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Essential critical care skills 1: what is critical care nursing?

18 October, 2021

Critical care nurses provide highly skilled, expert care for the most severely ill or injured patients. This introduction - part one of a six-part series – provides an overview of their role

In this first article of a six-part series on critical care nursing, we introduce the role and what it involves, as well as looking at how critical care nurses can support the whole patient, from a physical and psychosocial perspective. The importance of rehabilitation, assessment of risk of ongoing morbidity and delirium are also discussed. Part 2 describes the assessment of the critically ill patient.

Citation: Credland N et al (2021) Essential critical care skills 1: what is critical care nursing? Nursing Times [online]; 117: 11, 18-21.

Authors: Nicki Credland is reader in critical care, University of Hull; Louise Stayt is senior lecturer, Oxford Brookes University; Catherine Plowright is professional adviser, British Association of Critical Care Nurses; David Waters is associate professor, Birmingham City University.

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Introduction

Critical care nurses provide expert, specialist care to the most severely ill or injured patients in intensive care units and the wider hospital. They are highly trained and skilled safety-critical professionals working as part of a multidisciplinary team. Critical care is classified using four levels of patient acuity, as outlined in Table 1. Updated guidelines for the provision of intensive care services (Faculty of Intensive Care Medicine, 2019) recommend that level-3 patients should have a minimum registered nurse–patient ratio of 1:1 and level-2 patients must have a minimum nurse–patient ratio of 1:2.

To deliver highly skilled care, critical care nurses undertake postgraduate study and ongoing training. The Step Competency Framework underpins critical care nurse education; it recognises that, to be able to deliver high-quality care to patients, staff need the knowledge and skills so they can work at the highest level, with standardisation across all critical care units. Step 1 for adult critical care begins when a nurse with no previous experience of the specialty starts working in intensive care medicine. Steps 2 and 3 should be incorporated into academic intensive care programmes.

Critical care nurses also lead many outreach teams that identify, monitor and initiate timely treatment to prevent clinical deterioration, and support ward nurses (Department of Health, 2000). They offer advanced system assessment and rescue before irretrievable deterioration and cardiac arrest takes place.

This article is the first in a six-part series on essential critical care skills, which aims to explore essential critical care nursing competencies.

Managing organ dysfunction

Admission to a critical care unit is usually because of organ dysfunction or organ failure. Respiratory failure alone leads to around 100,000 annual admissions to critical care in the UK (FICM, 2019). The goal is to correct or provide support to these dysfunctional organs. Technological and medical advances over the past few decades have meant significant growth in treatments and interventions, and more-effective management of patients who need organ support.

The interventions most commonly used include mechanical ventilators, infusion devices and renal replacement therapy. Table 2 outlines the interventions used for different physiological systems.

Patient monitoring and documentation

It is crucial to gather accurate data on physiological parameters – such as oxygen saturation (SpO2), heart rate and fluid balance – at the bedside of the patient who is critically ill. Typically, each patient will have their own monitor that will display a range of clinical factors (Box 1) and provide real-time feedback to help evaluate critical care interventions, and detect any deterioration or emergency situations promptly.

Box 1. Clinical factors recorded by bedside monitors

• Heart rhythm
• Oxygen saturation
• Respiratory rate
• Exhaled carbon dioxide concentration/partial pressure
• Non-invasive blood pressure
• Arterial blood pressure
• Central venous pressure
• Temperature

Critical care nurses need technical skill and knowledge to effectively use and interpret bedside monitors. A further common technical resource is the clinical information system (CIS), which can record and process large amounts of data, such as:

• Patient physiological observations;
• Care or interventions delivered;
• Medication plans.

The FICM (2019) highlights how a CIS can not only improve efficiency, but also reduce errors and improve compliance with standards or guidelines.

