CRITICAL CARE NURSING GUIDELINES, STANDARDS AND COMPETENCIES

Drafted as of JULY 1, 2014

INTRODUCTION

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

Critical care nursing is the specialty within nursing that deals specifically with human responses to life-threatening problems¹.These problems deal dynamically with human responses to actual or potential life-threatening illnesses.

The framework of critical care nursing is a complex, challenging area of nursing practice. It utilizes the nursing process applying assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The critical care nursing practice is based on a scientific body of knowledge and incorporates the professional competencies specific to critical care nursing practice and is focused on restorative, curative, rehabilitative, maintainable, or palliative care, based on identified patient’s need³. It upholds multi and interdisciplinary collaboration in initiating interventions to restore stability, prevent complications, achieve and maintain optimal patient responses. The critical care nursing profession requires a clear description of the attributes guidelines and nursing practice standards in guiding the critical care nursing practice to fulfill this purpose.

In the Philippines, the Professional Regulation Commission – Board of Nursing (PRC-BON) is committed to provide need-driven, effective and efficient specialty nursing care services of high standard and at international level within the obtainable resources. To respond to this mission and commitment, a PRC-BON Working Group in Developing the Nursing Specialty Framework was formed in the 1996 to take on the task of setting the process-based framework and guidelines for specialty nursing services. The Working Group members are clinical nurse practitioners, nurse educators and nurse managers¹.

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

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

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

The specific objectives of this paper are to:

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

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

PHILOSOPHY OF CRITICAL CARE NURSING

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

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

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

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

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

THE RIGHT OF THE CRITICALLY ILL PATIENT

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

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

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

GOALS OF CRITICAL CARE NURSING

Critical or intensive care is a complex specialty developed to serve the diverse health care need of patients (and their families) with actual or potential life threatening conditions³. It is therefore important that a clear statement of what critical care nursing wishes to achieve and provide should be articulated.

Goals of Critical Care Nursing include the following:

To promote optimal delivery of safe and quality care to the critically ill patients and their families by providing highly individualized care so that the physiological dysfunction as well as the psychological stress in the ICU are under control;

To care for the critically ill patients with a holistic approach, considering the patient’s biological, psychological, cultural and spiritual dimensions regardless of diagnosis or clinical setting;

To use relevant and up-to-dateknowledge, caring attitude and clinical skills, supported by appropriate technology for the prevention, early detection and treatment of complications to facilitate recovery.

To provide palliative care to the critically ill patients in situations where their health status is progressing to unavoidable death, and to help the patients and families go through their painful sufferings.

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

LEVELS & CATEGORIES OF CRITICAL CARE PROVISIONS WITHIN PHILIPPINES

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

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

Levels of Care Provision

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

Level 1

Should be capable of providing immediate resuscitation for the critically ill and short term cardio-respiratory support because the patients are at risk of deterioration;
Has a major role in monitoring and preventing complications in “at risk” medical and surgical patients;
Must be capable of providing mechanical ventilation and simple invasive cardiovascular monitoring;
Has a formal organization of medical staff and at least one registered nurse.
A certain number of nurses including the nurse in-charge of the unit should possess post-registration qualification in critical care or in the related clinical specialties; and
Has a nurse: patient ratio of 1:1 for all critically ill patients.

Level 2

Should be capable of providing a high standard of general critical care for patients who are stepping down from higher levels of care or requiring single organ support/support post-operatively;
Capable of providing sustainable support for mechanical ventilation, renal replacement therapy, invasive hemodynamic monitoring and equipment for critically ill patients of various specialties such as medicine, surgery, trauma, neurosurgery, vascular surgery;
Has a designated medical director with appropriate intensive care qualification and a duty specialist available exclusively to the unit at all times;
The nurse in-charge and a significant number of nursing staff in the unit have critical care certification; and
A nurse: patient ratio is 1:1 for all critically ill patients.

Level 3

Is a tertiary referral unit, capable of managing all aspects of critical care medicine (This does not only include the management of patients requiring advanced respiratory support but also patients with multi-organ failure);
Has a medical director with specialist critical / intensive care qualification and a duty specialist available exclusively to the unit and medical staff with an appropriate level of experience present in the unit at all times;
A nurse in-charge and the majority of nursing staff have intensive care certification; and
A nurse: patient ratio is at least 1:1 for all patients at all times.

Categories of Critical Care Unit

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

A. Age Group

Neonatal
Pediatric
Adult

B. Specialty

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

Medical
Surgical
Cardio-thoracic
Cardiac
Respiratory
Neurosurgical
Trauma

System Operation of Critical Care Units

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

A. Open System

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

B. Closed System

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

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

SCOPE OF CRITICAL CARE NURSING

The scope of critical care nursing is defined by the dynamic interactions of the critically ill patient/family , the critical care nurse and the critical care environment to bring about optimal patient outcomes through nursing proficiency in an environment conducive to the provision of this highly specialized care⁴.

