotional support and education to their patients and their families.

Education Requirements

Critical care nurses must be BCLS and ACLS certified. They are highly encouraged to become critical care registered nurse (CCRN) certified after gaining experience in their specialty area. 

There are several certifications offered by the AACN.  Each is specifically geared towards either bedside nurses, advanced practice nurses, clinical specialists, educators, or managers. 

The certifications are divided into adult, pediatric and neonatal care but also may be cardiac or gerontology focused.

A CCRN needs to have worked either: 

• 1750 hours directly caring for acute or critically ill patients for the last two years, with 875 of the hours accrued in the year before applying.

• 2,000 hours directly caring for acute or critically ill patients for the last five years, with 144 of the hours accrued in the year before applying.

How to advance/career pathway

Critical care nurses must be BCLS certified but also need ACLS certification. Many places prefer you have at least one year of experience in Med/Surg or a similar setting to grow your skills.

Apply for work in your critical care interest area. These units often offer internships and residencies to learn needed skills:

• Adult Intensive care unit (ICU)
• Pediatric ICU
• Neonatal ICU

Other high acuity areas that are considered to be critical care: Emergency department, Step-down units, Cardiac care units, Telemetry units, or Progressive care units.

You can apply for your CCRN in (Adult, Pediatric or Neonatal) from the AACN after completing the required clinical hours in either two or five years.

You can also advance by getting an MSN or doctoral degree with a critical care focus as a Clinical Nurse Specialist (CNS) or an acute care nurse practitioner specializing in areas such as ED or ICU.

RESPONSIBILITIES

• Empathetic 
• Clear, calm communicator 
• Strong decision-maker and multi-tasker
• Critical thinker
• Organized, meticulous
• Detailed planner

MOST COMMON CASES

Adult, pediatric, or neonatal settings all have different types of cases, as do surgical ICU or medical ICUs. Any patient with a life-threatening medical or surgical condition, regardless of age, is sent to an ICU.

How to become a

1. Complete an Associate Degree in Nursing (ADN) or Bachelor of Science in Nursing (BSN) degree: takes two-to-four-years based on the program

2. Pass the NCLEX-RN exam and apply for your RN license after graduation

3. Apply as a new grad or from another nursing discipline such as Med-Surg or the ED

4. Become certified as a CCRN after meeting the prerequisites and gaining work experience.

Specialty Groups and Communities

• American Association of Critical-Care Nurses (AACN)
• Society of Critical Care Medicine

‍ The Pros of Being a Critical Care Nurse ‍

• Challenging, advanced learning opportunities of complicated patients
• Develop close relationships with patients in critical conditions and their families 
• Rewarding to see the recovery of patients from life-threatening illnesses 
• Work collaboratively with the critical care team

‍ The Cons of Being a Critical Care Nurse ‍

• Demanding, must be precise, patients entirely dependent on your skills
• Stressful since patients may do poorly, have low ability to get better, and die 
• Focus on critical care patients limits experiences with less intense medical conditions

Personality Traits

• Strong decision-maker

Average Salary

Critical care nurses typically make between $60,887- $103,872, with a median salary of $79,800, according to Salary.com .

The May 2021 Bureau of Labor and Statistics report shows which states have the highest and lowest wages for nurses. They do not list by nurse specialty, but critical care nurse salaries would likely follow suit. The highest-paid states are California, Hawaii, and Oregon. The lowest-paid states are South Dakota, Alabama, and Mississippi.

Certifications

American Nurses Credentialing Center (ANCC)

• CCRN (Adult, Pediatric or Neonatal)
• CCRN-K (Adult, Pediatric or Neonatal) for nurse supervisors
• CCRN-E (TeleICU, Acute/Critical Care)
• PCCN & PCCN-K (Adult) Progressive Care Certified Nurse
• CMC (Cardiac Medicine Certification)
• CSC (Cardiac Surgery Certification) 

There are other certifications for CNSs and acute care nurse practitioners.

Work Setting

Critical care nurses usually work in hospitals or in emergency transport but also in outpatient surgical centers.

Lippincott ® NursingCenter ®

Practice specialties, critical care nursing.

Critical care nursing, or intensive care unit (ICU) nursing, is a specialty focused on the care of unstable, chronically ill or post-surgical patients and those at risk from life-threatening diseases and injuries.

What do critical care nurses do?

What do critical care nurses need to know.

• an understanding of human anatomy and physiology.
• sharp clinical assessment skills.
• vast knowledge about diseases and conditions.
• ongoing education related to recommended ICU treatment options.

More critical care nursing resources

• Nursing Pocket Cards, including arterial blood gas analysis and mechanical ventilation
• Guideline Summaries, including ARDS and sepsis
• Blog posts, with infographics, mnemonics, tips, and more
• Critical Care Nursing Quarterly
• Dimensions of Critical Care Nursing
• Articles and nursing continuing professional development (NCPD) activities
• Headlines and news stories
• Society partners

Critical Care Nursing Certification Review Course

Use this Critical Care Nursing Certification Review Course to study for the critical care nursing specialty certification from the American Association of Critical-Care Nurses (AACN), which grants the credential CCRN ® (Adult).

From NursingCenter

Guideline Summaries

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What does a critical care nurse do?

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What is a Critical Care nurse?

A critical care nurse is a registered nurse who has received specialized training in the care of patients with life-threatening medical conditions. These nurses work in intensive care units (ICUs) and other critical care settings, where they provide care for patients who require constant monitoring and intervention. They are responsible for assessing patient needs, administering medications and treatments, monitoring vital signs, and providing emotional support to patients and their families.

Critical care nurses may work with a variety of patients, including those who have suffered from traumatic injuries, heart attacks, strokes, or other serious medical conditions. They work closely with other healthcare professionals, including doctors, respiratory therapists, and pharmacists, to provide the best possible care for their patients. In addition to providing direct patient care, critical care nurses also educate patients and their families about their conditions and help them to make informed decisions about their healthcare.

What does a Critical Care nurse do?

The expertise and attention to detail that critical care nurses have are essential in helping patients recover and return to a healthy state. Without critical care nurses, the quality of care for critically ill patients would suffer, and their chances of survival would decrease significantly.

Duties and Responsibilities The duties and responsibilities of critical care nurses may include:

• Patient assessment: Critical care nurses are responsible for assessing patients' conditions to identify any changes or deterioration in their condition. This includes monitoring vital signs such as blood pressure, heart rate, and respiratory rate. They must also evaluate laboratory and diagnostic test results to determine appropriate interventions.
• Medication administration: Critical care nurses are responsible for administering medications, including intravenous medications, and monitoring the patient's response to the treatment. They must also be knowledgeable about medication interactions and side effects to ensure patient safety.
• Ventilator management: Critical care nurses are responsible for managing patients who require mechanical ventilation. This includes assessing the patient's response to the ventilator, monitoring the ventilator settings, and making adjustments as needed.
• Communication with the healthcare team: Critical care nurses must communicate effectively with physicians, respiratory therapists, and other healthcare professionals to ensure that patients receive optimal care. This includes providing updates on the patient's condition and collaborating to develop a comprehensive treatment plan.
• Patient education: Critical care nurses must provide patient education, including explaining treatments and procedures, and helping patients and their families understand the patient's condition. This includes teaching patients and families about their medications, equipment, and other aspects of their care.
• Documentation: Critical care nurses must keep accurate records of patient care, including vital signs, medications, and treatments provided. This documentation is critical for ensuring that patients receive appropriate care and for communicating with other healthcare professionals.
• Support for families: Critical care nurses may provide emotional support to patients' families, including explaining the patient's condition and answering questions. They may also help families navigate the healthcare system and connect them with resources and support services.
• Infection prevention and control: Critical care nurses are responsible for implementing infection control measures to prevent the spread of infections in the critical care unit. This includes ensuring that patients and staff follow appropriate hand hygiene protocols, wearing personal protective equipment when necessary, and implementing isolation precautions as needed.
• Crisis management: Critical care nurses must be able to respond quickly to medical emergencies, including performing cardiopulmonary resuscitation (CPR) and other life-saving interventions. They must also be able to identify and respond to signs of patient distress and rapidly escalate care as needed.
• Collaborative care: Critical care nurses work closely with other healthcare professionals to provide coordinated care to patients. This includes developing and implementing treatment plans, coordinating care transitions, and communicating with other members of the healthcare team. They may also participate in multidisciplinary rounds to review patient progress and make care decisions.

Types of Critical Care Nurses There are several types of critical care nurses who specialize in different areas of critical care nursing. Here are some examples:

• Intensive Care Unit (ICU) Nurse: ICU nurses work in intensive care units and provide care to patients who are critically ill or injured. They may specialize in caring for patients with specific conditions, such as cardiac ICU nurses who care for patients with heart-related conditions, or neuro ICU nurses who care for patients with neurological conditions.
• Emergency Room (ER) Nurse : ER nurses work in emergency departments and provide care to patients who are experiencing a medical emergency or trauma. They must be able to respond quickly to emergencies and have knowledge of a wide range of medical conditions.
• Flight Nurse: Flight nurses provide care to critically ill or injured patients who require transportation by air. They may work in helicopters, fixed-wing aircraft, or air ambulances.
• Pediatric ICU Nurse: Pediatric ICU nurses specialize in providing care to critically ill or injured children. They may work in pediatric ICUs, neonatal ICUs, or pediatric emergency departments.
• Trauma Nurse: Trauma nurses specialize in caring for patients who have experienced severe trauma, such as from a car accident or gunshot wound. They work in trauma centers and emergency departments.
• Cardiac Catheterization Lab Nurse: Cardiac catheterization lab nurses specialize in providing care to patients undergoing cardiac catheterization procedures. They work in cardiac catheterization labs and must have a thorough understanding of cardiac anatomy and physiology.
• Perioperative Nurse: Perioperative nurses provide care to patients before, during, and after surgical procedures. They may work in operating rooms, preoperative areas, or post-anesthesia care units.

What is the workplace of a Critical Care nurse like?

The workplace of a critical care nurse can be demanding and fast-paced, as they are responsible for the care of critically ill patients in hospitals, intensive care units (ICUs), and other medical settings. Critical care nurses work alongside other healthcare professionals such as doctors, respiratory therapists, and pharmacists to ensure that patients receive the best possible care.

One of the key responsibilities of a critical care nurse is to closely monitor their patients' vital signs, such as heart rate, blood pressure, and oxygen saturation levels. They also administer medications, monitor intravenous lines and other medical equipment, and communicate with patients and their families about the patient's condition and treatment plan.

In addition to providing direct patient care, critical care nurses also collaborate with other members of the healthcare team to develop and implement treatment plans, participate in patient rounds and conferences, and ensure that medical orders and procedures are followed correctly.

Due to the unpredictable and often life-threatening nature of critical care nursing, nurses in this field must be able to think quickly on their feet, stay calm under pressure, and communicate effectively with both patients and other healthcare professionals. They may work long and irregular hours, and often have to adapt to changing patient needs and situations.

Frequently Asked Questions

Nursing related careers and degrees.

• Acute Care Nurse Practitioner (ACNP)
• Advanced Practice Registered Nurse (APRN)
• Certified Nurse Midwife (CNM)
• Certified Nursing Assistant (CNA)
• Clinical Nurse Specialist (CNS)
• Critical Care Nurse
• Geriatric Nurse
• Home Health Nurse
• Informatics Nurse Specialist
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• Nurse Educator
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Critical Care Nurses are also known as: Critical Care Registered Nurse

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HEALTHCARE CAREER GUIDES

Critical Care Nurse Career

What is a critical care nurse.

If you’ve ever been seriously ill or visited someone in the hospital who was, you’ve likely encountered a critical care nurse. Often called ICU nurses because of the unit they commonly work in, critical care nurses are highly trained to understand and provide care for people of all ages who are recovering from life-threatening illnesses or injuries. 

Today, there are more than  half a million  critical care nurses working in the United States. But despite that number, critical care careers continues to be in high demand thanks to the recent registered nursing shortage.

If you’re thinking about getting into critical care nursing, you should know it’s both a demanding career and a rewarding one. From a patient’s first assessment to end-of-life care, you’ll be a vital part of lifesaving treatments and actions. You’re also caring for people who are at their very worst, physically. For this reason, it takes a special kind of nurse to work in critical care units.

RESPONSIBILITIES

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.

A typical shift as an ICU nurse can include things like assessing a patient’s condition and starting treatment, taking vital signs, communicating with patients and their families, setting up IVs, and administering medication. Many times, patients in the ICU are ventilated or have multiple IV drips. For this reason, registered nurses in critical care unites (also known as intensive care units or ICUs) need more knowledge of equipment and charting than other registered nurses.

• Assessing and treating patients. It’s fairly common that a patient sees a nurse in the ICU before a doctor, so ICU nurses will be expected to assess a patient’s condition and start treatment. This could include everything from taking vital signs to dressing wounds. They'll also be in charge of monitoring a patient’s progress and reporting back to the physician. 
• Ordering diagnostic tests. Many of the critical care patients you will see on a day-to-day basis will be suffering from some kind of injury or illness, which means they’ll need diagnostic testing. It’s often up to the critical care nurse to send orders for x-rays, EKGs, or CT scans and then go over those results with the doctor to decide on a treatment plan. 
• Acting as a patient advocate. When critical care patients are physically at their worst, the nurse's role is to be there to provide support, education, and empathy. This is done in several different ways—from helping patients make informed decisions about their health, to translating complex medical terms, to acting as a liaison between patients and their doctor.  
• Monitoring medical equipment. Many critical care patients will be set up on cardiac monitors or ventilators, so their nurse will be the one in charge of setting up those machines and regularly monitoring and tracking a patient’s progress. 

EDUCATION & BEST DEGREES

How to become a critical care nurse.

Step One: Become a registered nurse.

The first step in becoming a critical care nurse is completing a  bachelor’s degree  in nursing. Most programs take four years for full-time students to complete. However, students who’ve already completed an associate nursing degree can apply to RN-to-BSN programs that let working nurses earn bachelor’s degrees in less time.

Step Two: Earn your critical care nursing licensure.  

After earning your degree, you’ll be required to pass the NCLEX-RN exam and meet your other  state’s other requirements  to be eligible for nursing licensure. This exam is a computer-generated test that’s offered by the American Association of Critical Care Nurses (AACN). The NCLEX-RN is divided up into four categories and six subcategories that cover the foundations of nursing practice and measure nursing competency.

Step Three: Get certified as a critical care nurse.

Nurses who want to establish their knowledge for nursing critically ill or injured patients should obtain the CCRN certification from the AACN. To be eligible for this exam, you’ll need to meet one of the following:

Practice as an RN or APRN (advanced practice registered nurse) for 1,750 hours in direct care of acutely or critically ill patients during the past two years. 875 of these hours must be accrued in the year preceding application.

Practice as an RN or APRN for at least five years with a minimum of 2,000 hours in direct care of acutely or critically ill patients. 144 of these hours must be accrued in the year preceding application.

Step Four: Explore additional certifications and education.

After working as a critical care nurse, you might decide to pursue a  master’s degree  or post-master's certificate in nursing. Or you may choose to earn specialty certifications depending on what type of patients you enjoy working with most. 

These additional certifications could include: 

CMC: providing care to critically ill cardiac patients

CSC: providing care to critically ill cardiac surgery patients

ACNPC-AG: providing care for very sick geriatric patients

Best Degrees for a Critical Care Nurse

Nursing (Prelicensure) – B.S.

A one-of-a-kind nursing program that prepares you to be an RN and a...

A one-of-a-kind nursing program that prepares you to be an RN and a baccalaureate-prepared nurse:

• Locations:  Due to in-person clinical requirements, students must be full time residents of Arkansas, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Michigan, Minnesota, Mississippi, Missouri, Nevada, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin to enroll in this program. The coursework in this program is offered online, but there are in-person requirements.
• Tuition:  $8,755 per 6-month term for the first 4 terms of pre-nursing coursework and $8,755 per 6-month term for the remaining 4 terms of clinical nursing coursework.
• Time:  This program has a set pace and an expected completion time of 4 years. Certain coursework may be accelerated to finish faster.
• WGU offers the prelicensure program in areas where we have partnerships with healthcare employers to provide practice sites and clinical coaches to help teach you and inspire you on your path to becoming a nurse.
• If you don't live in one of our prelicensure states or don't qualify to apply, consider getting our  Bachelor's in Health and Human Services  instead. This degree allows you to work inside the healthcare industry, while also working directly with patients who need help.