Psychosocial care

Holistic patient-centred care – as outlined by Jasemi et al (2017) – is vital in critical care, with effective psychosocial care, and cultural, spiritual and family care being of particular significance. Immediately on admission to a critical care setting, patients are subjected to an onslaught of physical and psychosocial stressors including:

• Physical pain;
• An unfamiliar environment; equipment and treatments;
• Sensory disturbances;
• Isolation from family;
• Loss of autonomy;
• Impaired communication;
• Fear for their life (Kiekkas et al, 2010).

It can lead to severe emotional distress and the development of delirium, anxiety, depression and post-traumatic stress disorder (PTSD) (Hatch et al, 2018) – all of which may persist long after the patient’s physical recovery and discharge from hospital (Ewens et al, 2018).

Psychosocial care is often considered the touchstone to person-centred care and, in this setting, refers to supportive interventions that may mitigate the stressors associated with critical illness. Evidence-based measures that may all help include:

• Providing information and explanations;
• Regularly orientating the patient to date, time and place;
• Reassurance;
• Empathetic touch;
• Early mobilisation;
• Family visits;
• Maintaining clear night and day routines;
• Minimising noise (Bani Younis et al, 2021; Alaparthi et al, 2020; Parsons and Walters, 2019).

Delirium is of particular concern in patients who are critically ill, and has an incidence range of 45-87% (Cavallazzi et al, 2012). It is characterised by the acute onset of cerebral dysfunction, with a change or fluctuation in baseline mental status, inattention, disorganised thinking or an altered level of consciousness (NICE, 2019). Delirium is associated with significant increases in mortality, morbidity and hospital stay, as well as having long-term ramifications such as cognitive impairment, PTSD, anxiety and depression (Cavallazzi et al, 2012) so the prevention, early recognition and effective management of it is of paramount importance. The ABCDEF bundle of care may help:

• A ssessment, prevention and management of pain;
• Awakening the patient and doing a spontaneous B reathing trial;
• C hoice of sedation and analgesia;
• Assessment, prevention and management of D elirium;
• E arly mobilisation;
• F amily engagement (Marra et al, 2017) .

Cultural and spiritual care

A patient’s cultural and spiritual background influences many aspects of nursing in critical care, such as patient and family roles, communication, nutrition, values and beliefs towards health, care and treatments, and end-of-life care. Careful assessment of the patients’ health beliefs, communication needs, social networks and family dynamics, dietary requirements, religious practices and values, is essential to plan and deliver culturally sensitive and spiritual care that contributes to the quality of life, care and satisfaction of patients as well as their families (Willemse et al, 2020).

Family care

Family members of patients who are critically ill can play an important part – often acting as surrogate decision makers – and be essential in providing emotional and social support. However, relatives may experience extreme stress, fear and anxiety, both during and after the patient’s admission. Relatives are also vulnerable to ongoing psychological illnesses such as PTSD, anxiety and depression (Johnson et al, 2019). Nurses need to develop a collaborative relationship with them to effectively identify and address their immediate needs, as well as prepare them to cope with their loved one’s discharge and ongoing rehabilitation. Families need honest and timely information, assurance, proximity, comfort and support (Scott et al, 2019).

Rehabilitation

Critical illness can cause significant long-term physical and non-physical problems for patients, and rehabilitation is important to improve recovery. National guidelines, such as those by the FICM (2019) and the National Institute for Health and Care Excellence (2017), have supported this, with the aim of improving these patients’ physical, psychological and cognitive outcomes.

Patients should be assessed at the following key stages:

• Within four days of admission to a critical care unit, or earlier if being discharged;
• Just before discharge to ward-based care;
• When receiving ward-based care;
• Before discharge to their home or community care;
• Two to three months after discharge from the critical care unit.

Rehabilitation should be patient centred, involve the whole multidisciplinary team and occur throughout the patient pathway, with plans updated as the patient’s condition changes (FICM, 2019). Physiotherapists, occupational therapists, dieticians, speech and language therapists, critical care nurses and doctors, as well as patients and their families, all have a role.