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

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

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

CRITICAL CARE NURSE QUALIFICATION

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

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

CRITICAL CARE NURSING WORKFORCE

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

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

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

ROLES OF THE CRITICAL CARE NURSES

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

Practitioner Role

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

1. Care Provider

A. Direct patient care

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 nurseutilizes the nursing process in an explicit systematic manner to achieve the goals of care.

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

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

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.

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. A copy of the Code of Professional Conduct for Nurses in the Philippines established by the PRC-BON is available.2. A copy of the Philippine Nursing Law of 2002 (RA 9173) is available.3. A copy of the organizational regulations, policies and procedures are available.

4. A copy of the CCNAPI Guidelines for Critical Care Nursing.

5. Other Laws such as but not limited to the Patient’s Bill of Rights (PhilHealth)

The critical care nurse:1.Gains access to relevant ordinances and organizational regulations.2. Maintains current nursing registration with the Professional Regulation Commission and membership to the accredited professional organization and CCNAPI.

3. Fulfills the duty of care in accordance with the laws.

4. Practices in accordance with the organizational regulations, by-laws, policies and procedures.

5. Practices in compliance with the scope of nursing practice and the equitable duty of confidence to deliver nursing care in a way to safeguard the rights, privacy, well being and interests of every patient.

6. Ensures that informed consents have been obtained prior to carrying out nursing procedures and medical treatment.

7. Maintains legible, dated, signed and accurate nursing records to fulfill the legal responsibilities.

1. Patient/Family states that his/her rights are protected.2. Patient’s privacy is not violated.3. Patient expresses satisfaction to the quality treatment and service that he/she is lawfully entitled to.

4. Legible, dated, signed and accurate nursing records are maintained.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. An explicit policy for selection of nursing staff is established.2. A recognized manpower indicator to calculate staffing level is used.3. Nurses with appropriate qualification to practice intensive care nursing are available at all times.

4. A contingency plan is available.

The critical care nurse:1. Demonstrates knowledge and responsibility in line with policies and procedures stipulated by the unit.2. Participates in the development of staffing patterns with flexibility to give optimum patient care on a 24-hour basis.

3. Practices intensive care nursing in a continuous manner

1. There is documented evidence that critically ill patients receive quality intensive nursing care in a continuous manner.2. The staffing level is sufficient to meet daily patient care requirements.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. The critical care nurse possesses the knowledge required for the care of the critically ill.2. The critical care nurse has knowledge and skills in assessing patient’s needs, planning, implementing and evaluating the care provided.3. There is always a nursing expert available in the ICU.

4. There is a mechanism in place to provide continuing nursing education.

5. There is a system in place to monitor the competency level of critical care nurses.

The critical care nurse:1. Maintains standards of nursing practice and professional behavior determined by the organization requirements and Scope of Nursing Practice (RA 9173).2. Demonstrates possession of psychomotor skills required for the care of the critically ill.

3. Shares knowledge and expertise with others through teaching programs, clinical supervision and research activities.

4. Demonstrates effective interpersonal skills in communicating with patients and families, physicians and other members of the health team.

1. The critical care nurse demonstrates competency according to his/her experience and knowledge base.2. There is documented evidence that care provided is individually assessed, planned, implemented and evaluated.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. The information regarding patient's rights and responsibilities is available for patients and families.2. A mechanism for identification and resolution of ethical issues related to the care of the critically ill is established.3. A copy of the Code of Professional Conducts for Nurses in Philippines is available.

4. Materials such as books, journals and training programs on nursing ethics are available.

The critical care nurse:1. Complies with the Code of Professional Conducts for Nurses in Philippines as determined by the Professional Regulation Commission.2. Provides care with respect for patient’s dignity.

3. Acts as patient advocate in terms of respecting patient’s rights and interests.

4. Maintains confidentiality of information as appropriate.

5. Informs and supports patient in his/her decision making regarding his/her well-being.

6. Acknowledges honestly the limitations of personal knowledge and skills and takes steps to remedy such deficits.

7. Reports perceived unethical incidents to the appropriate person.

1. Patient/Family states that his/her rights and dignity are protected.2. Patient/Family states that he/she is adequately informed and adequately supported in decision making.3. All perceived unethical incidents are recorded and reported.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. The philosophy of critical care nursing is available.2. The unit objectives to guide nursing activities are available.3. Policy and procedure manuals approved by the hospital are available.

4. A mechanism is available to ensure the eligibility of nursing practice.

5. An audit system to ensure safe nursing practice is established.

The critical care nurse:1. Accepts responsibility to deliver safe nursing care to critically ill patients.2. Take responsibility to clarify unclear instruction and question inappropriate intervention.

3. Practices within the guidelines and protocols issued by hospitals and professional organizations.

4. Audits nursing practice regularly.

5. Makes sound and independent clinical judgments based upon ongoing monitoring of critically ill patients and evidence-based practice.