Skills for your résumé that you will learn in this program:

• Community Health
• Women's and Children's Nursing

Nursing – Leadership & Management (BSN-to-MSN) – M.S.

For registered nurses with a bachelor's degree who are ready for...

For registered nurses with a bachelor's degree who are ready for additional career opportunities.

• Time:  61% of grads finish within 23 months
• Tuition: $5,035 per 6-month term
• Courses : 15 total courses in this program

This program is ideal for current RNs who have a BSN and are ready for the next step in their education.

Skills for your résumé you will learn in this program:

• Quality Outcomes in a Culture of Value-Based Nursing Care
• Nursing Leadership and Management
• Advanced Pathopharmacological Foundations
• Informatics for Transforming Nursing Care

Compare degrees

This program is not the only degree WGU offers designed to create leaders in the field of healthcare. Compare our health leadership degrees.

Nursing (RN-to-BSN Online) – B.S.

An online BSN degree program for registered nurses (RNs) seeking the added...

An online BSN degree program for registered nurses (RNs) seeking the added theoretical depth, employability, and respect that a bachelor's degree brings:

• Time:  The program is designed to be completed in 1 year.
• Tuition:  $4,685 per 6-month term.
• Courses : 23 total courses in this program.
• Transfers: Students can transfer up to 90 credits.
• Healthcare Policy and Economics
• Information Technology in Nursing Practice
• Anatomy and Physiology
• Applied Healthcare Statistics

If you don't currently have an RN and don't qualify for your nursing prelicensure program, consider getting our Bachelor's in Health and Human Services  instead. This degree allows you to work inside the healthcare industry in a unique way.

Nursing Leadership and Management – Post-Master's Certificate

A certificate for registered nurses with a master's degree in nursing who...

A certificate for registered nurses with a master's degree in nursing who are ready for greater responsibility in a leadership and management role.

• Time:  Students typically finish this program in 12 months.
• Tuition:  $5,035 per 6-month term. The cost to sit for the NAHQ Certified Professional in Healthcare Quality (CPHQ) exam is included in tuition.
• Courses : 8 total courses in this program.
• Strategic Planning
• Resource Management
• Business Case Analysis
• Evaluating Healthcare Improvements

Nursing – Leadership & Management (RN-to-MSN) – M.S.

This program for RNs includes a BSN component and is a substantial leap...

This program for RNs includes a BSN component and is a substantial leap toward becoming a nurse leader.

• Time: 62% of RN-to-MSN grads finish within 37 months.
• Tuition:  $4,685 per 6-month term during undergraduate portion and $5,035 per 6-month term during graduate portion.
• Courses : 32 total courses in this program.

If you're driven to lead, this online nursing degree will provide you everything needed to make that career a reality. This program is ideal for current RNs who are interested in earning both their BSn and MSN in an accelerated program.

How Much Does a Critical Care Nurse Make?

Critical care nurses are often paid higher than other nurses because of their specialized training. The U.S. Bureau of Labor Statistics (BLS) reports that the median average salary for RNs was  $81,220  in 2022.

What Is the Projected Job Growth?

The BLS also predicts the demand for RNs, which includes critical care nurses, is expected to  grow by 6%  from 2022 to 2032, faster than the average for all occupations. This growth is fueled by increasing rates of chronic conditions such as diabetes and obesity, the aging population, and an increase in emerging diseases like COVID-19.

What Skills Does a Critical Care Nurse Need?

Being a nurse in an intensive care unit is a demanding position—both physically and mentally. The physical demands might include working on your feet for long shifts, transporting patients by pushing or pulling wheelchairs, and lifting patients as needed. You’ll also be constantly monitoring highly unstable and at-risk patients, so strong analytical skills and the ability to make quick decisions under pressure is a must. 

To be successful working in critical care you’ll need a mix of clinical and non-clinical skills. Some of these include:

• Understanding medical technology and equipment 
• Strong knowledge of anatomy and physiology 
• The ability to create and implement patient care plans
• Understanding how to use various medical devices, such as catheters and feeding tubes
• In-depth knowledge of medications, including side effects and dosing calculations
• Operating life support systems
• Understanding patient safety and privacy rules and regulations 
• Good communication skills and the ability to work well in a team environment 
• Strong organizational skills and the ability to prioritize 
• Comfortably handling end-of-life situations

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No need to wait for spring or fall semester. It's back-to-school time at WGU year-round. Get started by talking to an Enrollment Counselor today, and you'll be on your way to realizing your dream of a bachelor's or master's degree—sooner than you might think!

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Interested in Becoming a Critical Care Nurse?

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CRITICAL CARE NURSING GUIDELINES, STANDARDS AND COMPETENCIES

Drafted as of JULY 1, 2014

INTRODUCTION

The health care industry all over the world has been undergoing significant changes over the past two decades and the Philippines has been part of these transformational events having great impact on the quality of nursing practice. There are new expectations in the way nurses and the nursing practices are to be delivered particularly now that there are many challenges that besiege the nursing profession as a consequence of the complexities of globalization.

Critical care nursing is the specialty within nursing that deals specifically with human responses to life-threatening problems 1 .These problems deal dynamically with human responses to actual or potential life-threatening illnesses.

The framework of critical care nursing is a complex, challenging area of nursing practice. It utilizes the nursing process applying assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The critical care nursing practice is based on a scientific body of knowledge and incorporates the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative care, based on identified patient’s need 3 . It upholds multi and interdisciplinary collaboration in initiating interventions to restore stability, prevent complications, achieve and maintain optimal patient responses. The critical care nursing profession requires a clear description of the attributes guidelines and nursing practice standards in guiding the critical care nursing practice to fulfill this purpose.

In the Philippines, the Professional Regulation Commission – Board of Nursing (PRC-BON) is committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources. To respond to this mission and commitment, a PRC-BON Working Group in Developing the Nursing Specialty Framework was formed in the 1996 to take on the task of setting the process -based framework and guidelines for specialty nursing services. The Working Group members are clinical nurse practitioners, nurse educators and nurse managers 1 .

The expanding healthcare and nursing knowledge together with new and evolving healthcare sites, structures, and technologies all have contributed to the need and desire for specialty nursing organizations like the Critical Care Nurses Association of the Philippines, Inc. (CCNAPI) to revisit the existing statements of its Standards of Nursing Practice to provide clear and updated statements regarding the scopes of practice and standards of critical care nursing. This will ensure continued understanding and acknowledgment of nursing’s varied specialty professional contributions in today’s healthcare environment.

The CCNAPI Standards of Practice of 1982 has been revisited and revised to be aligned with the 2005BON statements of the 11 Core Competencies for Entry Level for Safe and Quality Nursing Care. The CCNAPI Core Competencies of a Critical Care Nurse are stated according to the levels of expected behavior defining the actual knowledge, skills and abilities in the practice of critical care by a nursing professional. These statements cover expected behavior of a Nurse Clinician I, Nurse Clinician II and Nurse Specialist that will serve as the basis for assessing competence in critical care practice. The statement of the goals, scope of practice, competencies and standards on the care of the critically ill are all important aspects that are emphasized in this paper.

The focus of care for the critically ill patient is holistic. However, to organize statements in this paper, physiological focus has been categorized under bodily functional systems such as pulmonary system, cardiovascular system, renal system, neurological system and other system.

The specific objectives of this paper are to:

• To identify Critical Care Nursing Service characteristics and contributions of nurses to patient care in the specialty.
• To develop specific competencies required for the delivery of nursing care in the critical care.
• To provide a framework for evaluation of nursing practice within the specialty of critical care.
• Provide a basis for the assessment of continuous staff development needs in critical care nursing.
• Guide the development of collaborative working relationships with other members of the health care team.

This process-based framework not only describes the critical care nursing services in the Philippines, but also assists critical care nurses to have a better understanding of what is expected of them from the organization and the public perspectives.

PHILOSOPHY OF CRITICAL CARE NURSING

Critical Care Nursing reflects a holistic approach in caring of patients. It places great emphasis on the caring of the bio-psycho-social-spiritual nature of human beings and their responses to illnesses rather than salary on the disease process. It helps maintain the individual patient’s identity and dignity. The focus of caring includes preventive care, risk factor modification and education to decrease future patient admissions to acute care facilities.

The Critical Care Nurses of the Philippines, Inc. (CCNAPI) is responsible for the promotion of man’s health and welfare for national development. It desires to support the professional and personal growth and development of initial core nurses. CCNAPI has organized itself into a national association committed to the ideals of service to the people, equality, justice and social progress.

In the Critical Care Units, each patient is viewed as a unique individual with dignity and worth. The critically ill patient should receive comfort and provided privacy in a highly technological environment. In collaboration with other health care team members, critical care nurses provide high level of patient care which includes patient and family education, health promotion and rehabilitation. To achieve this holistic care process, participation by the patient and his/her family is always emphasized. At the forefront of critical care science and technology, critical care nurses maintain professional competence based on a broad base of knowledge and experience through continuous education and evidence-based research.

With the advances in sophisticated biomedical technology and knowledge, critical care nurses are able to continuously monitor and observe patients for physiological changes to confront problems proactively and to assist patients achieve and maintain an optimum level of functioning or a peaceful death.

In other words, this nursing philosophy of the CCNAPI is accomplished by looking after critically ill patient in an environment with specially trained nurses, appropriate equipment, adequate medical supplies and other members of the health care personnel.

THE RIGHT OF THE CRITICALLY ILL PATIENT

The International Council of nurses (ICN) views health care as the rights of every individual regardless of financial political, geographical, racial and religious consideration. This right includes the right to choose or decline care, including the right to accept or refuse treatment or nourishment; informed consent; confidentiality and dignity, including the right to die with dignity. It involves both the right of those seeking care and the providers⁵.

The World Federation of Critical Care Nurses (WFCCN) has considered the rights of the critically ill patients, WFCCN has agreed that the statement of the patient’s right from the ICN covers the requirement for position statement on the rights of the critically ill patients.

CCNAPI being a founding member of WFCCN likewise supports the ICN position statement on Nurses and Human Rights as stated in Annex I.

GOALS OF CRITICAL CARE NURSING

Critical or intensive care is a complex specialty developed to serve the diverse health care need of patients (and their families) with actual or potential life threatening conditions 3 . It is therefore important that a clear statement of what critical care nursing wishes to achieve and provide should be articulated.

Goals of Critical Care Nursing include the following:

• To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the physiological dysfunction as well as the psychological stress in the ICU are under control;
• To care for the critically ill patients with a holistic approach, considering the patient’s biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting;
• To use relevant and up-to-dateknowledge, caring attitude and clinical skills, supported by appropriate technology for the prevention, early detection and treatment of complications to facilitate recovery.
• To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the patients and families go through their painful sufferings.

On the whole, critical care nursing should be patient-centered, safe, effective, and efficient. The nursing interventions are expected to be delivered in a timely and equitable manner.

LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN PHILIPPINES

With respect to the physical set-up and supporting facilities of critical care units in the Philippines, the Department of Health (DOH) Standards requires the critical care units / intensive care unit to be a self-contained area, with the provisions for resources that will support critical care practice. Currently, the DOH is reviewing these standards to come-up with updated requirement.

In 2003, the Philippine Society of Critical Care Medicine (PSCCM), Society of Pediatric Critical Care Medicine (SPCCM) and the CCNAPI stratified the care provisions in critical care practice into different levels and categories  to make it similar to its counterparts overseas with the goal of having effective utilization and organization of resources. Hence, as a guide, CCNAPI will incorporate these standards into this guideline.

Levels of Care Provision

The role of a particular critical care unit will vary, depending on the staffing, facilities and support services as well as the type and number of patients it has to manage. Taking into consideration the recommendation of the Guidelines on Critical Care Personnel and Services published in 2003 by the Critical Care Medicine⁴, the critical care service provision in the Philippines can adapt theses guidelines and apply the 3 levels of classifications accordingly:

• Should be capable of providing immediate resuscitation for the critically ill and short term cardio-respiratory support because the patients are at risk of deterioration;
• Has a major role in monitoring and preventing complications in “at risk” medical and surgical patients;
• Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;
• Has a formal organization of medical staff and at least one registered nurse.
• A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related clinical specialties; and
• Has a nurse: patient ratio of 1:1 for all critically ill patients.
• Should be capable of providing a high standard of general critical care for patients who are stepping down from higher levels of care or requiring single organ support/support post-operatively;
• Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
• Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times;
• The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and
• A nurse: patient ratio is 1:1 for all critically ill patients.
• Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring advanced respiratory support but also patients with multi-organ failure);
• Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff with an appropriate level of experience present in the unit at all times;
• A nurse in-charge and the majority of nursing staff have intensive care certification; and
• A nurse: patient ratio is at least 1:1 for all patients at all times.

Categories of Critical Care Unit

The Critical Care Unit can be categorized according to patients’ age group or medical specialties.

A. Age Group

B. Specialty

In the existing environment, majority of the Critical Care Units in the Philippines provide service for patients of various specialties. They are labeled as General ICUs. In certain hospitals, the critical care unit / service is dedicated to the following specific groups:

• Cardio-thoracic
• Respiratory
• Neurosurgical

System Operation of Critical Care Units

The operation of critical care units can be classified into Open System and Closed System.

A. Open System

The admitting and other attending doctors dictate management, change management or perform procedures without consultation or communication with a Critical Care Specialist. A Critical Care Specialist may be available for advice or be consulted to provide interventional skills (optional). No designated person who assumes the “gatekeeper” role.

B. Closed System

Management is coordinated by a qualified Critical Care Specialist. The critical / intensive care specialist has clinical and administrative responsibility. There is a multi-disciplinary team of specially trained critical care staff. The “intensivist” is the final common pathway for all medical decision-making including the decision to admit or discharge patients.

Irrespective of the ICU “System” Operations, i.e. open system or closed system, or a mixture of the two, there should be a designated group of registered nurses under unique management to provide highly specialized care to the critically ill patients. The nurse in-charge and the majority of nursing staff in each unit should have the relevant qualification in the specialty of the respective Unit.

SCOPE OF CRITICAL CARE NURSING

The scope of critical care nursing is defined by the dynamic interactions of the critically ill patient/family , the critical care nurse and the critical care environment to bring about optimal patient outcomes through nursing proficiency in an environment conducive to the provision of this highly specialized care 4 .

Constant intensive assessment, timely critical care interventions and continuous evaluation of management through multidisciplinary efforts are required to restore stability, prevent complications and achieve optimal health. Palliative care should be instituted to alleviate pain and sufferings of the patient and family in situations where death is imminent.

Critical Care Nurses are registered nurses, who are trained and qualified to practice critical care nursing. They possess the standard critical care nursing competencies in assuming specialized and expanded roles in caring for the critically ill patients and their family. Likewise,  each critical care nurse is personally responsible and committed to continuous learning and updating of his/her knowledge and skills. The critical care nurses carry out interventions and collaborates patient care activities to address life-threatening situations that will meet patient’s biological, psychological, cultural and spiritual needs.

The critical care environment constantly support the interactions between the critically ill patients, their family and the critical care nurses to achieve desired patient outcomes. It entails readily available and accessible emergency equipment, sufficient supplies and effective support system to ensure quality patient care as well as staff safety and productivity.

CRITICAL CARE NURSE QUALIFICATION

A critical care nurse is a licensed professional nurse who is responsible for ensuring that all critically ill patients and their families receive optimal care.

To be able to work in a critical care area other requirements are necessary and may vary depending on the institution.  In the nursing schools, critical care nursing is considered an elective subject and  the exposure  of students to critical care practice may not be enough to prepare  them for the complexity of critical care nursing practice once these student nurses  become licensed professional nurses.  Therefore, it is necessary that the health institution as employer provide newly hired nurses with a basic critical care nurse specialty education and orientation prior to the deployment in the critical care areas. In the Advanced Practice Nursing level, the advanced practice nurses in the critical care, must earn an advanced degree either at the master’s or doctorate level in nursing.

CRITICAL CARE NURSING WORKFORCE

The CCNAPI adopt the Position Statement of the World Federation of Critical Care Nurses on the Provisions of Critical Care Nursing Workforce also called” the Declaration of Buenos Aires” ratified in the full council meeting last

August 27, 2011 at the Sheraton Hotel, Buenos Aires, Argentina.