Short clinical assessments should be done with all patients in critical care to identify their risk of physical and non- physical morbidity. A short clinical assessment is applicable for patients who are expected to recover quickly, despite requiring initial level-3 care, and should assess a range of factors (Box 2). If the patient is deemed at risk, a comprehensive clinical assessment should be undertaken; this will also assess physical and non-physical risk (Box 3).

Box 2. Short clinical assessment

The following may indicate that the patient is at risk of physical/non-physical morbidity and needs further assessment:

• Unable to get out of bed independently
• Anticipated long duration of critical care stay
• Obvious significant physical or neurological injury
• Lack of cognitive functioning to continue exercise independently
• Unable to self-ventilate on 35% of oxygen or less
• Presence of pre-morbid respiratory or mobility problems
• Unable to mobilise independently over short distances

Non-physical

• Recurrent nightmares, particularly if the patient reports trying to stay awake to avoid them
• Intrusive memories of traumatic events that occurred before admission (for example, road traffic accidents) or during their critical care stay (for example, delusion experiences or flashbacks)
• New or recurrent anxiety or panic attacks
• Expressing a wish not to talk about their illness or changing the subject quickly

Box 3. Comprehensive clinical assessment

This assessment should be undertaken for all patients identified as being at risk of physical or non-physical morbidity.

Physical issues

• Breathlessness
• Tracheostomy
• Artificial airway
• Swallowing issues
• Poor nutritional state
• Minor assistance needed
• Major assistance needed
• Full assistance needed
• Visual changes
• Hearing changes
• Altered sensations
• Sedated/pain
• Difficulties in speech
• Changes in voice quality
• Difficulty writing
• Poor wound healing

Non-physical issues

• Palpitations, irritability or sweating
• Hallucinations, delusions
• Flashbacks, withdrawal, traumatic memories of critical care
• Loss of memory
• Attention deficit
• Sequencing problems
• Lack of organisational skills
• Disinhibition
• Low self-esteem
• Low self-image
• Relationship difficulties
• Difficulty sleeping

During the assessment of these patients, a range of tools may be used including the following:

• Hospital Anxiety and Depression Score (Zigmond and Snaith, 1983);
• Barthel Activities of Daily Living Index (Wade and Colin, 1988);
• Chelsea Critical Care Physical Assessment Tool (Corner et al, 2013).

Many critical care units provide follow-up services for patients after discharge, giving them access to a range of health professionals, including critical care nurses, to assess physical and non-physical recovery (NICE, 2017). If these are not available, patients can be directed to ICU Steps (www.icusteps.org), which can help to support patients and families affected by critical illness.

This article aims to provide an overview of critical care and the critical care nurse role. The following articles in this series will explore in more detail key issues relating to the management of patients who are critically ill.

• Critical care nursing is highly skilled, and requires postgraduate study and training
• Critical care nurses provide outreach to support ward nurses who are caring for patients at risk of deterioration
• Care of patients on critical care units often involves organ system support and close monitoring is needed
• A holistic view of the patient – which takes into account physical and psychosocial matters – is vital, as is supporting families

Also in this series

• Essential critical care skills 2: assessing the patient
• Essential critical care skills 3: arterial line care
• Essential critical care skills 4: airway assessment and management
• Essential critical care skills 5: management of fluid balance
• Essential critical care skills 6: arterial blood gas analysis

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The Vital Role of Critical Care Nursing

In the vast and ever-evolving landscape of healthcare, one crucial aspect that often goes unnoticed by the public eye is critical care nursing. These unsung heroes play a pivotal role in ensuring the health and well-being of patients requiring a higher level of care.

Table of contents:

• What is critical care nursing

The role of critical care nurses

• How to become a critical care nurse

What is critical care nursing?

