Definition of Critical Care Nursing

Critical care nursing is that specialty within nursing that deals specifically with human responses to life-
threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring
that acutely and critically ill patients and their families receive optimal care.

Definition of a Critically Ill Patient

Critically ill patients are defined as those patients who are at high risk for actual or potential life-
threatening health problems. The more critically ill the patient is, the more likely he or she is to be highly
vulnerable, unstable and complex, thereby requiring intense and vigilant nursing care.

Number of Critical Care Nurses in the United States

According to “The Registered Nurse Population” study conducted in March 2004 by the Department of
Health and Human Services, there are 503,124 nurses in the U.S. who care for critically ill patients in a
hospital setting. Of these, 229,914 spend at least half their time in an intensive care unit (ICU); 92,826
spend at least half their time in step-down or transitional care units; 117,637 spend at least half their time
in emergency departments; and 62,747 spend at least half their time in post-operative recovery. Critical
care nurses account for an estimated 37% of the total number of nurses working in the hospital setting.

Where Critical Care Nurses Work

According to “The Registered Nurse Population” study, 56.2% of all nurses work in a hospital setting, and
critical care nurses work wherever critically ill patients are found – intensive care units, pediatric ICUs,
neonatal ICUs, cardiac care units, cardiac catheter labs, telemetry units, progressive care units, emergency
departments and recovery rooms. Increasingly, critical care nurses work in home healthcare, managed
care organizations, nursing schools, outpatient surgery centers and clinics.

What Critical Care Nurses Do

Critical care nurses practice in settings where patients require complex assessment, high-intensity
therapies and interventions, and continuous nursing vigilance. Critical care nurses rely upon a specialized
body of knowledge, skills and experience to provide care to patients and families and create environments
that are healing, humane and caring. Foremost, the critical care nurse is a patient advocate. AACN defines
advocacy as respecting and supporting the basic values, rights and beliefs of the critically ill patient. In this
role, critical care nurses:
· Respect and support the right of the patient or the patient’s designated surrogate to autonomous
informed decision making.
· Intervene when the best interest of the patient is in question.
· Help the patient obtain necessary care.
· Respect the values, beliefs and rights of the patient.
· Provide education and support to help the patient or the patient’s designated surrogate make decisions.
· Represent the patient in accordance with the patient’s choices.
· Support the decisions of the patient or designated surrogate, or transfer care to an equally qualified
critical care nurse.
· Intercede for patients who cannot speak for themselves in situations that require immediate action.
· Monitor and safeguard the quality of care the patient receives.
· Act as a liaison between the patient, the patient’s family and other healthcare professionals.

The Roles of Critical Care Nurses

Critical care nurses work in a wide variety of settings, filling many roles. They are bedside clinicians, nurse
educators, nurse researchers, nurse managers, clinical nurse specialists and nurse practitioners. With the
onset of managed care and the resulting migration of patients to alternative settings, critical care nurses
are caring for patients who are more ill than ever before. Managed care has also fueled a growing demand
for advanced practice nurses in the acute care setting. Advanced practice nurses are those who have
received advanced education at the master’s or doctoral level. In the critical care setting, they are most
frequently clinical nurse specialists (CNS) or acute care nurse practitioners (ACNP).

A CNS is an expert clinician in a particular specialty - critical care in this case. The CNS is responsible for
the identification, intervention and management of clinical problems to improve care for patients and
families. They provide direct patient care, including assessing, diagnosing, planning and prescribing
pharmacological and nonpharmacological treatment of health problems.

ACNPs in the critical care setting focus on making clinical decisions related to complex patient care
problems. Their activities include risk appraisal, interpretation of diagnostic tests and providing treatment,
which may include prescribing medication.

Level of Education Critical Care Nurses Have

To become a registered nurse (RN), an individual must earn a diploma in nursing, an associate’s degree in
nursing (ADN) or a bachelor’s degree in nursing (BSN) and pass a national licensing exam. Requirements
vary and are dictated by each state’s Board of Nursing. Many nursing schools offer students exposure to
critical care, but most of a critical care nurse’s specialty education and orientation is provided by the
employer. Advanced practice nurses must earn a degree at the master’s or doctoral level.