The declaration presents guidelines universally accepted by critical care professionals, which should be adopted to meet the critical care nursing workforce and the system requirements of a particular country or jurisdiction. The declaration states the specific central principles governing the provision and provides for specific recommended critical care nursing workforce requirement. The complete declaration is attached as Annex II to this guideline.

ROLES OF THE CRITICAL CARE NURSES

In response to the changes and expansions within and outside the healthcare environment, critical care nurses have broadened their roles in the practice levels. Competencies of critical care nurses are honed and developed to achieve their roles in practice, management / leadership and research.

Practitioner Role

The critical care nurses execute their practice roles 24-hours a day to provide high quality care to the critically ill patient.

1. Care Provider

A. Direct patient care

• Detects and interprets indicators that signify the varying conditions of the critically ill with the assistance of advanced technology and knowledge;
• Plans and initiates nursing process to its full capacity in a need driven and proactive manner;
• Acts promptly and judiciously to prevent or halt deterioration of patients’ condition when conditions warrant, and
• Co-ordinates with other healthcare providers in the provision of optimal care to achieve the best possible outcomes.

B. Indirect patient care – Care of the Family

• Understands family needs and provide information to allay fears and anxieties and
• Assists family to cope with the life-threatening situation and/or patient’s impending death.

2. Extended roles as critical care nurses

Critical care nurses have roles beyond their professional boundary. With proper training and in accordance with established guidelines, algorithms, and protocols that are continuously reviewed and updated, critical care nurses also perform procedures and therapies that are otherwise done by doctors. Such procedures and therapies are:

a. Sampling and analyzing arterial blood gases;

b. Weaning patients off ventilators;

c. Adjusting intravenous analgesia / sedations;

d. Performing and interpreting ECGs;

e. Titrating intravenous and central line medicated infusion and nutrition support;

f. Initiating defibrillation to patient with ventricular fibrillation or lethal ventricular tachycardia;

g. Removal of pacer wire, femoral sheaths and chest tubes,and

h. Other procedures deemed necessary  in their respective institutions under a clinical protocol.

3. Educator

As an educator, the critical care nurse must be able to:

• Provides health education to patient and family to promote understanding and acceptance of the disease process thus facilitate recovery and
• Participates in the training and coaching of novice healthcare team members to achieve cohesiveness in the delivery of patient care.

4. Patient Advocate

The critical care nurses’ role includes being an advocate – someone who acts or intercedes on behalf or another. Typically, the critical care nurse may be in the best position to act as the liaison between patient and family and other team members and departments because they are the healthcare professionals with the most interpersonal contact with the patients. To perform this function adequately, the nurse must be knowledgeable about the involved in all aspects of the patient’s care and have a positive working relationship with other team members. The critical care nurses are expected to:

• Acts in the best interests of the patient and
• Monitors and safeguards the quality of care which the patient receives.

Management and Leadership Role

The critical care nurse in her management and leadership role will be able to  assume the following responsibilities:

• Performance of management and leadership skills in providing safe and quality care;
• Accountability for safe critical care nursing practice;
• Delivery of effective health programs and services to critically-ill patients in the acute setting;
• Management of the critical care nursing unit or acute care setting;
• Taking the lead and supervision of nursing support staff, and
• Utilization of appropriate mechanism for collaboration, networking, linkage –building and referrals.

Role in Research

The critical care nurse’s role in research will entail the following responsibilities:

• Engage self in nursing or other health – related research with or under the supervision of an experienced researcher;
• Utilization of  guidelines in the evaluation of research study or report
• c. Application of the research process in improving patient care infusing concepts of quality improvement in partnership with other team-players.

ADVANCED PRACTICE LEVEL

The development of the Advanced Practice Nursing is the future direction in the Philippines and to be bench marked with other countries. For now, a thorough study of Advanced Practice in critical care  is being undertaken to align with the PRC- BON initiative on specialization framework.

The current global healthcare environment demands critical care nurses to have advanced knowledge and skills to provide the highest possible level of care to the critically ill patients. CCNAPI supports the following descriptions of advanced practice roles.

Expanded Roles

• Nurse Specialist / Clinical Nurse Specialist

The education and preparation of the critical care nurse practitioner is provided by the respective hospitals. CCNAPI recommends that a graduate study or a master’s degree program should support the development of critical care nursing specialization goes beyond the basic baccalaureate nursing degree. Advanced educational preparation refers to the critical care nursing educational program  run by the university offering Advanced Nursing Studies or other recognized advanced critical care program offered in the Philippines and overseas.

A registered nurse who is a nursing degree holder, should have more than 3 years of uninterrupted practice experience in the critical care field.He/she can function as a critical care nurse specialist when he/she has attained advanced education and expertise in caring patients with critical problems. He/she is  also eligible to be certified by the PRC- Board of Nursing as a Clinical Nurse Specialist.

The critical care nurse specialist is responsible for building up nursing competencies in the ICU entity. He / She contributes to continuous improvement in critical care nursing through staff and clients education and uphold quality nursing guidelines  on patient care through clinical research and refinement of ICU Standards.

B. Acute Care Nurse Practitioner

Acute Care Nurse Practitioner (ACNP) in the critical care unit takes lead in developing evidence-based practices to meet changing clinical needs and facilitates patient care processes across professional and organizational boundaries. The qualification of Acute Care Nurse Practitioner (ACNP) includes:  should have the recommended number of post registration (licensed experience) nursing experience which are spent in the critical field, exhibiting in –depth professional knowledge and skills. An Acute Care Nurse Practitioner (ACNP) is a holder of: a) clinical master’s degree in a clinical nursing specialty (Medical-Surgical) such as Critical Care Nursing or b) master’s degree in nursing or related discipline such as management together with recognized critical care training qualifications. The Acute Care Nurse Practitioner executes the nursing team leader’s responsibilities as designated in the position of Advanced Nurse Practitioner.

C. Outcome Specialist

Outcome management has been introduced into the healthcare system to ensure achievement of quality and cost-effectiveness in the delivery of patient care. Some critical care units have adopted clinical pathways (e.g., Critical Pathways, Protocols, Algorithms and Orders) in the management of specific diseases such as Acute Myocardial Infarction and Cardio-thoracic Surgeries. Qualified nurse experts are involved in the development and implementation of patient outcomes management.

CHALLENGES OF CRITICAL CARE NURSES

The challenging needs that the advanced critical care practitioner will face from the critical care nursing service and its environments demand for them to consider the following objectives:

• To develop, foster and maintain a level of knowledge about the norms, values, beliefs, patterns of illness, health and care needs of the people;
• To analyze and evaluate critical care nurses specialty skills and their evolving roles;
• To review current studies and researches and to examine contextual issues that will enable evaluation and synthesis of new knowledge, traditional techniques, religious and cultural influences to be applied in nursing practice, particularly evidence-based nursing practice, and
• To exercise professional judgments expected of them in the critical care clinical setting.

TRAINING OF NURSES FOR CRITICAL CARE SERVICES

The institution / hospital should provide training opportunities to ensure staff competencies.  This will enable the nurses working in the critical care units to cope with the complexities and demands of the changing needs of the critically ill patients.  The following training activities should be supported  by the higher level of management to maintain a high standard of care:

Orientation Program / Preceptorship and Mentoring Program

New recruits to the critical care units shall attend an orientation program and be given opportunities to work under senior staff supervision. Experienced staff in the unit should be readily available for consultation.

In-Service Training Program

a. Unit / hospital based training courses / workshop / seminar at hospital level

b. On-the-job training and bedside supervision

Critical Care Nursing Program (Post Graduate Specialty Program)

Critical Care Nurses Association of the Philippines, Inc. recommends that all practicing CCN shall continuously update their knowledge, skills and behavior through active participation in Critical Care Nursing Education or its related field.

The following are categorization of critical care nursing education:

• Post Graduate Courses

Post graduate courses are part of higher education taken after a Bachelor’s Degree that are accredited from the Commission on Higher Education (CHED) or the Professional Regulation Commission—Board of Nursing (PRC-BON).

It is recommended that this course has been reviewed, evaluated and endorsed to the accrediting body by the Critical Care Nurses Association of the Philippines, Inc.

Likewise it is further recommended that the World Federation of Critical Care Nurses policy statement of education shall be used as a framework for designing a critical care nursing program. (Please see Declaration of Madrid, 2005 Annex I)

• Certification Course

Certification courses provides recognition and designation earned by a professional nurse after completing with satisfaction the requirements of the course and has earned qualification to perform a job or task.

The certification courses should be recognized and accredited by the Professional Regulation Commission— Board of Nursing (PRC-BON) or other authorized accrediting body.

This shall include but not limited to the following:

• Advanced Cardiac Life Support
• Pediatric Advanced Cardiac Life Support
• Newborn Resuscitation
• Continuous Renal Replacement Certification
• Advanced Intravenous therapy
• Stroke Nursing

Continuing Professional Education (CPE)

Continuing Professional Education Programs is a type of education that consist of updated knowledge and other pertinent information that will help the Critical Care Nurse to attain broader understanding  of criticalcare practice and its related field. The goal includes Critical Care Nurses development of skill, behavior that will help them view the critically ill person in a holistic dimension

CCNAPI recommends that all practicing CCN shall ensure the they continuously update their knowledge, skills and behavior through active participation in related critical care nursing education and must earn at least 20 credit units per year.

The updated educational component includes but not limited to the following:

• Advanced/Comprehensive Critical Assessment
• Critical Care Practitioner
• End-of-Life and Palliative Care

STANDARDS OF CRITICAL CARE NURSING PRACTICE

Critical care specialty addresses the management and support of patients with severe or life-threatening illness. The goal of critical care nursing is to promote optimal adaptation of critically ill patients and their families by providing highly individualized care, so that the critically ill patients adapt to their physiological dysfunction as well as the psychological stress in the Critical Care Unit or Intensive Care Unit (ICU). To achieve this, standards should be developed to serve as a guide for monitoring and enhancing the quality of intensive care nursing practice.

Care standards for critical care nursing provide measures for determining the quality of care delivered, and also serve as means for recognizing the competencies of nurses in intensive care specialty.

Procedures standards for critical care nursing practice provide a step-by-step guideline for nurses to carry out day-to-day nursing procedure in a most appropriate manner.

The following 11 Standards are intended to furnish nurses with directions in providing quality care and excellence in Critical Care Nursing:

1.  The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.

2. The critical care nurse provides care to meet individual patient needs on a 24-hour basis.

3. The critical care nurse practices current critical care nursing competently.

4. The critical care nurse delivers nursing care in a way that can be ethically justified.

5. The critical care nurse demonstrates accountability for his/her professional judgment and actions.

6. The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

7. The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

8. The critical care nurse protects the patients from developing environmental induced infection.

9. The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.

10. The critical care nurse carries out health education for promotion and maintenance of health.

11. The critical care nurse acts to enhance the professional development of self and others.

The Structure-Process-Outcome model is used. Emphasis is put on management systems, nursing activities and interactions between the nurse and the care recipients, as well as the outcomes of nursing care provided.

Standard Statement 1: The critical care nurse functions in accordance with legislation, common laws, organizational regulations and by-laws, which affect nursing practice.

Standard Statement 2: The critical care nurse provides care to meet individual patient needs on a 24-hour basis

Standard Statement 3: The critical care nurse practices current critical care nursing competently

Standard Statement 4: The critical care nurse delivers nursing care in a way that can be ethically justified.

Standard Statement 5: The critical care nurse demonstrates accountability for his/her professional judgment and actions.

Standard Statement 6: The critical care nurse creates and maintains an environment which promotes safety and security of patients, visitors and staff.

Standard Statement 7: The critical care nurse masters the use of all essential equipment, available services and supplies for immediate care of patients.

Standard Statement 8: The critical care nurse protects patients from developing environmental induced infection.

Standard Statement 9: The critical care nurse utilizes the nursing process in an explicit systematic manner to achieve the goals of care.

Standard Statement 10: The critical care nurse carries out health education for promotion and maintenance of health.

Standard Statement 11: The critical care nurse acts to enhance the professional development of self and others.

COMPETENCIES FOR CRITICAL CARE NURSES

The competence of critical care nurses together with established nursing standards and the identified core competencies for registered nurses will result to excellence in critical care nursing practice. This three-pronged holistic framework ensures quality performance through an adherence to nursing standards, the demonstration of competencies, and the integration of appropriate nursing model/s into the health care delivery process.

To achieve safe and quality client-centered care, nurses working in the critical care units are envisioned to adopt not only the stated core competencies of registered nurses but also the specific competencies stipulated in the following eleven major key responsibility areas:

Safe and Quality Nursing Care

Management of Resources

Legal Responsibilities

Ethico-Moral Responsibilities

Collaboration and Teamwork

Personal and Professional Development

Communication

 Health Education

Quality Improvement

Record Management

Position Statement on the Provision of Critical Care Nursing Education - Declaration of Madrid, 2005

Introduction

At the 6th World Congress on Intensive Care and Critical Care Medicine in Madrid, Spain 1993 the World Federation of Societies of Intensive Care and Critical Care Medicine endorsed what has become know as the Declaration of Madrid on the preparation of critical care nurses.

In May 2003 the World Federation of Critical Care Nurses under took a review of the Declaration of Madrid and recommendations from the Australian College of Critical Care Nurses position statement on critical care nursing education and other similar documents from member associations. The current position statement aims to inform/assist critical care nursing associations, health care providers, educational facilities and other interested parties in the

development and provision of critical care nursing education.

The first draft of this position statement was distributed to member societies of the WFCCN between February 2004 and September 2004 and changes made following discussion and meeting of the WFCCN in Cambridge September 2004.

The second draft of this position statement was distributed to a wider audience including member societies of WFCCN, other international nursing and medicine organisations and individuals with an interest in critical care nursing between October 2004 and April 2005.

The third draft of this position statement was distributed to an ever-wider audience again including member societies of WFCCN, other international nursing and medicine organisations and individuals with an interest in critical care nursing between May2005 and August 2005.

A full meeting of the World Federation of Critical Care Nurses on Saturday 27 August 2005 at the Sheraton Hotel, Buenos Aires, Argentina, ratified this position statement.

Copyright of this statement is owned by WFCCN. Whilst this statement is freely available for all people to access its wording may not be changed under any circumstances.

Critical or intensive care is a complex specialty developed to serve the diverse health care needs of patients (and their families) with actual or potential life threatening conditions.

The role of the critical care nurse is essential to the multidisciplinary team needed to provide specialist knowledge and skill when caring for critically ill patients. The critical care nurse enhances delivery of a holistic, patient centred approach in a high tech environment bringing to the patient care team a unique combination of knowledge and caring. In order to fulfil their role, nurses require appropriate specialised knowledge and skills not typically included in the basic nursing programs of most countries.

Government, professional and educational bodies governing the practice of nursing must recognise the importance of dedicated specialised preparation for critical care nurses in order to assure the optimum health care delivery of their community. This declaration presents guidelines universally accepted by critical care professionals, which may be adapted to meet the educational and health care requirements of a particular country or jurisdiction.

Central Principles

  1. Critically ill patients and families have the right to receive individualised critical care from qualified professional nurses.

• Critical care nurses must possess appropriate knowledge, attributes and skills to effectively respond to the needs of critically ill patients, to the demands of society, and to the challenges of advancing technology.
• Where a basic nursing education program does not include these required specialised knowledge, attributes and skills, access to such further education must be provided to nurses responsible for the care of critically ill patients and their families.
• Nurses with specialised knowledge and expertise in the provision of care to critically ill patients should play an integral part in the education of critical care nurses, even when a multidisciplinary, educational approach is utilised.
• The preparation of critical care nurses must be based on the most current available information and research.

Recommendations for Critical Care Nursing Education

The World Federation of Critical Care Nurses believe that critically ill patients have very special needs and must be cared for by nurses with specialist skills, knowledge and attitudes.