Critical care nursing refers to a specialized area of nursing that focuses on managing and coordinating  the care of severely ill patients suffering from complicated medical or surgical illnesses. Critical care nurses work in emergency rooms, intensive care units (ICUs), post-anesthesia care units (PACUs), and other acute care departments.

These highly skilled nursing professionals are adept at assessing patients quickly and administering rapid interventions to stabilize and treat patients in critical conditions. Their competence and quick decision-making abilities are essential in ensuring positive patient outcomes.

• Rapid Response and Emergency Care: Emergency departments are where patients will encounter their first line of critical care nurses. They are rapid critical thinkers who respond swiftly and efficiently to patients' emergent needs. Their ability to remain calm under pressure and prioritize critical interventions can be the difference between life and death.
• Monitoring and Assessment: Critical care nurses closely monitor patients' vital signs, diagnostics, and overall condition to detect any changes or complications. Their ability to assess subtle and minute changes in a patient's condition promotes rapid intervention for the best possible patient outcomes.
• Collaborative Care: These nurses work closely with physicians, specialists, and other members of the interdisciplinary healthcare team to develop comprehensive plans of care individualized to a patient's specific needs. Effective communication and teamwork are vital in acute care settings, where time is of the essence.
• Medication Administration: Critical care nurses administer and titrate medications based on physician orders and a patient's condition, ensuring prompt treatment and a high quality of care.
• Patient Advocacy: Advocacy is a core principle of nursing, and critical care nurses are strong advocates for their patients. They ensure patients and their families are given every opportunity to make informed decisions even when the patient cannot speak for themselves.
• Emotional Support: Nurses in this role also provide emotional support to families. Critical care nurses comfort, educate, and care for patients and their families during some of the worst times in their lives.

What does it take to become a critical care nurse?

Becoming a critical care nurse requires a comprehensive blend of education, skills, and dedication. 

• Education: Aspiring nurses must first complete a registered nursing (RN) program, which involves obtaining a bachelor's degree in Nursing (BSN) or an associate degree in nursing (ADN) from an accredited institution. 
• Licensure: After successfully completing their nursing education, individuals need to pass the National Council Licensure Examination for Registered Nurses ( NCLEX-RN ) to become licensed RNs . 
• Further Training & Skills Development: Specializing in critical care will require additional training, experience, and in some situations, certifications. Critical care nurses must have advanced critical thinking and communication skills, work calmly and efficiently under pressure.
• Certifications & Specialization: They often pursue critical care nurse certifications such as the CCRN credential from the American Association of Critical-Care Nurses, which validates their high proficiency in providing direct care to acutely ill patients.
• Finding Work: Finding critical care nurse jobs can vary in ease depending on factors such as location, experience, and current demand within the healthcare industry. There are numerous critical care specific specialties available for RNs working in acute care - including ICU RN, NICU RN, flight nurse, and critical care transport nurse.

Critical care nursing plays a vital role in the healthcare ecosystem by providing comprehensive, rapid, life saving care to patients in critical conditions. Critical care nurses are the backbone of emergency departments and critical care units, demonstrating unwavering dedication, compassion, and expertise in their field.

As we acknowledge the significance of critical care nursing, let us also show our appreciation for this group of skilled professionals and the difference they make to patients and their families every day. Their commitment and resilience truly exemplify the essence of nursing care in its most critical form.

Want to learn about other in-demand healthcare professions? Explore more professions with shifts offered through the CareRev App.

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Critical care nursing is a field of nursing that practices predominantly in intensive care and emergency units. Critical care nurses are equipped to handle critically ill patients, often specializing in a particular aspect of critical illness, such as cardiac care, to provide the best care for patients who are seriously ill or injured.

In addition to caring for the physical health of patients, critical care nurses must deal with the emotional health of patients as they cope with their conditions, as well as working with family members to make the best health care decisions for the patients. The nurses usually work with a team of health care professionals to develop a patient’s care plan. Communication is imperative in critical care nursing; in addition, a nurse must be prepared for adapting a patient’s care quickly based on the patient’s health.