6. Recognizes on level of competence and limitation; and seeks appropriate plan of self-development.

1. The critical care nurse demonstrates ability to justify his/her own actions and judgment.2. No professional misconduct is reported.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. Written policies and procedures exist to minimize the risks of environmental hazards.2. A policy exists to ensure staff knows the correct use of new equipment.3. Copies of Occupational Safety and Health Ordinance and Regulation (OSHO & OSHR) are available.

4. A copy of the guidelines on Manual Handling Operations is in placed.

5. An established mechanism exists for reporting and auditing incidents.

6. The critical care nurse is cognizant of various rules and regulations governing the use of medical appliances for caring critically ill patients.

7. Resource persons are available to the intensive care staff at all times to provide service and advice on the safe use of medical appliances.

The critical care nurse:1. Implements agreed policies to minimize the risks of environmental hazards. Such policies and procedures shall include the prevention of fire and bio-medical hazards.2. Demonstrates knowledge of and responsibility for implementation of all aspects of the fire and bio-medical safety program.

3. Evaluates the effectiveness of preventive measures for controlling and counteracting the hazards periodically.

4. Ensures that the patient’s safety is protected through the planning and design of the unit:

Adequate space per patient bed, with allowance for potential equipment.
Adequate space for support areas.
Adequate electrical outlets.
Adequate illumination.
Adequate fire exits.
Windows, clocks, calendars
Sewage and sinks
Life-supporting systems, including medical gases, suction outlets and emergency power availability.
Emergency call system.
Auxiliary lighting system

5. Reports any environmental situation or defect, which is dangerous to patient/visitors/hospital staff.

1. Accidents are minimized.2. Hazardous incidents are documented and reported.3. A safe environment for patients, visitors and hospital staff is provided and maintained.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. An inventory of essential routine and emergency equipment is established and reviewed regularly.2. Access of above No. 1 to service provision is stipulated.3. Emergency equipment, medication and supplies are readily accessible.

4. Policies and guidelines for acquisition, preparation, utilization, cleaning and maintenance are available.

5. Policies for ordering, monitoring ad replacing equipment, medication and supplies for the intensive care unit are in place.

The critical care nurse:1. Participates in mandatory equipment training ensuring safe, efficient and effective utilization.2. Participates in establishing written policies and procedures for ordering, reordering, monitoring and replacing equipment, medication and supplies needed.

3. Reviews inventory of all equipment at regular intervals and ensures functionality through preventive maintenance program

4. Ensures that all necessary equipment and supplies are readily available at all times, and in proper working order.

5. Is familiar with the available hospital services, such as laboratory and pharmacy services during emergency situations.

1. Harm to patient from equipment failure is prevented.2. Harm to patient from deficiencies of service and supply system is prevented.3. There is written document for all equipment being checked for proper functioning on a regular basis.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. Written infection control policies are established.2. Immunization programs for all critical care nurses are provided when condition warrants.3. In-service programs regarding current infection control practices are provided.

4. Necessary protective devices are available for standard precautions.

5. Isolation facilities are provided to cohort and contain infectious outbreak.

6. A standing work group composing of staff of critical care and infection control units for controlling infection is established.

7. An ongoing system for reporting, reviewing and evaluating infection incidents are established.

The critical care nurse:1. Demonstrates knowledge of various infectious conditions requiring isolation and precaution.2. Adheres to the defined policies, procedures and guidelines for control of infection.

3. Reviews and revises infection control policies and procedures regularly.

4. Works collaboratively with infection control nurses for controlling infection.

1. The outbreak of infection is controlled.2. The infection rate in the intensive care unit is reduced or stays low.3. Decreased infection incidents are reported and documented.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

A. Performance of Health Assessment1. Guidelines for critical care nurse to perform health assessment are available.2. An agreed conceptual model for guiding nursing practice is available.

3. The Health Assessment form is available for documentation of patient data.

4. Experienced staffs are available to give advice on health assessment to less-experienced staff.

5. The critical care nurse possesses the knowledge and skills in performing physical examination and psycho-social assessment

B. Formulation of nursing diagnoses/identification patient problems in priority of patient’s needs

1. References to guide formulating nursing diagnoses/identifying patient problems are available.

2. Guidelines for formulating nursing diagnoses/identifying patient problems are established.

3. Experienced staffs are available to advise nurses in formulating nursing diagnoses/identifying patient problems.

4. The critical care nurse possesses the knowledge and skills to make accurate nursing diagnoses to identify patient problems.

C. Planning for Collaboration of Care

1. References and information on nursing care plans are available.

2. Experienced staff advises novice nurses in care planning when appropriate.

3. The critical care nurse possesses knowledge and skills to devise an individualized care plan pertinent to patient needs.