The following recommendations have been adopted to represent universal principles to help guide health services, educational facilities and critical care nursing organisations in the development of appropriate educational programs for nurses who are required to care for critically ill patients and

their families:

• As a minimum, the critical care dimensions of the following topics should be included in programs to prepare critical care nurses. The categories are not listed in order of importance:
• Anatomy and physiology
• Pathophysiology
• Pharmacology
• Clinical Assessment (including interpretation of diagnostic and laboratory results)
• Illnesses and alterations of vital body functions
• Plans of care and nursing interventions
• Medical interventions and prescriptions with resulting nursing care responsibilities
• Psychosocial aspects (including cultural and spiritual needs)
• Technology applications
• Patient and family education
• Legal and ethical issues
• Professional nursing issues and roles in critical care, including clinical teaching strategies, team leadership and management issues
• Use of current research findings to deliver evidence based multidisciplinary care
• Caring for the carer (including dealing with stress and peer support)
• Programs preparing critical care nurses to function at a specialist level of practice should be provided at a post-registration level and conducted by a higher education provider (for example, a university or equivalent provider).
• The curricula of critical care nursing post-registration courses must provide an appropriate mixof theoretical and clinical experience, to prepare nurses to meet the challenges of clinical practice effectively.
• WFCCN recommends that national critical care nursing associations establish agreed Standards for Specialist Critical Care Nursing to be utilised as a framework for both critical care curriculum development and assessment of clinical practice.
• Post-registration courses for critical care nurses must provide a balance between clinically oriented content and broader generic content that enables the specialist nurse to contribute to the profession through processes such as research, practice development and leadership.
• Close collaboration between the health care and higher education sectors is important, in order that post-registration critical care nursing education be provided at a standard that meets the expectations of both sectors.
• Graduates of post-registration courses in critical care must be able to demonstrate clinical competence as well as a sound theoretical knowledge base. A strong emphasis on the application of theory to practice, and the assessment of clinical competence, should be an integral component of post-registration critical care courses.
• The provision of appropriate clinical experience to facilitate the development of clinical competence should be a collaborative responsibility between education and health care providers. Critical care nursing students should have access to support and guidance from appropriately experienced staff such as clinical teachers and nurse preceptors.
• Clinical teachers and nurse preceptors for post-registration critical care nursing students should be appropriately supported in their role by both education and health care providers.
• Critical care education providers should have in place policies and processes for recognition of prior learning and alternative entry pathways into formal post-registration specialist courses, in order to create a more flexible yet consistent means for students to attain recognition of competence.
• Health care and higher education providers need to establish strategies to help reduce the financial burden faced by nurses undertaking post-registration critical care courses.
• Education providers must implement educational strategies to facilitate access to post registration courses for critical care nurses from a range of geographical locations.
• Innovative strategies need to be implemented to address the deficit of qualified critical care nurses, rather than resorting to short training courses to resolve the problem. Such strategies could include comprehensive critical care workforce planning, innovative retention strategies, nurses undertaking post-registration critical care courses, refresher ‘training’, professional development programs and the provision of greater support for nurses undertaking post-registration critical care courses.
• Providers of short critical care training courses should seek credit transfer (recognition of prior learning) within the higher education sector for nurses completing these courses.

References:

• Australian College of Critical Care Nurses, Critical Care Nursing Education Advisory Committee, Position Statement on postgraduate critical care nursing education – October 1999. Aust. Critical Care, 1999 (vol 12, No 4. p160-164)
• World Federation of Societies of Intensive and Critical Care Medicine. Declaration of Madrid on the preparation of Critical Care Nurses. Aust. Critical Care 1993 vol 6 No 2 p.24.
• International Nursing Council. The Global Shortage of Registered Nurses: An Overview of Issues and Actions (and accompanying Issues Papers) www.icn.ch/global

Position Statement on the Provision of Critical Care Nursing Workforce - Declaration of Buenos

Aires, 2005

In May 2003 the World Federation of Critical Care Nurses undertook a review of available national critical care nursing associations’ position statements on critical care nursing workforce requirements. The current position statement aims to inform and assist critical care nursing associations, health services, governments and other interested stakeholders in the development and provision of appropriate critical care nursing workforce requirements.

Development of the nursing workforce within of critical care units requires careful planning and execution to ensure an appropriate balance and mix of staff skills and attributes that allow for safe and effective care. In parallel is the provision of a learning environment for novice critical care nurses, a flexibility to respond to changes in demand and efficiencies to ensure economic

sustainability without clinical compromise.

Critical Care nursing workforce planning must be considered in the context of the total hospital requirement for access to critical care beds in addition to the regional requirement for integrated and accessible critical care services across a number of hospitals and institutions in a population defined health service.

Governments, hospital boards and professional bodies that inform and support the provision of critical care services must recognise the importance of providing adequately skilled, educated and available critical care nurses, doctors and other support staff to assure the health and safety of some of the most vulnerable patients in the health care system.

This declaration presents guidelines universally accepted by critical care professionals, which may be adapted to meet the critical care nursing workforce and system requirements of a particular country or jurisdiction.

• Every patient must be cared for in an environment that best meets his or her individual needs. It is the right of patients whose condition requires admission to a critical care unit to be cared for by registered nurses. In addition the patient must have immediate access to a registered nurse with a post registration critical care nursing qualification (refer to WFCCN Declaration of Madrid on the provision of critical care nursing education).
• There should be congruence between the needs of the patient and the skills, knowledge and attributes of the nurse caring for the patient.
• Unconscious and ventilated patients should have a minimum of one nurse to one patient. High dependency

patients in a critical care unit may have a lesser nurse patient ratio. Some patients receiving complex

therapies in certain critical care environments may require more than one nurse to one patient.

• When calculating nurse-to-patient ratios and roster requirements in critical care, consideration and care must be given to the skill sets and attributes of nursing and support colleagues within the nursing shift team as they vary and require re-evaluation with fluctuations in patient care requirements.
• Adequate nursing staff positions must also be in place to assist with nursing education, inservice training, quality assurance and research programs, management and leadership activities, and where institutionally required, external liaison and support services beyond the confines of the critical care unit.
• Critical care nurses should focus their labor on roles and tasks that require advanced skill, expertise and knowledge of best practice in patient care. Therefore, adequate numbers of support staff should be employed to preserve the talents of critical care nurses for patient care and professional responsibilities wherever possible.
• Flexible workforce strategies and incentives should be employed by management to recruit, retain and remunerate expert critical care nurses at the patient bedside, and to ensure appropriate succession planning for future leadership needs. Additionally, contingencies should also be in place to respond to fluctuating and unexpected demands on the critical care service.

Recommendations for Critical Care Nursing Workforce Requirements

As a minimum, the critical care unit should maintain or strive to achieve the following nursing workforce requirements:

• Critically ill patients (clinically determined) require one registered nurse at all times.
• High dependency patients (clinically determined) in a critical care unit require no less than one registered nurse for two patients at all times.
• Where necessary extra registered nurses may provide additional Assistance, Coordination, Contingency (for late admission, sick staff), Education, Supervision, and Support to a sub-set of patients and nurses in a critical care unit. (some times referred to as ACCESS nurse)
• A critical care unit must have a dedicated head nurse (otherwise called Charge Nurse or similar title) to manage and lead the unit. This person must have a recognised post-registration critical care nursing qualification. It is also recommended the Head Nurse/Nurse in Charge have management qualifications.
• Each shift must have a designated nurse in charge to deputise for the head nurse and to ensure direction and

supervision of the unit activities throughout the shift. This person must have a recognised post-registration

critical care nursing qualification.

• A critical care unit must have a dedicated nurse educator to provide education, training and quality improvement activities for the unit nursing staff. This person (s) must have a recognised post-registration critical care nursing qualification.
• Resources must be allocated to support nursing time and costs associated with quality assurance activities, nursing and team research initiatives, education and attendance at seminars and conferences.
• Adequate support staff within the critical care area including: administrative staff, support staff to assist with manual handling, cleaning and domestic duty staff and other personnel exist to allow nursing staff to focus on direct patient care and associated professional requirements.
• Appropriately skilled and qualified medical staff are appointed and accessible to the unit for decision making and advice at all times. A medical director is appointed to work collaboratively with the head nurse in order to provide policy/protocol, direction and collaborative support.
• Remuneration levels for nursing staff are such that they are competitive with similar professions in the country and are scaled in such away as to reward and retain qualified, experienced and senior critical care nurses.
• Appropriate, accessible and functional levels of equipment and technology are available and maintained to meet the demands of the expected patient load at any given time and nursing staff are adequately trained and skilled in the application of such equipment and technology.
• Adequate occupational health and safety regulations should be in place and enforced to protect nurses from hazards of manual handling and occupational exposure.
• Organised and structured peer support and debriefing procedures are in place to ensure nursing staff support and wellbeing following critical incident exposure.
• Australian College of Critical Care Nurses Position Statement on Intensive Care Nursing Staffing. www.acccn.com.au 
• British Association of Critical Care Nursing. Position Statement. Nurse-patient ratios in critical care. Nursing in Critical Care.2001. Vol No2.P59-63 
• Williams, G.F. & Clarke, T. 2001. “A Consensus Driven method to measure the Required Number of Intensive Care Nurses in Australia”. Aust.Critical Care. 14(3):106-115. 

  Position Statement on the Rights of the Critically Ill Patient - Declaration of Manila, August 2007

At the 1st World Federation of Critical Care Nurses (WFCCN) meeting in Cambridge in 2004 the WFCCN chose to develop a position statement on Rights of the Critically Ill Patient. The existing situation was considered and similar documents from other organisations were examined. This was then discussed further at the 2nd Congress of WFCCN in Buenos Aires, August 2005.

The current position statement aims to inform and assist critical care nursing associations, health services, educational facilities and other interested parties in the development of patient’s rights for the critically ill.

I. Preamble

In 1948 the United Nations proclaimed the Universal Declaration of Human Rights. The rights of individuals have been proclaimed and expanded since then in many statements and nations. The specific rights in health care have been stated by many nations and some health care groups.

Critical care nursing is specialised nursing care of critically ill patients who have manifest or potential disturbance of vital organ functions.

The World Federation of Critical Care Nurses (WFCCN) has considered the rights of critically ill patients. WFCCN have agreed that the statement on patient’s rights from the International Council of Nurses (ICN) covers the requirements for a position statement on the rights of the critically ill patient.

The WFCCN accept and support the ICN position statement on Nurses and Human Rights reproduced below.

II. Nurses and Human Rights

ICN Position:

The International Council of Nurses (ICN) views health care as a right of all individuals, regardless of financial, political, geographic, racial or religious considerations. This right includes the right to choose or decline care, including the right to accept or refuse treatment or nourishment; informed consent; confidentiality, and dignity, including the right to die with dignity. It involves both the rights of those seeking care and the providers.

Human Rights and the Nurse’s Role

Nurses have an obligation to safeguard and actively promote people’s health rights at all times and in all places. This includes assuring that adequate care is provided within the resources available and in accordance with nursing ethics. As well, the nurse is obliged to ensure that patients receive appropriate information in understandable language prior to consenting to treatment or procedures, including participation in research.

Nurses are accountable for their own actions and inactions in safeguarding human rights, while National Nurses Associations (NNAs) have a responsibility to participate in the development of health and social legislation related to patient rights.

Where nurses face a “dual loyalty” involving conflict between their professional duties and their obligations to their employer or other authority, the nurse’s primary responsibility is to those who require care.

Nurses’ Rights

Nurses have the right to practice in accordance with the nursing legislation of the country in which they work and to adopt the ICN Code of Ethics for Nurses or their own national ethical code.  They also have a right to practice in an environment that provides personal safety, freedom from abuse and violence, threats or intimidation. Nurses individually and collectively through their national nurses associations have a duty to speak up when there are violations of human rights, particularly those related to access to essential health care and patient safety.

National nurses’ associations need to ensure an effective mechanism through which nurses can seek confidential advice, counsel, support and assistance in dealing with difficult human rights situations.

Background:

Nurses deal with human rights issues daily, in all aspects of their professional role. As such, they may be pressured to apply their knowledge and skills in ways that are detrimental to patients and others. There is a need for increased vigilance, and a requirement to be well informed, about how new technology and experimentation can violate human rights. Furthermore

nurses are increasingly facing complex human rights issues, arising from conflict situations within jurisdictions, political upheaval and wars. The application of human rights protection should emphasise vulnerable groups such as women, children, elderly, refugees and stigmatised groups.To prepare nurses to adequately address human rights, human rights issues and the nurses’ role

need to be included in all levels of nursing education programmes.

ICN endorses the Universal Declaration of Human Rights[1]and ICN addresses human rights issues through a number of mechanisms including advocacy and lobbying, position statements, fact sheets, and other means.

Adopted in 1998

Revised in 2006

(Replaces previous ICN Position: “The Nurse’s Role in Safeguarding Human Rights”, adopted 1983, updated 1993).

1 Universal Declaration of Human Rights (1948), New York: United Nations

• International Council of Nurses Position Statement on Nurses and Human Rights, Adopted in 1998,revised in 2006. Accessed on December 2008, at. http://www.icn.ch/pshumrights.htm

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National Health Care Decisions Day 2024: As Certain as Death and Taxes

Gould, Kathleen Ahern PhD, RN

Editor in Chief Dimensions of Critical Care Nursing

Kathleen Ahern Gould, https://orcid.org/0000-0002-2874-0794

The author has disclosed that she has no significant relationships with, or financial interest in, any commercial companies pertaining to this article.

Address correspondence and reprint requests to: Kathleen Ahern Gould, PhD, RN, 247 Washington St, Duxbury, MA 02332 ( [email protected] ).

“Our new Constitution is now established, everything seems to promise it will be durable; but, in this world, nothing is certain except death and taxes.”

In November 1789, this quote was credited to Ben Franklin as he pondered his own mortality. In a letter to his friend, French scientist Jean-Baptiste Le Roy, Franklin writes, “My health continues much as it has been for some time, except that I grow thinner and weaker so that I cannot expect to hold out much longer.” 1 Within the year, Franklin would succumb to a combination of illnesses at the age of 84 years on April 17, 1790. Although the concept of a “death and taxes” may have existed before Franklin, his use of the quote in correspondence near the end of his life commits the words to popular culture. 1

The arrival of spring reminds us to file tax returns. Now, since 2008, it also reminds us to consider our mortality. National Health Care Decisions Day (NHDD) falls on the same date in April each year. It is fitting that these 2 events converge. The designation of the April date was inspired by Franklin's words through a collaboration with the Conversation Project, a public engagement initiative of the Institute for Healthcare Improvement. 2 In 2008, NHDD was founded by an attorney to provide clear, concise, and consistent information on values-based, health care decision-making for individuals, health care providers/facilities, and community leaders through the widespread availability and dissemination of simple, free, and uniform tools (not just forms) to guide the process ( https://theconversationproject.org/wp-content/uploads/2024/01/NHDD-Toolkit-2024.pdf ).

The goal of this work is simple: “to help everyone talk about their wishes for care through the end of life (EOL), so those wishes can be understood and respected.” 3 This April, I replicated my annual letter to friends, family, and colleagues, inviting them to celebrate NHDD by completing a personal advance directive. 2 This begins by talking to friends and loved ones about advance care planning. For some, it serves to provide information about this process. To begin, I use details from the Conversation Project 4 to explain that advance directives have 2 parts, which will be discussed hereinafter.

YOUR HEALTH CARE PROXY

This is the part of the advance directive where you name the person you have chosen to make health care decisions on your behalf, if needed, as well as an alternate if your first choice is unavailable. Over time, continue the conversation with these people to be sure they understand what matters to you. 4

YOUR LIVING WILL

This is the part of the advance directive where you describe your preferences and wishes for your health care if you cannot speak for yourself. A living will is only one component of an advance directive.

These may be some of the same things that you have thought about and discussed with patients, families, or colleagues. Often, discussions include more questions than answers. Fortunately, the Conversation Project provides many tools to guide these consultations. 4 The many definitions and documents can be confusing. The team at CaringInfo has prepared a blog that provides definitions and links to more resources, even a direct link to advance directive forms for each state ( https://www.caringinfo.org/blog/types-of-documents-to-make-healthcare-wishes-known/ ).

You do not need an attorney to fill out any of these documents, but advance directives are either witnessed or signed. Each state has specific requirements about witnesses or notarization, but none requires the services of an attorney. Advance directives may also contain instructions around organ donation, appointment of a guardian, and other matters depending on which state you live in ( https://www.caringinfo.org/planning/advance-directives/by-state/ ).

Everyone begins these discussions at a different place. Often, simple definitions, word choices, or diagrams are useful ( Figure ). For others, a link to social media resources works best 5 ( Table ). For the digital consumer, blogs may be a great resource, such as the one found in @ convoproject's blog at https://bit.ly/3OedZjc . Many social media accounts tag to post within other sources such as @5WishesOrg, @prepareforcare, @CoPractice, @CACforCC, and @thedeathdeck.