Critical Care Nurse Certification

Although certification is not mandatory for practice in a specialty like critical care, many nurses choose to
become certified. Some employers prefer to hire certified nurses because they have demonstrated
acquisition of a specific high level of knowledge in their specialty through successful completion of a
rigorous, psychometrically valid, job-related examination. Certification examinations test critical care
knowledge primarily at the application/analysis level, which indicates strong critical thinking abilities. A
required number of clinical hours in the specialty are also an examination prerequisite. Certified nurses
validate their continuing knowledge of current practices in critical care nursing through a renewal process
every three years, which includes meeting extensive continuing education and clinical experience
requirements. Certified critical care nurses (CCRN) must have been in critical care practice for a minimum
of two years to be eligible for the examination.

An advanced practice certification for clinical nurse specialists who care for patients who are acutely or
critically ill was introduced in 1999. Because of the availability of Medicare and managed care
reimbursement to clinical nurse specialists, a growing number of employers are requiring advanced
practice certification. Additionally, as state boards of nursing attain statutory authority to issue advanced
practice nursing licenses, nurses are often being required to pass a nationally recognized certification
examination. The CCNS examination administered by the AACN Certification Corporation is an example of
the type of certification that is required for advanced practice licensure status.

The PCCN credential is awarded to critical care nurses in progressive care, which describes areas referred
to as intermediate care units, direct observation units, step-down units, telemetry and transitional care
units as well as a specific level of care. AACN has two subspecialty exams. The CMC (cardiac medicine
certification) is a subspecialty designed for nurses who provide care for acutely and critically ill cardiac
patients. Nurses with this certification work in such areas as the CCU; combined ICU/CCU; medical ICU; and
telemetry or progressive care. The CSC (cardiac surgery certification) is a subspecialty for nurses who
provide care for the acutely and critically ill cardiac surgery patient within the first 48 hours post-op.
Specialty nurses interested in this subspecialty certification may work in areas such as cardiac surgery,
cardiothoracic surgery, and cardiovascular surgery.

Nursing Shortage More Pronounced for Critical Care Nurses

The growing nursing shortage is especially acute in the specialty areas of nursing. Although specific figures
are not available on the extent of the shortage, we do know that the number of requests for temporary and
traveling critical care nurses to fill staffing gaps has skyrocketed in every part of the U.S. These requests
were most pronounced for adult critical care units, pediatric and neonatal ICUs and emergency
departments. Recruitment advertising for critical care nurses in AACN’s publications continues to grow,
especially in the annual Career Guide. Hospitals are offering critical care nurses ever more attractive
incentives, including sign-on bonuses, relocation bonuses, reimbursement for continuing education and
certification, and other attractive benefits. In addition, many hospitals are launching critical care
orientation and internship programs, such as the Web-based Essentials of Critical Care (ECCO) program, to
attract and prepare experienced and newly licensed nurses to work in critical care.

History of Critical Care Nursing

Although there have always been very ill and severely injured patients, the concept of critical care is
relatively modern. As advances have been made in medicine and technology, patient care has become
more complex. To provide appropriate care, nurses needed specialized knowledge and skills, and the care
delivery mechanisms needed to evolve to support the patients’ needs for continuous monitoring and
treatment. The first intensive care units emerged in the 1950s to provide care to very ill patients who
needed one-to-one care from a nurse. From this environment the specialty of critical care nursing
emerged.
Future of Critical Care Nursing
Rapid advances in healthcare and technology have contributed to keeping more people out of the hospital.
However, patients in critical care units are more ill than ever before. Many patients who would have been
cared for in a critical care unit five years ago are now being cared for on medical floors or at home. Many
patients in today’s critical care units would not have survived in the past. It has been proposed that the
hospitals of the future will be large critical care units, and other types of care will be provided in alternative
locations or at home. Critical care nurses will need to keep pace with the latest information and develop
skills to manage new treatment methods and technologies. As issues relating to patient care become
increasingly complex and new technologies and treatments are introduced, critical care nurses will need to
become ever more knowledgeable.