4. An agreed nursing care delivery model and medical treatment protocol, algorithm are available.

D. Implementation of Planned Nursing Care

1. The critical care nurse possesses the knowledge and skills in implementing the agreed care plan.

2. Standards of nursing care and practice are established.

3. Experienced staffs are available to give advice on the implementation of care.

4. Appropriate equipment for the implementation of the agreed care plan is available.

5. A policy to ensure the continuity of patient care is in place.

E. Evaluation of Outcome of Nursing Care

1. The critical care nurse possesses the knowledge and skills to evaluate the implemented care.

2. Experienced staff are available who advises nurses on the evaluation of delivered care.

3. A policy is available to evaluate patient’s responses to nursing care in a continuous manner.

The critical care nurse:1. Collects data on a continuous basis starting from admission.2. Collects subjective and objective data to determine patient needs.

3. Collects data in a systematic manner to ensure completeness of assessment.

4. Uses appropriate physical examination techniques to gather data.

5. Uses effective communication skills to obtain psycho-social subjective data from patient/family.

6. Collects relevant data from previous patient record(s).

7. Documents all relevant data in the patient record.

8. Updates the database regularly and whenever necessary.

9. Ensures pertinent data are accessible to all health care team members.

The critical care nurse:

1. Utilizes collected data to establish a list of actual and potential patient problems/needs.

2. Collaborates with the patient, family and other health care team members in the identification of problems/needs.

3. Formulates appropriate nursing diagnosis relevant to the patient’s condition wherein the nurse has the ability and experience to implement plan of care

4. Establishes the priority of problems/needs according to the actual/potential threats to the patient.

5. Documents prioritized nursing diagnoses/patient problems in the patient record.

6. Updates nursing diagnoses/patient problems when patient’s condition changes.

The critical care nurse:

1. Develops goals for each nursing diagnosis/patient problem.

2. Plans appropriate nursing interventions in collaboration with the patient, family and other health care team members whenever necessary.

3. Devises an individualized care plan.

4. Communicates the plan with those involved in caring the patients

5. Updates planned nursing actions in accordance with changes in patient health status.

6. Provides coordinated continuity of care.

7. Identifies activities through which care will be evaluated.

8. Documents the nursing care plan in patient record.

The critical care nurse:

1. Utilizes accepted principles for nursing interventions according to the dynamic environment.

2. Implements care according to standards and protocols.

3. Implements the planned care in collaboration with the patient, family and other health care team members.

4. Implements the planned care in an organized and humanistic manner.

5. Integrates current scientific knowledge with technical and psychomotor competencies.

6. Provides care in such a way as to anticipating and preventing complications and life-threatening situations.

7. Provides individualized and continuous care to achieve identified goals.

8. Documents interventions in patient’s records.

9. Reviews and modifies interventions based on patient’s progress.

The critical care nurse:

1. Collects data for evaluation within an appropriate time interval after intervention.

2. Compares the patient’s responses with expected outcomes.

3. Determines the causes of significant differences between the patient’s responses and the expected outcomes.

4. Reviews and revises the plan of care based on the evaluation.

5. Documents evaluation findings in patient record.

1. Individualized patient assessment is performed in an accurate, continuous and systematic manner.2. There is documented evidence that patient’s physical, psycho-social and spiritual needs are identified.3. The intensive care nurse is cognizant of the current condition of each patient under his/her care.

4. Patient’s data are kept up-to-date.

There is documented evidence that nursing diagnoses are formulated. Patient problems are identified according to priority of needs.

1. Patient care reflects the identified patient problems/needs.

2. The planned care reflects appropriate nursing interventions.

1. The agreed nursing care plan is implemented.

2. A nursing intervention record for individual patient is kept.

3. The identified goals for individual patient care are achieved

The implemented care is evaluated and documented.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. An education framework for intensive care setting is established.2. An optimal learning environment is created.3. A tool for assessing patient’s/family’s needs is established.

4. Plans and programs for promoting and maintaining health are devised.

5. The critical care nurse possesses competency in the provision of health education.

The critical care nurse:1. Assesses patient’s/family’s learning ability or any barriers to learning.2. Modifies health teaching strategies according to patients /family’s literacy level.

3. Establishes good rapport with patient and family.

4. Assists patient in setting short-term and long-term goals for the promotion and maintenance of health.

5. Plans and implements individualized health educational activities.

6. Provides educational information for patient and family in promotion and maintenance of health.

7. Facilitates patient’s/family’s ability to comply with the health education provided.

8. Documents the teaching-learning progress.

9. Evaluates the effectiveness of health teaching and modifies the approach if necessary.

1. Patient demonstrates a positive attitude towards health promotion and health maintenance.2. There is documented evidence that patient/family understands the health education material.

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

STRUCTURE CRITERIA

PROCESS CRITERIA

OUTCOME CRITERIA

1. A system to offer nurses the opportunity for continual professional development is established.2. An objective performance appraisal system is available.3. Professional journals and textbooks related to critical care nursing are available.

4. A mechanism to facilitate career progression program is available.

The critical care nurse:1. Sets and reviews objectives for professional development at regular intervals.2. Participates in continuing educational programs to update intensive care knowledge and skills.