Medical providers often direct these discussions but, often, have not executed these discussions with their own loved ones. This information may help providers become comfortable with patient and families' questions and concerns as they explore the resources for personal use.

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Guideline on positioning and early mobilisation in the critically ill by an expert panel

• Conference Reports and Expert Panel
• Open access
• Published: 29 July 2024

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• Stefan J. Schaller   ORCID: orcid.org/0000-0002-6683-9584 1   na1 ,
• Flora T. Scheffenbichler 2 ,
• Thomas Bein 3 ,
• Manfred Blobner 2 , 4 ,
• Julius J. Grunow 1 ,
• Uwe Hamsen 5 , 6 ,
• Carsten Hermes 7 , 8 ,
• Arnold Kaltwasser 9 ,
• Heidrun Lewald 4 ,
• Peter Nydahl 10 , 11 ,
• Anett Reißhauer 12 ,
• Leonie Renzewitz 13 , 14 ,
• Karsten Siemon 15 ,
• Thomas Staudinger 16 ,
• Roman Ullrich 17 , 18 ,
• Steffen Weber-Carstens 1 ,
• Hermann Wrigge 19 , 20 ,
• Dominik Zergiebel 21 &
• Sina M. Coldewey   ORCID: orcid.org/0000-0002-7130-0006 22 , 23   na1  

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A scientific panel was created consisting of 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology delegated from scientific societies together with a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II. The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The panel formulated PICO questions (addressing the population, intervention, comparison or control group as well as the resulting outcomes), conducted a systematic literature review with abstract screening and full-text analysis and created summary tables. This was followed by grading the evidence according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence and a risk of bias assessment. The recommendations were finalized according to GRADE and voted using an online Delphi process followed by a final hybrid consensus conference. The German long version of the guideline was approved by the professional associations. For this English version an update of the systematic review was conducted until April 2024 and recommendation adapted based on new evidence in systematic reviews and randomized controlled trials. In total, 46 recommendations were developed and research gaps addressed.

Avoid common mistakes on your manuscript.

Introduction

In adult critically ill patients in intensive care units (ICU), prolonged immobility is associated with several short- and long-term sequelae such as intensive care unit-acquired weakness (ICUAW) [ 1 ], loss of muscle mass [ 2 , 3 ] and functionality [ 4 ], delirium [ 5 , 6 , 7 , 8 ], cognitive decline [ 9 , 10 ], and reduced quality of life [ 10 ] which may be minimised by early mobilisation. There is increasing evidence that electrophysiological changes in the neuromuscular system occur as early as 48 h after admission [ 11 ]. The complex pathophysiological changes within neuromuscular pathways promote the upregulation of muscle-wasting systems, leading to ICUAW [ 11 ]. This results in a loss of muscle mass and, importantly, in a loss of functionality and insulin resistance [ 12 ]. Inflammation, a common coexisting condition in critically ill patients, amplifies these effects [ 13 – 15 ].

An interdisciplinary and interprofessional panel of experts from Germany and Austria formulated clinical key questions, conducted a systematic literature review, and developed a guideline to support healthcare providers in implementing positioning and early mobilisation for critically ill adult patients in the ICU. Early mobilisation was defined as mobilisation commencing within 72 h of ICU admission.

Panel composition

This interdisciplinary and interprofessional guideline, an update from [ 16 ], was formulated by experts representing scientific societies in Austria and Germany [electronic supplementary material (ESM) 1, Table S1], following a more rigorous methodology than the previous version, which adhered to the Manual for Guidelines of the Association of the Scientific Medical Societies in Germany (AWMF) [ 17 ].

Literature review and evidence preparation

A systematic literature search on Pubmed, Cochrane Library, PEDro (Physiotherapy Evidence Database) and Cinahl (Cumulative Index to Nursing and Allied Health Literature) was conducted in April 2021, with another update in June 2022. Search terms are provided in ESM 1, Table S2. Two reviewers independently screened titles and abstracts for each chapter and graded full texts based on the Oxford Centre of Evidence-Based Medicine Level of Evidence (version 2011) [ 18 ]. The risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2) [ 19 ], the Robis tool [ 20 ] or the Agree-2 tool [ 21 ], depending on the study type. This was followed by level of evidence (LoE) modification of the studies (see ESM 2). Discrepancies between reviewers were resolved through independent third-party expert review at each step and subsequently assessed by the guideline members.

Clinical recommendations and structured consensus

In three online Delphi rounds, the phrasing, referenced studies in the recommendation, including their LoE, and strength of recommendation using GRADE (strong (recommend) and weak (suggest) recommendations) [ 22 ] were voted (and commented) on (Fig.  1 ). In the final hybrid structured consensus meeting, the recommendations that had not yet achieved 100% agreement in the previous Delphi rounds were finally discussed and voted on. Only recommendations with more than 75% agreement were included in the guideline; firm agreement was defined as > 95%. Details on the regulation of conflicts can be found in ESM 1, Methods.

Guideline process overview. The scientific panel comprised 23 interdisciplinary and interprofessional experts in intensive care medicine, physiotherapy, nursing care, surgery, rehabilitative medicine, and pneumology from Germany and Austria (details in ESM 1, Table S1). In addition, a patient representative and a delegate from the Association of the Scientific Medical Societies who advised methodological implementation were part of the interprofessional and interdisciplinary panel. (1) The topics of (early) mobilisation, neuromuscular electrical stimulation, assist devices for mobilisation, and positioning, including prone positioning, were identified as areas to be addressed and assigned to specialist expert groups, taking conflicts of interest into account. The following steps included (2) the formulation of PICO questions (addressing the population, intervention, comparison or control group as well the resulting outcomes, see ESM 1, Table S3), (3) a systematic literature review with abstract screening and full-text analysis and the subsequent creation of summary tables, (4) the grading of evidence according to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence [ 18 ] and risk-of-bias assessment, and (5) a Delphi-lead process for the voting on recommendations, followed by a final hybrid consensus conference. The final steps were (6) the consensus conference and (7) the final guideline approval by the professional associations. The guideline was created according to the German Association of the Scientific Medical Societies (AWMF), based on The Appraisal of Guidelines for Research and Evaluation (AGREE) II [ 17 ]. AWMF  Association of the Scientific Medical Societies,  LoE level of evidence

Additional literature update and adaptions of recommendations

An additional literature update from 1 June 2022 until 4 April 2024 was conducted during the review process. Methodological details and results are presented in ESM 1, Literature search update and modification. Changed recommendations based on the update are marked with an asterisk (*) in the manuscript.

Recommendations for clinical questions

After reviewing 14,258 titles and abstracts since 2014, 446 studies were included (details in ESM 1, Fig. S1). A translation of the German full-text version, including links to evidence tables, is provided in ESM 3.

We developed 46 recommendations: 23 for positioning, 17 for mobilisation, 4 for devices and robotics, and 2 for neuromuscular electrical stimulations (NMES).

Positioning of critically ill patients

For recommendations on positioning of critically ill patients see then Table 1 .

Should ICU patients receive upper body elevation?

Upper body elevation reduces the incidence of ventilator-associated pneumonia (VAP) and duration of ventilation compared with the supine position but does not influence ICU or hospital length of stay (LOS) and mortality [ 24 ]. An elevation of 30–60° versus 0–10° had significant benefits concerning clinically suspected VAP but no difference for microbiologically confirmed VAP, LOS and duration of ventilation. In another meta-analysis comparing 45° with 30° upper body elevation, the 45° group had a lower incidence of VAP and gastric reflux compared with 30° elevation with an increased risk of developing decubitus ulcers (Recommendation 1.1) [ 25 ].

Furthermore, upper body elevation in patients with brain injury should be individualised, including regular cerebral perfusion pressure (CPP) and intracranial pressure (ICP) monitoring at 0°, 15°, and 30° to capture gravity-dependent effects. In all positions, the head should be positioned straight to ensure venous return (Recommendation 1.2) [ 26 ].

Notably, observational studies consistently show an association between higher degrees of upper body elevation and increased intraabdominal pressure  (Recommendation 1.3) [ 27 – 29 ].

Most studies on upper body elevation were performed in ventilated patients. Therefore, generalisability may be limited for non-ventilated patients, where the positive effects of upper body elevation due to a higher level of consciousness and lower aspiration risk may be less pronounced.

Should ICU patients be placed in the lateral position to prevent VAP?

A randomised controlled trial (RCT) investigating lateral 5–10° head-down position (lateral Trendelenburg positioning with side changes every 6 h) versus upper body elevation to prevent VAP was terminated early due to a low VAP incidence, lack of benefits in secondary outcomes, and six serious adverse events intervention group. Although patients with lateral positioning had a lower incidence of VAP, no significant difference in 28-day mortality occurred (Recommendation 1.4) [ 30 ].

In a Cochrane Review on the effect of lateral positioning, only two studies with a very low sample size investigated the effect in ICU patients with unilateral lung injury [ 31 ]. The mean difference in oxygenation between good lung down versus bad lung down was approximately 50 mmHg (Recommendation 1.5). Immobilisation in the same position poses many risks, and the flat supine position should be strictly limited to interventions that require it (Recommendation 1.6) [ 32 ].

Should ICU patients receive continuous lateral rotation therapy?

In an RCT of ventilated ICU patients comparing continuous lateral rotation therapy (CLRT), a continuous rotation of the patient along the longitudinal axis, with usual care, there was no difference in microbiologically confirmed VAP between groups. Importantly, 39% of patients showed intolerance to CLRT during the weaning phase [ 33 , 34 ], reflected by a deeper sedation level  in the intervention group [ 35 ]. A meta-analysis in trauma patients showed a reduction in nosocomial pneumonia for prophylactic CLRT versus usual care but no effect on existing pneumonia or mortality (Recommendation 1.7) [ 36 ].

How should prone positioning be conducted?

Prone positioning of 16 h daily for patients affected with acute respiratory distress syndrome (ARDS) with a duration of ventilation < 36 h and a PaO 2 /FiO 2  < 150 mmHg showed a significant survival benefit for 28-day mortality (Recommendation 2.1) [ 37 ]. Meta-regressions of continuous predictors indicated threshold values for a significant position effect at ≥ 12 prone h/day, ≤ 8.5 mL/kg tidal volume, and PaO 2 /FiO 2  ≤ 130 [ 38 ].

Duration of prone positioning

Most subgroup analyses within meta-analyses [ 38 – 40 ] have found a significant survival benefit using a cutoff value of 12 h of prone positioning. In contrast, Sud et al. [ 41 ] and Lee et al. [ 42 ] defined 16 and 10 h as the minimum duration, respectively, and found a survival advantage with a more extended period of prone positioning aligning with the frequently used 12 h cutoff. According to available evidence, a minimum duration of 12 h seems necessary for a positive effect of prone positioning, with each additional hour improving it (Recommendation 2.3). However, a period longer than 16 h has yet to be studied [ 37 ].

Start of prone positioning

In a Cochrane review, a subgroup analysis revealed a positive effect on mortality if patients were placed in prone position ≤ 48 h of the start of mechanical ventilation [ 43 ]. These are congruent with the time frames in another meta-analysis and the PROSEVA trial [ 37 , 40 ].

No studies explicitly analyse the optimal time to start the prone positioning. However, all available studies and the positive physiological effects indicate that it is optimal to start immediately after its indication (Recommendation 2.2).

End of prone positioning

It has not yet been investigated when therapy in the prone position can be terminated. Based on the survival benefit in the PROSEVA trial, prone positioning should be performed until there is an improvement in oxygenation (PaO 2 /FiO 2  ≥ 150) under de-escalated ventilation (positive end-expiratory pressure (PEEP) ≤ 10 cmH 2 0 and FiO 2  ≤ 0.6) 4 h after supine positioning [ 37 ] (Recommendation 2.9).

Due to the lack of evidence as to whether and for how long prone positioning should be performed in non-responders, the pragmatic expert recommendation is that prone positioning therapy should be terminated after two unsuccessful attempts (lack of improvement in oxygenation) (Recommendation 2.10).

Ventilator parameters be set during prone positioning

Subgroup analyses of meta-analyses suggest that the limitation of tidal volume is necessary for the mortality benefit from prone positioning [ 44 ]. While most of the meta-analyses have used a cutoff of 8 ml/kg predicted body weight, evidence suggests that lowering this cutoff has a beneficial effect [ 44 ].

Gainnier et al . showed that prone positioning and PEEP have an additive effect on improving oxygenation [ 45 ]. Specific evidence on the optimal PEEP setting in the prone position is lacking.

Although deep sedation and analgesia are commonly used in the prone position to avoid discomfort, spontaneous breathing is also possible during prone positioning (Recommendation 2.4) [ 44 ].

Preparation of prone positioning

The studies on the haemodynamic effects of prone positioning in patients with ARDS showed that the intervention was haemodynamically well tolerated and may also positively affect right ventricular load [ 46 – 49 ]. The volume status of patients should be optimised prior to positioning. Studies on the relevance of vasopressor therapy in the context of prone positioning are lacking. Due to the lack of negative haemodynamic effects of prone positioning, ongoing vasopressor therapy is not a contraindication (Recommendation 2.5).

Prone positioning and intraabdominal pressure

During prone position, the intraabdominal pressure increased from 12 ± 4 mmHg to 14 ± 5 mmHg [ 49 ]. In obese patients undergoing prone positioning, an increased rate of hypoxic hepatitis and renal failure was present, without a mortality difference [ 50 ]. According to a case–control study, obese patients did not experience more complications, and the oxygenation improved more compared with non-obese patients [ 51 ]. Due to lacking evidence, the possible positive effects of prone positioning in obese patients or patients who underwent abdominal surgery should be critically evaluated (Recommendation 2.6).

Prone positioning and intracerebral lesions

In an RCT, six patients (24%) with continuous ICP monitoring had a significant ICP increase from 11 to 24 mmHg during prone positioning [ 52 ]. Two studies confirmed these findings, which found a higher frequency of ICP > 20 mmHg and decreased CPP in neuro-ICU ARDS patients receiving prone positioning [ 53 , 54 ]. However, patients benefited from prone positioning regarding oxygenation [ 53 – 55 ]. In contrast, others did not report ICP changes in prone position [ 56 ].

Based on the available evidence, a recommendation concerning patients with acute cerebral lesions and prone positioning in ARDS is currently not possible [ 57 ], and it is required to weigh the potential harms and benefits individually (Recommendation 2.7).

Prone positioning and extracorporeal membrane oxygenation

In a systematic review including 13 trials, prone positioning additive to veno-venous (VV-) extracorporeal membrane oxygenation (ECMO) showed a significant survival benefit [ 58 ], which was not confirmed in a similar review [ 59 ].

Based on the available literature, including current evidence in patients affected with coronavirus disease 2019 (COVID-19) and the safe applicability, we recommend prone positioning of ARDS patients with VV-ECMO in experienced centres (Recommendation 2.16) [ 58 , 60 – 64 ].

Further considerations for prone positioning

Prone positioning is recommended for moderate to severe ARDS, but individual assessment is crucial due to potential comorbidities. A multi-professional and interdisciplinary consensus should balance potential benefits and risks in cases of an open abdomen, unstable spine, increased intracranial pressure, haemodynamically effective cardiac arrhythmias, or shock (Recommendation 2.8).

Incomplete prone position

Scientific studies on incomplete prone positioning are scarce [ 65 , 66 ]. Based on the magnified effect on oxygenation of complete vs. incomplete prone position [ 66 ] and evidence for a reduction in mortality for prone vs. supine position [ 37 ], the complete prone position seems superior (Recommendation 2.11).

Risks and side effects

Prone positioning causes a weight redistribution to body parts not typically exposed in healthy individuals. Meta-analysis and RCTs have repeatedly shown that prone positioning significantly increases the risk of pressure ulcers [ 41 , 43 , 66 – 73 ]. Therefore, it is recommended to regularly conduct thorough inspection of the  vulnerable locations  (Recommendation 2.12).

Should ICU patients receive awake proning during non-invasive ventilation?

In multiple meta-analyses and a meta-analysis of meta-analyses, there was a significant reduction in the need for intubation [ 74 , 75 ] and a reduced mortality [ 75 – 77 ] when awake prone positioning was used in critically ill COVID-19 patients.