Critical Care Nursing Theories and Models

• Erickson’s Modeling and Role Modeling Theory
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• Watson’s Philosophy and Science of Caring
• Nightingale’s Environment Theory
• Pender’s Health Promotion Model
• Roper-Logan-Tierney’s Model for Nursing Based on a Model of Living
• Henderson’s Nursing Need Theory

For more information on Critical Care Nursing, try the following sources:

Lippincott ® NursingCenter ®

Practice specialties, critical care nursing.

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

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What do critical care nurses need to know.

• an understanding of human anatomy and physiology.
• sharp clinical assessment skills.
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Critical Care Nursing Certification Review Course

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

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Critical Care Nursing

• Reference work entry
• First Online: 01 January 2022
• pp 1219–1225
• Cite this reference work entry

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Emergency care nursing ; High-acuity care nursing ; Intensive care nursing

Critical care is defined by the US Department of Health and Human Services as the direct delivery of care for people who are critically ill, which means that an illness or injury has acutely impaired one or more vital organ system to a degree that there is a high probability of life-threatening deterioration (Duke 2006 ). According to the Association of American Critical Care Nurses, critical care nursing is a specialty that deals specifically with human responses to life-threatening problems; a critical care nurse is a licensed professional nurse who is responsible for ensuring that critically ill patients and their families receive optimal care (Burns 2014 ).

Critical care nursing emerged from the early 1950s. At that time, the use of mechanical ventilation and cardiopulmonary resuscitation began, and there was a great demand for providing efficient care to gravely ill patients (Perrin...

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Ward NS, Chong DH (2015) Critical care beds and resource utilization: current trends and controversies. Semin Respir Crit Care Med 36(6):914–920. https://doi.org/10.1055/s-0035-1564876

World Federation of Critical Care Nurses (2017) WFCCN resources for clinical guidelines. Retrieved from http://wfccn.org/clinical-guidelines/

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Rick Yiu Cho Kwan & Kitty Chan

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Kwan, R.Y.C., Chiang, V., Chan, K. (2021). Critical Care Nursing. In: Gu, D., Dupre, M.E. (eds) Encyclopedia of Gerontology and Population Aging. Springer, Cham. https://doi.org/10.1007/978-3-030-22009-9_844

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Critical Care Nurse Career Overview

Are you ready to earn your online nursing degree?

how long to become

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

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

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

Where Do Critical Care Nurses Work?

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

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

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

Step-down Units

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

Why Become a Critical Care Nurse?

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

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

Advantages to Becoming a Critical Care Nurse

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

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

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

Frequently Asked Questions

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

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

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

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

What career advancement opportunities are available for critical care nurses?

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

Resources for Critical Care Nurses

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

What to Know About Getting a BSN Degree: Common Courses and Requirements

To receive a BSN degree, you must complete coursework, clinicals, and lab work. Learn more about BSN requirements in this guide.

The Best Online RN-to-MSN Programs

Online RN-to-MSN programs allow nurses to earn an advanced nursing degree quickly. This guide helps you decide whether an online RN-to-MSN program is right for you.

How to Become a Registered Nurse

Registered nurses (RNs) provide patient care in every healthcare setting. Learn how to become a registered nurse.

How to Become a Travel Nurse

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

Reviewed by:

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

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

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HEALTHCARE CAREER GUIDES

Critical Care Nurse Career

What is a critical care nurse.

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

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

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

RESPONSIBILITIES

What Does A Critical Care Nurse Do?

Critical care nursing involves working with doctors and specialists to assess, treat, and monitor critically ill patients while also providing their basic care.

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

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

EDUCATION & BEST DEGREES

How to become a critical care nurse.

Step One: Become a registered nurse.

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

Step Two: Earn your critical care nursing licensure.  

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

Step Three: Get certified as a critical care nurse.

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

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

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

Step Four: Explore additional certifications and education.