3. Contributes to professional development through teaching activities and clinical supervision.

4. Participates in conducting clinical research and application of evidence-based nursing practice.

5. Participates and promotes the activities of professional nursing organizations.

6. Demonstrates interest in pursuing advanced critical care nursing practice

1. Patient receives quality nursing care based on current scientific knowledge and research findings.2. The critical care nurse completes continuing nursing education programs and demonstrates commitment in further professional advancement.3. Expertise in intensive care nursing is developed and respected by 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

Research

Record Management

Key Responsibility Areas	Responsibilities / Tasks	Competent Behavior Clusters
I. *Safe Quality Nursing Care*	1. Conducting nursing assessmentDescription: The critical care/ intensive care unit (ICU) nurse performs patient health assessment accurately, continuously, comprehensively and systematically. The critical care nurse prioritizes the health needs of the patient from a holistic perspective.	The critical care nurse: obtains comprehensive patient information from a holistic perspective with the aid of advanced technologies and physical examination techniques, paying particular attention to the psychosocial impact of the critical care environment on patients and relatives. prioritizes the health needs of the patient based on the assessment data and communicates this information to the right people in a correct and timely manner. collects patient’s data in a systematic, objective and continuous manner from clinical observation and monitoring devices. ensures pertinent data are clearly documented and accessible to all health care team members.
	2. Formulating care plansDescription: The critical care identifies patient’s problems in relation to patient’s needs /nurse develops individualized, holistic and patient-centered care plans that document nursing diagnoses.	Thecritical carenurse: utilizes collected data to establish a list of actual and potential patient problems/needs. collaborates with the patient, if applicable, family and other health care team members in identifying problems/needs and planning of appropriate nursing actions accordingly. establishes and records the priority of problem/needs according to the actual danger or potential threats to the patient. formulates an individualized care plan with continuous review to match both the needs of the patient and family
	3. Implementing planned careDescription: The critical care nurse implements planned care to achieve optimal health status of dignified death of the patient.	The critical care Nurse: carries out planned patient care or immediate nursing actions in a safe, comprehensive, effective and humanistic manner according to patient’s response. adopts evidence based-practice in the care of the critically ill patients where applicable. assists the patient towards end-of-life attaining peaceful and dignified death.
	4. Evaluating patient’s health progress and outcomeDescription: The critical care nurse evaluates the outcomes of nursing care in an explicit, systematic and ongoing manner.	The critical care nurse: maximizes clinical skills with monitoring devices to evaluate the care process and compares the patient’s response with expected outcome. identifies the cause for any significant difference between the patient’s response and the expected outcome. Identifies potential risk of patients, such as but not limited to Deep Venus Thrombosis (DVT), aspiration, pressures, infection, fall risk, malnutrition / starvation, patient abuse, iatrogenic etiologies revises the care plan to ensure patient centered and quality of care to patient. implements appropriate and effective nursing interventions to help patients and significant others address hospice, palliative and end-of-life care needs.
	5. Maintaining effective c communicationDescription: The critical care nurse communicates relevant, accurate and comprehensive information, both verbal and written, about the patient’s health status to related health care team members and family members.	The critical care nurse: reports instantly key changes of patient’s health condition in an emergency situations. monitors and documents relevant information objectively and systematically. maintains information in an accessible and retrievable form. conducts effective patients and family health education.
	6. Acting in emergency situations such as rapid deterioration, life- threatening , unstable, and critical eventsDescription: The critical care nurse responds swiftly in a calm and proficient manner when faced with an unexpected or rapidly changing situation related to the patient or environment.	The critical care nurse: demonstrates knowledge of ICU emergencies such as medical emergencies, civil disasters and contingency plan for hospital emergencies. anticipates possible changes / complications associated with particular diseases and/or treatment procedures. implements prompt and appropriate resuscitative interventions. keeps the medical team informed of patient’s deteriorating condition in a timely manner fulfills the specific team role during large-scale crisis to provide safe, effective and efficient care of the patient.
	Demonstrating specific knowledge and skills in the critical care setting Description: The critical care nurse provides quality and effective care to patient in the following aspects: Pulmonary Cardiovascular Neurological Renal Gastrointestinal Endocrine Peri-operative Trauma Burn Organ Transplantation Control of Infection Psychosocial and Spiritual Care	A. Pulmonary careThe critical care nurse: Has an understanding of the applied respiratory physiology Demonstrates nursing competencies in: Respiratory assessment Respiratory monitoring such as clinical observation, arterial blood gases, SpO2, ETCO2 Airway management such as suctioning, chest physiotherapy, oral care, use of airway gadgets and others Respiratory investigation and therapy such as bronchoscopy, tracheostomy, chest physiotherapy Provides holistic care to patients in the following conditions: Before and after thoracic surgery With acute or chronic respiratory disorders On ventilator support Being weaned from mechanical ventilator On oxygen therapy Initiates and assists in the emergency and resuscitative procedures such as endotracheal intubation, tracheostomy and chest drain insertion. Educates and supervises patients and families on home oxygen therapy. B. Cardiovascular care The critical care nurse: Has an understanding of the applied cardiac physiology Demonstrates