Accordingly, it is recommended that this measure be performed in this patient population (Recommendation 2.13). A recommendation concerning other causes of hypoxic lung failure is currently not possible (Recommendation 2.14).

Duration of awake prone positioning

Very heterogeneous protocols were applied in the published trials with conflicting results regarding dose–response relationships [ 77 – 84 ]. Due to the heterogeneity of results, no recommendation can be made regarding the duration and frequency of prone positioning while awake (Recommendation 2.15).

Mobilisation

For recommendations on mobilisation see then Table 2 .

When should (early) mobilisation be started in the ICU?

In RCTs, an early start of mobilisation within 72 h of mechanical ventilation had a beneficial effect on functional independence, mobility, ICU LOS, hospital LOS, delirium-free days, ventilation-free days, discharge home and long-term cognitive and functional benefits [ 4 , 10 , 85 ]. On the contrary, other studies with delayed start of mobilisation after five and seven days, respectively, found no effect on outcomes [ 86 , 87 ]. In addition, a network meta-analysis demonstrated a decreased risk of ICUAW and shortened ventilation duration when mobilisation was started within 72–96 h or 48–72 h of ventilation, respectively [ 88 ]. Given the available evidence from meta-analyses [ 89 – 93 ], early mobilisation should be started within 72 h of ICU admission (Recommendation 3.1).

How should (early) mobilisation be performed?

Mobilisation protocol.

Protocols are known to increase the feasibility, safety, duration, and level of mobilisation [ 94 , 95 ]. Most mobilisation protocols include passive and active mobilisation elements, ranging from passive mobilisation to walking independently [ 96 , 97 , 98 , 99 , 100 , 101 ]. The various mobilisation protocols differ in terms of initiation criteria, patient cohort, and levels of mobilisation [ 99 , 100 , 102 – 107 ].

The ICU mobility scale (IMS), which is commonly used, includes only active mobilisation, and its protocol aims to mobilise the patient to the highest possible level at the beginning of the mobilisation session [ 108 ]. This leads to higher mobilisation levels and longer mobilisation duration than the control group [ 109 – 111 ]. However, this early active mobilisation concept was not superior to standard of care with early mobilisation [ 112 ].

Similarly, by applying the surgical optimisation mobilisation score (SOMS) protocol, patients achieved the highest level of mobilisation at ICU discharge compared to the control group [ 4 ]. However, the SOMS algorithm consists of passive and active components, ranging from no mobilisation to ambulation. Passive mobilisation represents the lowest level in most mobilisation protocols. It is applied when the patient’s consciousness, cognition or haemodynamics are impaired so that active mobilisation cannot be performed [ 102 – 104 , 113 ]. Passive mobilisation benefits patients with impaired consciousness and stroke patients [ 105 , 113 – 115 ] but has not yet been compared with active mobilisation.

The benefits of mobilisation protocols that combine passive and active mobilisation have been shown [ 4 , 95 , 115 ] (Recommendations 3.11, 3.14). Due to the robust data available on the superiority of mobilisation, immobilisation should be the exception (Recommendation 3.8).

Level and duration of mobilisation

The effect of the level of mobilisation on patient outcomes was investigated in an observational study, whereby a higher level of mobilisation was associated with a better state of health [ 109 ]. Active mobilisation, measured by IMS ≥ 4 (standing), reduced the risk of developing ICUAW [ 110 ]. Similarly, a retrospective analysis indicated that achieving an IMS ≥ 4 within 5 days of ICU admission increased the likelihood of being discharged home [ 111 ]. The TEAM trial, however, which initiated  active mobilisation at the highest possible level and aimed to  achieve the maximum  level of activity, demonstrated no benefit [ 112 ]. A recent meta-analysis demonstrated positive effects on duration of ventilation, especially by progressive mobilisation programmes [ 116 ]. Consequently, a stepwise approach without overburdening the patients is recommended (Recommendation 3.16*).

There is evidence that the duration of mobilisation influences the effectiveness of mobilisation on patient outcomes. A higher dose reduced the risk of unfavourable discharge disposition and mortality and led to shorter ICU and hospital LOS [ 117 , 118 ]. In a meta-analysis, a pre-defined subgroup analysis of three studies indicated that a higher dose of mobilisation (≥ 30 min/day) led to improved quality of life at 6 months [ 2 ]. A recent observational study further confirmed this, demonstrating that a mobilisation duration of more than 40 min positively impacts functional outcomes at ICU discharge [ 119 ]. The individual mobilisation dose for each patient may depend on the baseline physical criteria and the underlying disease (Recommendation 3.15*). Further studies in this area are required.

Which patients should receive early mobilisation?

Functional status.

The evidence for the effects of early mobilisation differs between specific patient groups based on the inclusion and exclusion criteria used; most studies enrolled critically ill patients who had been functionally independent prior to ICU admission. In these patients, the beneficial effect of early mobilisation is pronounced in outcomes such as duration of ventilation, ICU LOS, muscle strength, and ICUAW (see ESM 1, Table S4) [ 120 – 122 ] (Recommendation 3.3).

Currently, no studies specifically investigate the effect of (early) mobilisation in patients with functional dependence prior to ICU admission. However, some studies do not explicitly exclude these patients. Two RCTs, including patients ≥ 60 years after cardiac surgery or septic shock, demonstrated that mobilisation reduces the hospital LOS and improves health-related quality of life [ 123 , 124 ]. Another non-randomised controlled study showed that mobilisation increased the level of mobilisation on the last day of rehabilitation, even in previously functionally dependent patients [ 125 ]. In a multivariate analysis within a matched cohort, frail patients did not exhibit functional deterioration more frequently than non-frail patients, suggesting that efforts should be made to at least maintain the functional status in this patient group (Recommendation 3.4) [ 126 ].

Renal replacement therapy and ECMO

Concerns about catheter and tube dislocation are a common barrier to mobilisation. In patients who were mobilised during continuous renal replacement therapy (CRRT), only 1.8% of 436 patients experienced an adverse event [ 127 ] (Recommendation 3.5). In a prospective observational study including patients receiving ECMO, mobilisation was conducted on 24.9% of 1242 ECMO days. Low blood flow alarms occurred in 3.4% of mobilisations. All adverse events were self-limiting or resolved by the treatment team [ 128 ]. Another observational study had a similar rate of 3.6% of adverse events [ 129 ]. One accidental femoral cannula displacement during one mobilisation episode, with immediate and effective recannulation, is reported [ 128 ]. Therefore, only centres with the necessary expertise in ECMO therapy should perform mobilisation in this high-risk cohort, following consultation with the interprofessional team and thorough evaluation of contraindications (Recommendation 3.7).

Neurocritical ICU patients

Neurocritical care patients commonly have bed rest due to concerns about alterations in intracranial pressure and vasospasm [ 130 ]. In a pre-post-study in neurocritical ICU patients diagnosed with subarachnoid haemorrhage, cerebral malignancy, or stroke, (early) mobilisation following a progressive protocol was safe, increased mobility, and reduced VAP rates and ICU and hospital LOS [ 131 ]. These effects were confirmed in patients with severe brain injury [ 132 ]. In contrast, data derived from stroke patients in stroke units (i.e. not in an ICU) indicate that very early mobilisation (< 24 h) may be harmful [ 133 ] (Recommendation 3.6).

When should a mobilisation session be discontinued, and what are the contraindications for mobilisation?

Adverse events occur in 2.6–3.9% of cases, which makes close monitoring a critical tool for recognising a deterioration in vital signs at an early stage [ 134 , 135 ]. To date, there have been no studies comparing different discontinuation criteria. Thus, the clinical symptoms used in the literature were adopted [ 101 , 136 , 137 ], which are considered reference values without general validity (Recommendation 3.10*).

Assessing respiratory and cardiovascular reserves before mobilisation to adjust intensity appropriately is necessary (Recommendation 3.9). No evidence supports absolute parameters as safety criteria for mobilisation initiation, emphasising the importance of the patient’s overall clinical presentation. Values in ESM 1, Table S8, are expert-based, aiding individual risk–benefit assessment. We recommend integrating ICU-specific safety criteria into mobilisation protocols (Recommendation 3.12). If mobilisation is not possible during the assessment, implementing therapeutic measures for improvement, followed by a re-evaluation, is warranted [ 136 ].

What are the requirements to perform (early) mobilisation?

Early mobilisation therapy must overcome structural barriers to mobilisation such as insufficient personnel and financial support and a lack of equipment [ 138 , 139 ]. The hospital management is responsible for creating the conditions for implementing this guideline’s recommendations (Recommendation 3.2).

How should mobilisation be implemented in intensive care?

Implementing bundles that include (early) mobilisation consistently improve patient outcomes [ 6 , 7 , 140 , 141 ]. In a multicentre cohort study, ABCDEF bundle implementation correlated with a reduced likelihood of severe outcomes [ 142 ]. Recommendations from other guidelines and the implied synergistic effect of accompanying elements support a coordinated bundle approach (Recommendation 3.17*).

How should a mobilisation session be prepared?

Before mobilisation, the treatment team and the patient should be informed. Therapeutic measures, such as line or tube extensions, should be adjusted for safe continuation during mobilisation. Alarm limits should be modified for safety and additional staff support should be considered. These aspects should be planned individually within the interprofessional team based on the patient’s clinical background. The patient’s status, consciousness, and vital signs should be closely monitored during mobilisation. In ventilated patients, essential ventilation parameters should be continuously monitored (Recommendation 3.13).

How can nutrition supplement (early) mobilisation?

The interaction between exercise, energy consumption, and diet in critically ill patients remains unclear. Active transfer to the chair for 20 minutes required less than five additional kilocalories in ventilated patients [ 143 ]. A meta-analysis of 19 studies comparing high versus low protein intake showed no impact on mortality, ventilation duration, or ICU/hospital length of stay but significantly reduced muscle atrophy [ 144 ], while the EFFORT trial showed no benefit and a signal of harm in patients with acute kidney injury and high organ failure scores [ 145 ]. Increased protein intake with NMES [ 146 ] or supine cycling [ 147 ] has been associated with reduced muscle atrophy. However, current evidence is insufficient for a recommendation (Recommendation 3.18).

How should relatives be involved in critically ill patients' (early) mobilisation?

The burden on ICU patients’ relatives has garnered recent scientific attention. Involvement in care, including mobilisation therapy, has been well-received by the treatment team, patients, and their families [ 148 ]. The ABCDE bundle has expanded to ABCDEF (F for family) to acknowledge this aspect. Limited evidence prevents a recommendation on caregiver involvement in mobilisation currently (Recommendation 3.19).

Mobilisation assist devices and robotics

For recommendations on assist devices and robotics see then Table 3 .

Assist devices include equipment-assisted (e.g. supine cycling, treadmill, and tilt table) and robotic-assisted measures (e.g. automated stepping device) for passive, assisted-active or active mobilisation. Assist devices represent an opportunity to overcome barriers to (early) mobilisation, such as staff shortages while adapting to the patient’s individual rehabilitation needs.

Do mobilisation assist devices or robotics have a beneficial effect?

Supine cycling is the most studied assist device; however, it is often evaluated as part of heterogeneous study protocols concerning intervention, control group, and outcomes. The combination of bed cycling with mobilisation showed no improvement in functionality or quality of life [ 149 – 151 ].

In eight of nine RCTs and meta-analyses [ 149 , 152 , 153 , 154 , 155 , 156 , 157 , 158 , 159 ], the duration of ventilation was not influenced by the additional use of cycling in the supine position. Similarly, in seven of nine RCTs and meta-analyses [ 73 , 75 – 80 , 82 , 83 ], cycling in bed did not reduce ICU or hospital LOS. In patients with acute respiratory failure, cycling in the supine position led to improved functionality, a shorter duration of mechanical ventilation and a shorter ICU LOS [ 154 ] (Recommendations 4.1, 4.2).

Cycling in the supine position is safe [ 151 , 152 , 154 , 160 ]. Only one RCT showed increased intracranial pressure elevations in the intervention group who received a progressive mobility programme, including functional electrical stimulation and bed cycling. In the subgroup of patients with intracranial pressure monitoring, the combination of early mobilisation, NMES and supine cycling led to an increase in intracranial pressure compared to early mobilisation alone (Recommendation 4.3) [ 149 ].

There are only a few studies that investigate assistive devices. Kwakman et al . trained patients on a treadmill using their body weight until they could walk with walking aids. The authors found a significantly shorter hospital LOS compared to supervised physiotherapy sessions [ 161 ]. In a pilot RCT, stepping verticalization was evaluated in addition to physiotherapy sessions. In patients with impaired consciousness, the intervention led to a longer ICU LOS but improved Disability Rating Scale and the Coma Recovery Scale (Recommendation 4.4) [ 162 ].

Neuromuscular electrical stimulation

For recommendations on NMES see then Table 4 .

NMES is the non-invasive, transcutaneous application of electrical stimuli that leads to active muscle contraction independent of the patient’s cooperation. This therapeutic option can be particularly beneficial in the early phase of a critical illness when patients are often sedated but pathophysiological catabolic processes are already taking place at the muscular level [ 11 ].

Should NMES be used in the early mobilisation of intensive care patients?

Several systematic reviews and meta-analyses reported beneficial effects of NMES on physical function [ 137 , 163 ], muscle strength [ 163 , 164 ], duration of mechanical ventilation [ 164 , 165 ], extubation success rate [ 166 ], and ICU and hospital LOS [ 164 ]. In contrast, others showed no differences in these outcomes (Recommendation 5.1) [ 153 , 167 ].

NMES is generally a safe intervention [ 165 , 168 ]. However, in a monocentric RCT, the intervention group that received protocol-based physiotherapy with functional electrical stimulation (combination of NMES and in-bed cycling) showed significantly more ICP elevations and poorer health-related quality of life in the cognitive domain [ 149 ]. Therefore, assessing ICP information is recommended for patients with already established ICP monitoring (Recommendation 5.2).

Conclusion and outlook

The beneficial effect of mobilisation in critically ill patients is evident. Still, it is necessary to determine which dose of mobilisation (frequency, duration, level, exertion) is appropriate for which group of patients to achieve the best possible outcome.

The same applies to positioning, where the optimal dosage (frequency and duration), especially for prone positioning, needs to be clarified.

Further evidence will most likely lead us down the path of individualised positioning and mobilisation therapy, similar to other areas of medicine. Despite technological progress, (early) mobilisation and positioning remain a (physical) effort that should be a collective responsibility of the whole intensive care team. This guideline should make a useful contribution to this effort.

Data availability

The authors confirm that all information supporting the recommendations is available within the article and its supplemental information.

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Acknowledgements

We would like to thank the following project collaborators supporting the work: Charité–Universitätsmedizin Berlin, Department of Anaesthesiology, and Intensive Care Medicine (CCM/CVK), Berlin Germany: Buyukli, Alyona; Daum, Nils; Meyer, Josephin; Schellenberg, Clara; Warner, Linus Oliver; Grimm, Aline; Bald, Annika; Baum, Felix; Verfuß, Michael; Arsene, Vanessa; Hollstein, Wiebke; Carbon, Niklas Martin; Lindholz, Maximilian; Berg, Nicolas. Jena University Hospital, Department of Anaesthesiology and Intensive Care Medicine, Jena, Germany: Engelmann, Markus; Götze, Juliane; Neu, Charles; Pfohl, Silke. Association of the Scientific Medical Societies in Germany (AWMF): Nothacker, Monika. Patient representative from the Global Sepsis Alliance: Kredler, Dennis.

Open Access funding enabled and organized by Projekt DEAL. This project was partly supported by the German Society of Anaesthesiology and Intensive Care Medicine (DGAI).

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Stefan J. Schaller and Sina M. Coldewey are the joined senior authors and contributed equally.

Authors and Affiliations

Department of Anaesthesiology and Intensive Care Medicine (CCM/CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany

Stefan J. Schaller, Julius J. Grunow & Steffen Weber-Carstens

Department of Anaesthesiology and Intensive Care Medicine, Ulm University, Ulm, Germany

Flora T. Scheffenbichler & Manfred Blobner

Universität Regensburg, Regensburg, Germany

Thomas Bein

Department of Anaesthesiology and Intensive Care Medicine, School of Medicine and Health, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany

Manfred Blobner & Heidrun Lewald

Ruhr University Bochum, Bochum, Germany

Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany

Hochschule für Angewandte Wissenschaften Hamburg (HAW Hamburg), Hamburg, Germany

Carsten Hermes

Akkon-Hochschule für Humanwissenschaften, Berlin, Germany

Academy of the District Hospitals Reutlingen, Kreiskliniken Reutlingen, Reutlingen, Germany

Arnold Kaltwasser

University Hospital of Schleswig-Holstein, Kiel, Germany

Peter Nydahl

Institute of Nursing Science and Development, Paracelsus Medical University, Salzburg, Austria

Department of Rehabilitation Medicine, Charité-Universitätsmedizin Berlin, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany

Anett Reißhauer

Department of Physiotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

Leonie Renzewitz

Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University of Duisburg-Essen, Essen, Germany

Department of Pneumology, Fachkrankenhaus Kloster Grafschaft, Schmallenberg, Germany

Karsten Siemon

Department of Medicine I, Medical University of Vienna, Vienna, Austria

Thomas Staudinger

Department of Anaesthesia, General Intensive Care and Pain Medicine, Medical University of Vienna, Vienna, Austria

Roman Ullrich

Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Center Vienna, Vienna, Austria

Department of Anaesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany

Hermann Wrigge

Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany

Münster University Hospital (UKM), Münster, Germany

Dominik Zergiebel

Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany

Sina M. Coldewey

Septomics Research Center, Jena University Hospital, Jena, Germany

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SJS received grants and non-financial support from Reactive Robotics GmbH (Munich, Germany), ASP GmbH (Attendorn, Germany), STIMIT AG (Biel, Switzerland), ESICM (Geneva, Switzerland), grants, personal fees, and non-financial support from Fresenius Kabi Deutschland GmbH (Bad Homburg, Germany), grants from the Innovationsfond of The Federal Joint Committee (G-BA), personal fees from Springer Verlag GmbH (Vienna, Austria) for educational purposes and Advanz Pharma GmbH (Bielefeld, Germany), non-financial support from national and international societies (and their congress organisers) in the field of anaesthesiology and intensive care medicine, outside the submitted work. Dr. Schaller holds stocks in small amounts from Alphabet Inc., Bayer AG, and Siemens AG; these holdings have not affected any decisions regarding his research or this guideline. MB received research support from MIPM (Mammendorf, Germany) and GE Healthcare (Helsinki, Finland), reports consulting fees from Senzime, (Uppsala, Sweden), received honoraria for giving lectures from GE Healthcare (Helsinki, Finland) and Grünenthal (Aachen, Germany), all outside the submitted work. MB participated in a DSMB sponsored by GE Healthcare (Helsinki, Finland). UH reports personal fees for lectures from Pfizer, outside the submitted work. CH reports personal fees for lectures from Baxter, Arjo, and TapMed, non-financial support from national and international societies (and their congress organisers) in the field of anaesthesiology, intensive care medicine and nursing, outside the submitted work. AK reports personal fees for lectures and non-financial support from BBraun and Avanos, non-financial support from national societies (and their congress organisers) in the field of anaesthesiology, intensive care medicine and nursing, outside the submitted work. HL reports personal fees for lectures from Xavant Technology (Pty) Ltd, outside the submitted work. TS reports personal fees for lectures from Mitsubishi Pharma, Getinge and Xenios, outside the submitted work. RU reports grants from APEPTICO GmbH, Bayer AG, Philips, and Biotest, personal fees for lectures from Biotest and medical societies, reports a patent WO2017064285 A—Membrankatheter, participation in a DSMB of F4 Pharma Gmbh and CCORE Technologies GmbH, as well as a leadership role in CCORE Technologies GmbH, all outside the submitted work. SW reports grants from Dräger GmbH, outside the submitted work. HW reports grants and consulting fees from Liberate Medical, personal fees from lectures from Arjo. All the other authors report no conflict of interest.

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Schaller, S.J., Scheffenbichler, F.T., Bein, T. et al. Guideline on positioning and early mobilisation in the critically ill by an expert panel. Intensive Care Med (2024). https://doi.org/10.1007/s00134-024-07532-2

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Online digital health and informatics education for undergraduate nursing students in China: impacts and recommendations

• Hongxia Shen 1 , 2 , 3   na1 ,
• Chong Chen 1   na1 ,
• Sijing Yan 1 ,
• Cynthia Hallensleben 2 , 3 ,
• Rianne van der Kleij 2 , 3 ,
• Minyi Li 1 ,
• Huohuo Dai 2 , 3 ,
• Niels Chavannes 2 , 3 &
• Ying Zhou 1  

BMC Medical Education volume  24 , Article number:  803 ( 2024 ) Cite this article

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Metrics details

Digital health plays a vital role in healthcare services. Governments in many countries, including China, are increasingly advocating for the appropriate use of digital technologies to address significant health system challenges. It is crucial to incorporate digital health education into the curriculum for future nurses to adapt to the changes in the digital medical system. This study aimed to evaluate the impact of an online Digital Health and Informatics Course in China on the knowledge and comprehension of key digital health and informatics topics, self-assessment of nursing informatics competencies, and satisfaction among undergraduate nursing students. The findings of this study provide recommendations for the design and implementation of future digital health education.

This study employed a one-group, quasi-experimental mixed-methods design with pre- and post-assessments. The participants received digital health and informatics education through six three-hour online sessions in six interactive days, with online self-learning materials in between. An online quiz and focus group discussions pre- and post the course were designed to evaluate the knowledge and comprehension of key digital health and informatics topics. Also, a validated Chinese version of the Self-assessment of Nursing Informatics Competencies Scale was conducted pre- and post-course to assess self-assessment of nursing informatics competencies. Additionally, all students were invited to participate in an online survey with a performance-focused course evaluation form as well as focus group discussions to gather their feedback on the learning experience and their evaluations of the course.

A total of 24 undergraduate nursing students were enrolled in the course. All students completed all sessions of this course, resulting in an attendance rate of 100%. Additionally, all students completed both pre- and post-assessments. In terms of the knowledge and comprehension of key digital health and informatics topics, scores of the quiz on knowledge assessment improved from the pre-test [mean pretest score: 78.33 (SD 6.005)] to the post-test [mean post-test score: 83.17 (SD 4.86)] upon completion of the course ( P  < 0.001). Also, students acknowledged that the course enhanced their knowledge and comprehension of informatics and digital health, the benefits of (nursing) informatics in clinical practice, and the role of health care professionals in informatics and digital health. In terms of self-assessment of nursing informatics competencies, scores on nursing informatics attitudes demonstrated significant improvement (P  < 0.001). Furthermore, students reported high satisfaction with various aspects of this course, including the opportunity to explore broad horizons in informatics for future careers, engaging in group discussions, and analyzing case studies on the use of informatics and digital health in clinical practice.

Conclusions

This Online Digital Health and Informatics education effectively improved undergraduate nursing students’ knowledge and comprehension of the key digital health and informatics topics, nursing informatics attitudes in the self-assessment of nursing informatics competency with high levels of satisfaction. In order to ensure that future education in digital health and informatics for nursing students is in line with the technological advancements in clinical settings, it is necessary to foster collaboration between medical school training and clinical practice. This collaboration should involve the use of clinical examples to illustrate advanced digital health applications and the inclusion of practical exercises on the use of digital health technology in clinical settings.

Peer Review reports

Digital health is defined by the World Health Organization (WHO) as the field of knowledge and practice associated with the development and use of digital technologies to improve health. Developments such as digitally mediated diagnosis and treatment, cloud computing, machine learning, artificial intelligence, block-chain, telehealth, and consumer-facing mobile health applications have enhanced the delivery of care for individuals across the spectrum of health promotion and disease prevention, diagnosis, treatment, and rehabilitation [ 1 , 2 ]. Digital health solutions are also recognized for their benefits in nursing practice, including integrating data records across various databases, providing electronic decision support and resources, and developing digital devices that facilitate remote monitoring and individuals’ positive behavior change [ 3 , 4 , 5 ]. Especially during the coronavirus disease (COVID-19) pandemic, digital health applications have been noted as an innovative health solution that improves continued healthcare accessibility and streamlines public health action to stop the rapid spread of the crisis [ 6 , 7 ].

Governments in the United States, India, Tanzania, Ethiopia, and other countries have developed national digital health strategies, which outline a shared vision for addressing health priorities through the coordinated and strategic use of interoperable digital technologies [ 8 , 9 , 10 ]. As the largest developing country, policymakers and healthcare experts in China have launched the national health strategy ‘Healthy China 2030’ [ 11 ]. This strategy recognizes digital health technology as an essential pillar to enhance disease self-management, as well as improving the accessibility and cost-effectiveness of care in (rural) China- where over 558 million people have access to mobile phones. According to the correspondence from the National Health Commission of China, as of August 2022, more than 1700 internet hospitals have been established nationwide [ 12 ]. In order to promote the appropriate use of digital technologies and therefore help address key health system challenges in general and in China in specific, it is important to enhance individuals’ understanding and use of digitally enabled approaches to care. This will ultimately lead to improved quality of care, better health outcomes and reduced medical costs.

Currently, numerous digital health technologies remain in the pilot stage and have not yet demonstrated their effectiveness or been successfully implemented on a larger scale in a real-world setting. The limited knowledge and skills of healthcare professionals (HCPs) in utilizing new technologies and concerns regarding privacy, and security quality are significant obstacles to the adoption of digital health in clinical practice [ 13 ]. The Global Digital Health Strategy 2020–2025 of WHO emphasizes the importance of incorporating specific actions to ensure that all health professionals and allied workers, at all levels of formal education and informal training, receive education and training on digital health [ 14 ]. Developing high levels of digital health informatics competencies among health professional students will facilitate their understanding of the essential requirements for successful implementation of digital health [ 15 ]. Therefore, there is an urgent need to develop courses on digital health in medical schools to educate future HCPs on integrating digital health technological innovations and preparing them to adapt to future changes in the digital medical system within their workforce.

At present, many medical schools and research institutions worldwide have incorporated the digital health education into their curricula for the next generation of HCPs. For instance, digital health education programs were designed and implemented as mandatory or elective courses for bachelor or master health professional students at the University of Maryland-Baltimore, Vanderbilt University, Duke University, New York University, the University of Pittsburgh [ 16 , 17 ]. These programs cover a range of topics, including an introduction to health informatics, system design, implementation, evaluation, and policy and ethics in digital health.

While there has been an increasing amount of research on digital health education within the medical school curriculum in Western countries, a systematic review has shown that the literature on digital health courses often lacks comprehensive evaluation, and more evaluation and implementation research is recommended in low and middle-income countries [ 17 ]. Also, there is a lack of literature on this topic in the Chinese context. Health professional students in China have expressed a need for digital health knowledge and skills in their medical curriculum [ 18 ].

Nurses, as the largest group of HCPs, play a crucial role in the digital health transformation. It is important to enhance the readiness and education of the nursing workforce in digital health to provide effective, safe, and efficient patient care with the support of existing and emerging digital health technologies. Therefore, to prepare future nurses to meaningfully contribute to the design, development, implementation, and evaluation of digital health technologies in China, the present study aimed to evaluate the impact of an online Digital Health and Informatics Course in China on undergraduate nursing students’ knowledge and comprehension of key digital health and informatics topics, self-assessment of nursing informatics competencies, and satisfaction. Based on the actual experiences of nursing students, our study will also provide recommendations for medical educators, medical universities, and health institutions to improve the design and implementation of digital health education in China and beyond.

Study design and participant

This study employed a one-group, quasi-experimental mixed-methods design with pre- and post-assessments. The study focused on an online Digital Health and Informatics Course for undergraduate nursing students in China. All students who enrolled in the course at our university, a medical university located in Guangzhou, southern China, were invited to participate in the study. To be eligible, students had to agree to participate and successfully complete the six-week course. Students who expressed disinterest or were already engaged in other digital health learning or programs were excluded from the study.

Course details

Development of course.

A multidisciplinary team of experts in digital health, informatics, and the medical field was established at a medical university in Guangzhou, southern China. The team consisted of three nurses, two doctors, two health informatics specialists, and a teacher with extensive experience in designing and conducting medical courses for nursing students. The team held monthly meetings to discuss the development, implementation, and evaluation planning of the course.

The course was developed in three stages. Firstly, a comprehensive list of digital health and informatics areas was generated based on previous education in this field [ 16 , 17 ]. This list was used to define the most relevant topics for nursing students. Secondly, the team of eight experts reviewed the objectives, learning activities, and assessment tools for the course. Based on this review, a proposed course with five core topics was devised, which all eight experts agreed upon. Thirdly, the course procedure was enhanced by incorporating multimedia learning materials such as illustrations, photos, animations, and videos. This was in accordance with the Multimedia Learning Theory [ 19 ]. Through group meetings and discussions, the multidisciplinary team reached a consensus on the final course module and procedure.

Digital health and nursing innovation topics

The course was named as the Digital Health and Informatics course and was held at a medical university in Guangzhou, China, for eleven days in six weeks. Details of the overview and content of the course are shown in additional file 1 . The content of this course focused on five key topics: digital health informatics, nursing informatics, emerging technologies for eHealth solutions, patient data security and privacy, and eHealth. The timetable and focus of each topic are shown in Table  1 .

In the final week of the course, students were assigned group work-based learning activities to present a critical reflection on the following three questions:

Given the recent emergence and certification of health informatics professionals, will there continue to be a role for nurses in informatics within the next decade?

Should there be a specific professional designation for nurses with informatics expertise? What will the role of the Informatics Nurse look like in the future?

In the face of the evolving sophistication of technology, will there still be a need for nurses with informatics expertise?

During the group work, students were encouraged to read materials such as scientific papers and textbooks related to digital health and nursing informatics. Following each group’s presentation, the teachers provided feedback on students’ performance and on the material they were presenting, thus enabling them to review their strengths, areas that needed improvement, their development and learning, and to reconsider their learning processes.

Teaching members

For the Digital Health and Informatics course, teachers were eligible if they had extensive experience in digital health and informatics, software engineering, information management, and knowledge management. They were also eligible if they had previous teaching experience in software engineering and enterprise systems development, or if they had conducted wide-ranging research in the areas of information sharing, healthcare informatics, artificial intelligence, machine learning, and digital health.

In this course, all lectures were delivered by two teachers, all of whom hold a Doctoral degree and have a proven academic or professional background in the fields of software engineering, artificial intelligence, and information systems, or digital health research, nursing, public health, and implementation science. Additionally, both teachers have obtained Teacher Qualification Certificates, which demonstrate that they possess the basic teaching skills necessary to perform educational and teaching activities in higher education. Furthermore, both teachers have in-depth knowledge of the course content, aligning with the course’s subject expertise. Moreover, they have more than three years of teaching experience and were extensively involved in digital health course planning and education administration. As a result, they are capable of delivering engaging online lessons, promoting interactive student online participation, and maintaining open discussions between students and teachers.

Course procedure

The course commenced on July 23, 2022. The students who enrolled in the course were sent a link via email. In order to take part in the study, they were required to provide informed consent and complete the electronic baseline questionnaires. Following each lesson, students were granted access to the course through various modalities, including offline and online access to downloadable lesson videos for offline viewing on their electronic devices. Participants had the flexibility to watch the modules in their preferred order. The course structure for each topic is outlined in Table  1 .

The assessment of the impacts of the course was conducted using a mixed methods approach to evaluate (1) knowledge and comprehension of the key digital health and informatics topics, (2) the self-assessment of nursing informatics competencies, and (3) the students’ satisfaction with the Digital Health and Informatics course. Table  2 summarizes the below-described outcome and outcome measurements.

Research materials

The demographic questionnaire.

The questionnaire was used to collect students’ demographic data, including age, gender, year of bachelor study, and experience with nursing informatics use.

Knowledge and comprehension of key digital health and informatics topics

To evaluate the knowledge and comprehension of key digital health and informatics topics, an online quiz with a total score of 100 points and focus group discussions pre-and post the course were designed.

The quiz consisted of a total of 25 choice questions that were developed by the multidisciplinary team of experts. These questions were considered important learning topics and were based on relevant lecture materials. Before finalizing the quiz, a pilot version was tested by ten nurses who had graduated from the same medical university within one year and had experience with digital health learning. The pilot test aimed to improve the content, length, and understandability of the quiz. The final version of the quiz focused on eliciting students’ knowledge and comprehension of digital health, health informatics, and nursing informatics including definitions, nursing’s early role, and nursing informatics competencies (see additional file 2 ).