nursing competencies in: Cardiovascular assessment Cardiovascular investigation Interpretation of electrocardiogram Hemodynamic monitoring such as non-invasive, arterial pressure, pulmonary artery pressure, CVP Administration of cardiac medication Provides holistic care to patients with the following conditions: Before and after cardiac surgery With cardiac arrhythmias and heart block With cardiac disorders such as myocardial infarction, Acute Coronary Syndrome, heart failure, shock On cardiovascular support such as intra-aortic balloon pump, ventricular assist devices Initiates and assists in cardiovascular resuscitation e.g. cardiac pacing, cardioversion, defibrillation, pericardiocentesis, advanced cardiac life support. C. Neurological care The critical care nurse: Has an understanding of the applied neurological physiology. Demonstrates nursing competencies in: Neurological assessment Neurological investigation Provides holistic care to patient: Before and after neurological operation Suffering from neuro-medical disorders On intracranial pressure monitoring D. Renal care The critical care nurse: Has an understanding of the applied renal physiology. Demonstrates nursing competencies in: Renal assessment Renal investigation Interpretation of blood biochemistry Provides holistic care to patients with renal failure by: Peritoneal dialysis Hemodialysis Continuous renal replacement therapy (CRRT) E. Gastrointestinal care The critical care nurse: Has an understanding of the applied gastrointestinal physiology. Provides holistic care to patient: With gastrointestinal disorder such as acute pancreatitis, hepatic failure Before and after gastrointestinal operation With gastrointestinal emergencies such as gastrointestinal bleeding, esophageal varices bleeding Undergoing different procedures such as peritoneal lavage Early access and early feeding using appropriate gadgets. F. Endocrine care The critical care nurse: Has an understanding of the applied endocrine physiology. Provides holistic care to patients with the following conditions: Diabetic emergencies such as diabetic ketoacidosis, hyperglycemia, hypoglycemia Thyroid storm Other endocrine emergencies G. Peri-operative care The critical care nurse: Equips oneself with knowledge and skills for implementation of safe, adequate evidence-based care of clients during the pre-, intra- and post operative procedures Provides holistic care to patients with the following conditions: Before and after different types of operations With wounds and drains. Demonstrates nursing competencies in pain assessment and pain management H. Trauma care The critical care nurse: Has an understanding on the mechanism of different types of injury. Demonstrates nursing competencies in: Primary and secondary assessment Stabilization, transfer and transport of trauma patients Emergency and resuscitative procedures c. Provides holistic care to patients with different types of trauma I. Burn care The critical care nurse: Has an understanding of the: Applied skin physiology Mechanism of injury associated with burn and inhalation injury Demonstrates nursing competencies in: Burn assessment Burn resuscitation such as airway, breathing and circulation Burn wound care Provides holistic care to patients with burn . Educates patient on long term skin care J. Organ transplantation care The critical care nurse: Demonstrates knowledge in brain stem death test Identifies potential organ donor Provides holistic care to: Potential donor Perioperative transplant patient d. Identifies potential risk associated with organ transplant and takes appropriate actions K. Pain Management The critical care nurse: Applies evidence-based practices on pain prevention Selects appropriate assessment and intervention tools and techniques in collaboration and consultation with other team members (such as WHO Pain Ladder or other similar framework) Demonstrate management capabilities of clients using pharmacological and non-pharmacological interventions. L. Prevention and Control of Infection The critical care nurse: Has an understanding of the principles of prevention of infection Complies with infection prevention and control guidelines Demonstrates competency in handling and preventing infection Monitors patient’s treatment compliance and the related outcome Provides health education on infection control to the patients and relatives M. Psychosocial and spiritual care The critical care nurse: Identifies the psychosocial and spiritual needs of ICU patent and his/her families Demonstrates nursing competence in communication and counseling skills Supports the family during the loss, grieving and bereavement process Provides psychosocial care such as music therapy, therapeutic touch and relaxation therapy to patient and his/her family according to their needs N. Miscellaneous The critical care nurse provides holistic care to patients with the following problems: Drug overdose Hematological failure Obstetrical emergencies Pediatric emergencies Near drowning Thermal injuries – heat stroke, hypothermia
II. *Management of Resources*	1. Managing within the organizationDescription: The critical care nurse understands the vision, mission and core values of the organization and facilitates the achievement of the organizational goals.	The critical care nurse: Demonstrates specialty knowledge in managing within the organization Uses organizational core values and objectives in line with daily work Follows organizational policies, procedures and protocols Participates in organizational initiatives by contributing constructive proposals for improvement Strengthens and develops critical care delivery in paced with rapid advanced technologies Maximizes effective resource utilization
	2. Empowering subordinatesDescription: The critical care nurse achieves targets through subordinates using the processes and techniques associated with motivating, coaching, delegating and supervising.	The critical care nurse: Motivates subordinates to achieve assignments and goals by providing them with the rationale for performing the task; considering and accepting their suggestions when appropriate; and reinforcing good practice Collaborates tasks and deploys subordinates according to their capabilities and job experiences, to allow immediate delivery of critical care services in crisis management Encourages subordinates to participate in specialty activities, and stimulates their innovation in critical care nursing development