In addition to the quiz, all students were invited to participate in focus group discussions pre- and post-course. The focus group topic lists were developed based on examples from similar studies and research team discussions. The focus group discussion questions aimed to assess participants’ knowledge and comprehension on informatics and digital health such as definitions and emerging technologies. The discussion also explored the importance of informatics and digital health as well as the role of nurses in nursing informatics and digital health implementation (See additional file 3 ).

Self-assessment of nursing informatics competencies

All students were invited to participate in an online nursing informatics competency survey pre- and post-course. According to previous literature [ 20 ], nursing informatics competencies include not only computer-related skills, but also the knowledge and attitudes needed by nurses to complete specific informatics tasks. The online survey consisted of two parts (See additional file 4 ).

• Part one provided instructions for completing the survey.

• Part two included a validated Chinese version of the Self-assessment of Nursing Informatics Competencies Scale (SANICS) [ 21 ] developed by Yoon [ 22 ]. The scale consisted of a total of 28 items, covering three domains: computer technology, information technology, and information knowledge. The Cronbach’s alpha of the Chinese version of SANICS was 0.931 [ 21 ]. Five-point Likert-type criteria was applied (1 = not competent; 2 = somewhat competent; 3 = competent; 4 = proficient; 5 = expert), with a higher total score indicating a higher level of nursing informatics competency. The Chinese version of SANICS items were categorized into 5 sub-scales: role of clinical informatics (Factor 1; items 1–5), basic computer knowledge and skills (Factor 2; 6–16), applied computer skills (Factor 3; 17–20), wireless device skills (Factor 4; 21–24), and nursing informatics attitudes (Factor 5; 25–28). The five domains and examples of items are presented in Table  3 .

Satisfaction with the Digital Health and Informatics course

Following the implementation of the course, all students were invited to join an online survey using a performance-focused course evaluation form (See additional file 5 ). The survey aimed to gather feedback on students’ learning experience and obtain specific comments regarding the course. Also, students were invited to take part in focus group discussions on the course evaluation. The focus group discussion questions were as follows:

“What do you like about the course?”

“What do you dislike about the course?”

“Do you have any suggestions on the future improvement of the course?”

Data collection

Quiz and survey.

Prior to the study, participants were provided with information regarding the purpose of the study. They were asked to complete web-based questionnaires in the form of an online quiz, SANICS surveys, and course evaluation forms. The surveys were conducted between June and July 2022. A link containing a password to access the private survey questionnaires was sent to each student’s individual email inbox. Participants were informed that their participation in the study was voluntary and that choosing not to participate would not affect their learning or assessments. They were assured that they could withdraw from the study at any time without any negative consequences or impact on their academic grades. Furthermore, their privacy and confidentiality would be protected, and all participants provided written consent to participate. Participation in the online poll was also voluntary and anonymous.

Focus group discussions

A total of five pre- and post-course focus group discussions were conducted with all students to explore their knowledge and comprehension of key topics in digital health and informatics, as well as their satisfaction with the course. The face-to-face focus group discussions were conducted by one researcher (HS, PhD, female). The interviewer had received training and possessed extensive experience in qualitative research. Each focus group discussion lasted approximately 50–60 min and was recorded with the participants’ consent. The recordings were later transcribed and used as textual data.

Data analysis

For the quantitative data, survey data were exported from SPSS version 23 (IBM, Armonk, NY, USA) for analysis. After data cleaning, frequency descriptive statistics were utilized for categorical variables. Descriptive statistics such as the mean, standard deviation, median, and range of linear variables were calculated, along with frequencies and percentages of categorical variables. We compared the difference of the SANICS scores pre- and post-course using paired t-test analysis. P -values < 0.05 was considered statistically significant.

For the focus group discussion data, transcripts were imported into Atlas.ti for Windows version 7.5.18 (Scientific Software development, Berlin). Qualitative content analysis was performed inductively using the following steps: (1) open coding, (2) categorization, and (3) theming. Rigor was enhanced by repeatedly reading the transcripts, keeping a record of the analytic decision trail, and through crystallization with multiple researchers engaging in discussions of evolving categories and emergent themes. In terms of students’ knowledge and comprehension of key digital health and informatics topics, related quotations were compared to identify the changes in the same themes extracted pre- and post-course. For instance, the theme of emerging digital health technologies was extracted from pre- and post-course focus group discussions. We will compare the differences in relevant quotations, such as whether students mentioned more types of technology after the course.

Additionally, based on the focus group discussion data and responses to two open-ended questions in the course evaluation form provided by students, we analyzed their evaluations and suggestions regarding the course. Data saturation was achieved as being the point at which no new or relevant information could be identified through the iterative, preliminary analysis of the data [ 23 ]. After the first two focus group discussions, a preliminary analysis using the proposed codes was performed, and a data saturation grid [ 23 ] was developed to determine if saturation was reached. The data saturation grid consists of a report of the occurrence of themes and codes (displayed in rows) during each focus group (displayed in columns) in a tabular format. In the grid, saturation is considered reached when the grid column for the current focus group indicates no new information emerged for that particular theme or code. We found that in the fifth focus group discussion, data saturation on all themes and codes was achieved (data saturation table included as additional file 6 ).

Ethics and consent

This study was assessed and approved by The University Ethics Committee of Guangzhou Medical University (Reference Code: L202303012). All methods were carried out per relevant guidelines and regulations. Informed consent was obtained from all participants.

Demographic characteristics of students

A total of 24 undergraduate nursing students were enrolled in the course. All students completed all sessions of this course (attendance rate 100%) and pre- and post-assessments. Most participants (83.33%; n  = 20) were in the 19 to 20-year age category. Also, 22 students (91.7%) were in the first or second year of their bachelor study. Additionally, students’ experience with nursing informatics was limited before launching the digital health and nursing informatics course, with only 41.7% of students having prior experience with nursing informatics system use.

Impact of the Digital Health and Informatics course

Scores of the quiz on knowledge assessment improved from the pre-test [mean pretest score: 78.33 (SD 6.005) to the post-test [mean post-test score: 83.17 (SD 4.86)] upon completion of the course ( P  < 0.001).

Furthermore, when analyzing the data from focus group discussions, three key themes emerged regarding nursing students’ knowledge and comprehension of key digital health and informatics topics before and after the course. Overall, the students acknowledged that the course improved their understanding of informatics and digital health, the benefits of (nursing) informatics in clinical practice, and the role of HCPs in informatics and digital health. For instance, after the course, the theme of ‘Understanding of informatics and digital health’ was formulated based on constructs that emphasized the application of information management and analytical abilities, more guiding principles of nursing informatics and digital health use, and more emerging technologies of digital health compared with pre-course. Also, after the course, students highlighted detailed technologies for improving clinical practice. In addition, students noted the different types of informatics roles held by HCPs working in the field of informatics and the critical roles they play after the course. The main constructs frequently mentioned by students were summarized from the interview transcripts before and after the course, which were translated into English from colloquial Chinese, supporting these findings (Table  4 ).

Scores of students’ nursing informatics attitudes improved significantly after the course. There were no statistically significant changes observed in the scores of students’ competency including the role of clinical informatics, basic computer knowledge and skills, applied computer skills, and wireless device skills (Table  5 ).

Students’ satisfaction with Digital Health and Informatics course

All 24 Students responded to six questions regarding the effects of the digital health and informatics course (Table  6 ). A total of 50% of the students indicated that “I am now somewhat familiar with the concept of (nursing) informatics.” and 41.7% of the students indicated that“I am now really familiar with the concept of (nursing) informatics.” Also, a total of 83.3% of the students indicated that,“The learning made me more sensitive to issues related to (nursing) informatics”.

Furthermore, based on the focus group discussions and responses to two open-ended questions in the course evaluation form, three themes were generated including the pros and cons of the course, and suggestions for the course. Details are presented in Table  7 .

Digital health and informatics education is an unmet need to address the global shortage of health workers by promoting the adoption of digital health technologies among future HCPs. This study analyzed the impacts of an online digital health and informatics course for nursing students in China. Students reported improved knowledge and comprehension of key digital health and informatics topics, nursing informatics attitudes in the measure of self-assessment of nursing informatics competencies, and high satisfaction with the course. Also, qualitative results showed notable advantages of the course, including the provision of a broader understanding of informatics for future careers, opportunities for engaging in group discussion, and case analysis on the use of informatics and digital health in clinical practice. The findings of this study provide recommendations for the design and implementation of incorporating digital health and informatics education into the course for health professional students.

What content of digital health and informatics education should be provided?

Previous research has shown that an individual’s performance expectancy has an impact on their acceptance and use of information technologies in the workplace [ 24 ]. Our study highlights that improving education on the role of HCPs in health information systems, raising awareness of the impact of informatics, and introducing emerging digital health technologies in clinical care can potentially enhance the adoption of digital health technologies. This finding is consistent with previous research [ 25 ].

To ensure that students develop a comprehensive understanding of digital-enabled healthcare, we have designed this course to provide a broad and foundational education in digital health and informatics for undergraduate students. However, we did not observe significant improvements in students’ self-assessment of nursing informatics competencies in the areas of basic computer knowledge and skills, applied computer skills, and wireless device skills. This may be explained by that these domains are more practical aspects of competence in digital health and informatics. Online lectures may not be the most effective approach for developing practical competency, and real-life practice with digital innovation is necessary. Also, nursing students in our study expressed a need for more practice lessons on digital health use. Therefore, we suggest that nursing students should be exposed to specialized digital health innovation use to enhance their digital literacy in clinical decision support and quality improvement in future course development. This could include trainings on handling medical data and applying data in patient care. Also, case analysis should be incorporated to help students understand how technology and data are used in modern health and social care services, such as electronic medical records, telehealth, and mHealth.

What teaching methods and components should be provided in digital health and informatics education?

Through a review and reflection of this online education, we have identified useful components of the course that can be applied to other educational programs. Firstly, our course utilized information communication technologies to enhance the quality, accessibility, and sustainability of education. Consistent with previous research [ 26 , 27 ], the online course offers significant benefits in terms of self-paced, self-directed, and personalized learning. Also, due to the adaptability of an online platform, this course can be easily and flexibly implemented in various settings within medical schools with minimal adjustments. Secondly, students reported that a valuable feature of the course is the group work. In our program, students with different levels of ability and readiness in groups worked together in groups to critically reflect on the role of HCPs in informatics and digital health, promoting interactive group work. Students may lack confidence initially. However, through continuous group cooperation, they were able to develop skills and make progress in the learning and building process. Third, given the distance-learning nature of our course, emphasis is placed on online collaboration tools; both formal and informal synchronous and asynchronous communication tools were used to facilitate communications between instructors, students, and members of student groups (e.g., chat rooms, video-conferencing software). Since each course was conducted online, an interactive class management system can provide students with access to course information, reading assignments, and electronic resources for their final presentation.

How to improve the quality the digital health and informatics education?

Most students are in the first or second year of their bachelor’s studies and have limited experience in the use of computers and wireless devices in clinical practice. Therefore, we recommend that digital health and informatics should be longitudinally integrated into a compulsory course throughout nursing education, with specific learning objectives and content for each year of nursing student education. Previous studies have shown that at the undergraduate level, students should be equipped with the necessary digital skills to practice medicine in a digital-enabled healthcare environment while also assuring the mastery of compassionate care and improving outcomes for patients [ 28 , 29 ]. Some studies have reported that digital health education should be provided earlier in the medical university curriculum such as in the first year, and that digital health-specific practice or clinical innovation use should be trained in the final year of health professional education [ 30 , 31 ]. Additionally, prior studies show that specialized digital skills, such as using digital health for specific clinical tasks in an interdisciplinary environment, should be taught in the advanced years of medical training when HCPs enter residency and train to become specialists [ 32 ]. Therefore, we suggest that future research should use the digital health competency framework, such as the International Medical Informatics Association Recommendations on Medical Informatics Education, to design and tailor education for the undergraduate health professional students.

Furthermore, we highlighted the value and significance of collaboration efforts between medical school training and clinical practice [ 33 ]; using clinical examples to explain more novel digital health applications, such as the application of artificial intelligence or big data in patient-centered care. To ensure that this course is aligned with the technological advances in clinical settings, training to improve digital competencies in students’ clinical practice is necessary. One way to achieve this is by incorporating a practical exercise on the use of digital health technology in the clinical setting, while also considering the need for patient privacy and liability concerns [ 34 ].

Limitations

Nevertheless, several limitations need to be considered. Firstly, the main limitation of the study was that it was a single-arm study. This raises questions about whether the observed improvements in outcomes, such as knowledge, were solely due to the course or if other factors may have influenced the results. For example, students’ previous use of digital health and eHealth literacy levels could have potentially influenced their experience and evaluation of the course. This could have resulted in a bias in their responses towards course evaluation. Additionally, improvements in students’ learning outcomes could be attributed to the test itself, as factors such as participants remembering questions or the questions raising awareness and triggering learning after the pre-test may have influenced the results, independent of our course implementation. Therefore, future course evaluations should consider using a two-arm or Solomon four-group design. Secondly, this was a small study with a sample size of 24 students and may not be generalizable to all health professional students in China or a larger population. Also, study results report the nursing students’ subjectively experienced changes in nursing informatics competence, and no objective measures in this area were conducted. Therefore, self-reported data may be subject to bias, and may not accurately reflect the actual improved competency of the students. Additionally, the measurement of knowledge and comprehension of key digital health and informatics topics must be interpreted with caution since the quiz has not been validated. Furthermore, the duration of the course was only six weeks. The relatively short duration of the course may limit the depth of knowledge and competencies that students can acquire. A longer course with follow-up assessments could provide a more comprehensive understanding of the long-term impacts.

Digital health and informatics education for future healthcare professionals is an urgent need to equip them to adapt to future digital medical system changes in their workforce. This Online Digital Health and Informatics education showed promising results for undergraduate nursing students in their knowledge and comprehension of the key digital health and informatics topics, nursing informatics attitudes in the self-assessment of nursing informatics competency, and satisfaction. To optimize the digital health course effect, future course developers should improve students’ basic knowledge and comprehension of digital health and informatics. Also, to enable the standard design and scale-up of effective digital health and informatics education for nursing students, collaboration between medical school training and clinical practice is needed to enhance students’ practical exercise on the application of digital health technologies in the clinical setting. We suggest that the content and teaching methods of this course may form a mandatory part of digital health education for health professional students and could be expanded to students in other contexts and countries.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Abbreviations

World Health Organization

Coronavirus disease

healthcare professionals

Self-assessment of Nursing Informatics Competencies Scale

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Acknowledgements

We would like to express our appreciation to the students for participating in our study and for their valuable responses.

This study is supported by the Guangdong Higher Education Teaching Research and Reform Program of the Department of Education of Guangdong Province (grant numbers: 01-408-2301062XM, 2023) and The Key Discipline Project (Nursing) of Guangzhou Education Bureau (grant numbers: 06-410-2001016, 2022).

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Hongxia Shen and Chong Chen contributed equally to this work.

Authors and Affiliations

School of Nursing, Guangzhou Medical University, 195# Dongfeng West Road, Guangzhou, Guangdong, 510182, China

Hongxia Shen, Chong Chen, Sijing Yan, Minyi Li & Ying Zhou

Department of Public Health and Primary Care, Leiden University Medical Centre, Leiden, Netherlands

Hongxia Shen, Cynthia Hallensleben, Rianne van der Kleij, Huohuo Dai & Niels Chavannes

National eHealth Living Lab, Leiden University Medical Centre, Leiden, Netherlands

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Contributions

HS, CC, SY, and ZY contributed to the conceptualization, methodology, validation, formal analysis, investigation, resources, writing original draft, reviewing, and editing. CH contributed to methodology, validation, reviewing, and editing. RK, ML HD and NC contributed to conceptualization, methodology, validation, reviewing, and editing.

Corresponding authors

Correspondence to Hongxia Shen or Ying Zhou .

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Informed consent was obtained from all participants (all participants are older than 16), which was in the form of online questionnaires. The informed consent form described the purpose and method of data collection and ensured that the data would be kept confidential. The University Ethics Committee of Guangzhou Medical University approved the study (Reference Code: L202303012). All methods were carried out per relevant guidelines and regulations.

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Shen, H., Chen, C., Yan, S. et al. Online digital health and informatics education for undergraduate nursing students in China: impacts and recommendations. BMC Med Educ 24 , 803 (2024). https://doi.org/10.1186/s12909-024-05785-5

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