	3. Assisting in maintaining a safe and healthy working environmentDescription: The critical care nurse carries out activities to assist in maintaining a favorable working environment	The critical care nurse: Creates a favorable working environment that maximizes the production of high quality critical care delivery Establishes effective feedback loop between health care teams, patients and relatives Contributes to the maintenance of occupational health and safety, and prevention of occupational hazard ensuring positive practice environment. Establishes effective linkages between inter and intra departments and hospitals to share updated specialty information and different experiences, thus preparing the organization to cope with continuous external changes more efficiently Reports any unfavorable environment which may have a negative impact on the patient’s physical, psychological and social well being as well as the process of rehabilitation.
III. *Legal Responsibilities*	Fulfilling legal responsibilities and acting as patients advocateDescription: The critical care nurse functions in accordance with common law, ordinance and regulations influencing nursing practice.	The critical care nurse:a. Demonstrates awareness of the relevant ordinances and organizational regulations that have legal regulations such as Code of Professional Conduct for Nurses and the Philippines Nursing Law of 2002 (RA 9173).b. Acts based on ethical principles and ensures that no action or omission is detrimental to the safety of patients. c. Familiarizes with the legal procedures for organ transplantation and be sensitive to organ preservation management and family support. d. Ensures that informed consent has been obtained prior to carrying out invasive and non-invasive procedures and medical treatment, particularly when patient or/and family does not have complete information to make an informed decision. e. Facilitates delivery of comprehensive explanation to patient/family if indicated to empower them to make responsible choice. f. Maintains legible, dated signed and accurate nursing records to fulfill legal responsibilities. g. Is aware of self-limitation and seeks advice and supervision from senior if a delegated task or responsibility is felt to be beyond current training or ability, (e.g., informs seniors that he/she has no experience and training in caring patient undergoing continuous renal replacement therapy). h. Reports any unfavorable environment which may have a negative impact on the patient’s physical, psychological and social well being as well as the process of rehabilitation.
IV. *Ethico-Moral Practice*	Practicing ethico-moral standards of the nursing profession.Description: The critical care nurse demonstrates the appropriate application of knowledge in nursing practice, which complies with the code of professional conduct, principles of autonomy, beneficence and justice. She / He also accepts personal responsibility for one’s own professional judgments and actions as well as consequence of one’s behavior	The critical care nurse:a. Has respect for patient / family rights including confidentialityb. Conducts intensive care nursing practice and makes sound independent clinical judgment in a way that can be ethically justified c. Aware of the importance of open discussion with others about his/her own views on ethical dilemmas d. Reports all perceived unethical incidents to responsible person such as but not limited to, responsible use of technology (clinical or administrative); use of communication devices not related to clinical practice e. Maintains professional decorum in dealings with patient, family and co-workers.
V. *Collaboration and Teamwork*	1. Maintaining collaborative relationships in the multi-disciplinary teamDescription: The critical care nurse maintains collaborative relationships within the ICU team. This relationship contributes towards the achievement of smooth and effective team performance in accomplishing common goals.	The critical care nurse:a. Contributes in various clinical meetings to provide professional input in patient care management such as case conference and risk management meetingb. Values team members’ participation and joint decision-making c. Seeks opportunities to participate in cross-functional, multi-disciplinary quality improvement initiatives
	2. Maintaining a cohesive nursing teamDescription: The critical care nurse establishes and maintains harmonious working relationships with nursing colleagues	The critical care nurse: Demonstrates knowledge of team concepts (e.g., discuss the dynamic of teams, participates in various stages of team growth: forming, brainstorming, and performing) Demonstrates understanding of the structure, functions and purposes of the team Demonstrates understanding of the role of different team members and the agreed goals Takes initiatives to participate in team discussion and to achieve team goals and objectives Shows willingness to share workload when needed Participates in various intensive care related activities such as CQI projects, research activities, infection prevention and control survey
VI. *Professional and Personal Development*	1. Facilitating the development of nursing knowledge in clinical settingDescription: The critical care nurse takes initiative to support or conduct activities, which promote the advancement of nursing knowledge	The critical care nurse: Develops the necessary skills and initiates efforts to improve efficiency and effectiveness of service; seeks opportunities for further development within the organization and contributes to the training and development needs Facilitates learners to achieve their training and development needs Conducts coaching and actively participates in the preceptor ship and mentorship program. Assists in ward orientation/induction for new nurses and alerts them to the specific requirements in caring of ICU patients. Assimilates the evidence-based research findings to further improve clinical practice Supports or participates in nursing research Shares and disseminates evidence-based findings Shares clinical experience and knowledge with colleagues Applies theoretical knowledge to practice j. Identifies areas for enhancement of nursing knowledge such as counseling and communication skills in all areas of critical care practice including bereavement process
	2. Promoting the professional image of ICU nurseDescription: The critical care nurse acts in manner that maintains active ongoing involvement in activities related to the nursing profession such as ICU conference, workshop and course; and promotes the professional image of nursing	The critical care nurse: Asserts professionally in the health care team Shows concerns about the public interest regarding health promotion and maintenance Acts in the manner of a knowledgeable, competent, responsible, accountable and caring professional with critical thinking to achieve the aimed objective Supports activities run by professional organization such as micro-teaching and sharing session of clinical experiences Promotes spirit of professional cohesiveness Acts for the collective interest of the profession Adopts continuous quality improvement in nursing
	3. Evaluating own nursing practice and knowledge to enhance personal skillsDescription: The critical care nurse assesses self-awareness of his/her own professional competence continuously and independently; maintains up-to-date nursing knowledge to keep abreast of nursing trends and nursing standards in specialty practice.	The critical care nurse: Uses professionally acceptable standards or practice to assess self-performance Demonstrates proficiency in providing care to patients receiving different modes of treatment in acute settings to achieve intended outcomes and prevent or minimize adverse outcomes Demonstrates awareness of individual strength and limitations and the importance of enhancing nursing knowledge Seeks additional information/opportunities to polish personal skills and qualities e.g. attending courses/seminars or reading books on relevant subjects when unfamiliar clinical situations with no precedents are encountered Develops own personal development plans that include attending in-service ICU courses, ICU scientific meetings, overseas ICU conferences, tertiary educational programs and reading ICU specialty journals/literature, etc. Shares up-to-date ICU nursing knowledge and current practice with nursing colleagues
VII. *Communication*	Communicates with individual patient and/or groups and with other members of the health care teamDescription: The critical care nurse takes initiative to communicate with individual and / or groups and with other members of the health team to facilitate care and management of the patients	The ICU nurse: Develops the necessary skills and initiates efforts to improve efficiency and effectiveness of communication; Uses a range of appropriate communication strategies which will have effective outcome such as but not limited to Hand-off communication, use of SBAR on referral, use of ICU flow sheet . Encourages the use of non-verbal / alternative communication techniques including information technologies where appropriate to elicit appropriate communication. Responds rapidly and appropriately to the needs of the critically ill patients, their significant others and the members of the health team
VIII. *Health Education*	*Provides appropriate health education based on comprehensive learning needs of the patient and family*Description: The critical care nurse makes thorough assessment of the learning needs of the patient and family for the provision of health education to assist the patient and family towards a productive life	The critical care nurse: Assesses comprehensively the needs and learning barriers of critically-ill clients, family and their significant others Provides refined health education plan which is individualized and comprehensive based on the client’s needs Demonstrates ability to develop and use appropriate learning tools for health education Conducts health education to significant others of the critically-ill clients with emphasis on basic concepts of the disease process Facilitates the thorough understanding of the critically ill client’s significant others regarding the disease process and course of management to enable them to participate in the care process Demonstrates ability to appraise outcome of the health education g. Integrates the helping and coaching role of a nurse during expressed need of the client, his family and significant others
IX. *Quality Improvement*	Proactive in theimplementation of changes as a consequence of quality improvement initiativesDescription: The critical care nurse demonstrates positive attitudes towards change for improvement	The critical care nurse: Demonstrates in-depth understanding and facilitates the achievement of the organization’s mission, vision and goals through quality improvement Identifies areas for quality improvement initiatives Establishes effective feedback loops between the organizations, health teams, patients and significant others pertaining to quality improvement. Facilitates the implementation of new policies, changes in implementing rules and regulations for quality improvement. Utilizes available and existing data to support quality improvement initiatives.
X. *Research*	Supports a positive climate for research within the practice settingDescription: The critical care nurse maintains currency of knowledge and practice based on relevant research findings	The critical care nurse: Demonstrates active involvement in research activities Incorporates evidence-based and research findings into nursing practice. Identifies areas of practice for which further research is indicated Seeks continuous improvement of professional practice through research activities.
XI. *Record Management*	Ensures that written information conforms to legal and ethical frameworkDescription: The critical care nurse maintains accurate and updated documentation of the care for the critically ill patients	The ICU nurse: Demonstrates ability to document information in a comprehensive and clear manner within the legal and ethical framework. Protects and safe guards the document conforming legal and ethical framework and institutional policies. Demonstrates effective and appropriate methods of documenting information d. Analyzes variances in the data recorded for improvement of client care

ANNEX I

EDUCATION

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.

Preamble

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

ANNEX II

Workforce

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

Aires, 2005

Introduction

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.

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.

Preamble

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.

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.

Central Principles

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.

References:

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.
International Nursing Council. The Global Shortage of Registered Nurses: An Overview of Issues and Actions (and accompanying Issues Papers) www.icn.ch/global

ANNEX III

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

Introduction

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

References:

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

CRITICAL CARE NURSING GUIDELINES, STANDARDS AND COMPETENCIES

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