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

These additional certifications could include: 

CMC: providing care to critically ill cardiac patients

CSC: providing care to critically ill cardiac surgery patients

ACNPC-AG: providing care for very sick geriatric patients

Best Degrees for a Critical Care Nurse

Nursing (Prelicensure) – B.S.

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

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

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

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

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

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

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

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

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

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

Skills for your résumé you will learn in this program:

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

Compare degrees

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

Nursing (RN-to-BSN Online) – B.S.

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

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

• Time:  The program is designed to be completed in 1 year.
• Tuition:  $5,325 per 6-month term.
• Courses : 23 total courses in this program.
• Transfers: Students can transfer up to 90 credits.
• Healthcare Policy and Economics
• Information Technology in Nursing Practice
• Anatomy and Physiology
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If you don't currently have an RN and don't qualify for your nursing prelicensure program, consider getting our Bachelor's in Health and Human Services  instead. This degree allows you to work inside the healthcare industry in a unique way.

Nursing Leadership and Management – Post-Master's Certificate

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

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

• Time:  Students typically finish this program in 12 months.
• Tuition:  $5,035 per 6-month term. The cost to sit for the NAHQ Certified Professional in Healthcare Quality (CPHQ) exam is included in tuition.
• Courses : 8 total courses in this program.
• Strategic Planning
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Nursing – Leadership & Management (RN-to-MSN) – M.S.

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

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

• Time: 62% of RN-to-MSN grads finish within 37 months.
• Tuition:  $5,325 per 6-month term during undergraduate portion and $5,035 per 6-month term during graduate portion.
• Courses : 32 total courses in this program.

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

How Much Does a Critical Care Nurse Make?

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

What Is the Projected Job Growth?

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

What Skills Does a Critical Care Nurse Need?

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

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

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

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What does a critical care nurse do?

Would you make a good critical care nurse? Take our career test and find your match with over 800 careers.

What is a Critical Care nurse?

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

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

What does a Critical Care nurse do?

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

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

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

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

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

What is the workplace of a Critical Care nurse like?

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

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

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

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

Frequently Asked Questions

Nursing related careers and degrees.

• Acute Care Nurse Practitioner (ACNP)
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• Certified Nurse Midwife (CNM)
• Certified Nursing Assistant (CNA)
• Clinical Nurse Specialist (CNS)
• Critical Care Nurse
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Continue reading

Critical Care Nurses are also known as: Critical Care Registered Nurse

How to Become a Critical Care Nurse

Critical care nurses provide nursing care for critically ill patients, as well as pre- and postoperative patients. They work in hospital intensive care units (ICUs), specialized critical care units, emergency departments, and emergency transport. Critical care patients require continuous monitoring and treatment for life-threatening conditions related to injuries, long-term illness, and other medical events, such as heart attacks and strokes.

If you’re wondering how to become a critical care nurse, the journey entails meeting rigorous education requirements, receiving on-the-job training, and earning certification. Additionally, you must meet the ongoing training requirements defined by the American Association of Critical-Care Nurses (AACN). Maryville University’s  RN to BSN online  program helps students gain the skills needed to advance into a critical care  nursing career .

What Does a Critical Care Nurse Do?

A critical care nurse provides specialized care to patients who are critically ill or suffer from life-threatening injuries that require advanced care in ICUs, emergency rooms, neonatal ICUs, pediatric ICUs, cardiac care units, cardiac catheter labs, telemetry units, progressive units, and recovery rooms. Critical care nurses work alongside other healthcare professionals, including doctors, surgeons, nurse practitioners, clinical nurse specialists, nurse researchers, nurse educators, and healthcare case managers.

In addition to hospitals, work settings for critical care nurses include patients’ personal residences, outpatient surgery centers, private physicians’ offices, managed care centers, and nursing schools. Critical care nurses perform complex patient assessments, implement intensive interventions and therapies, and monitor patients. A critically ill or injured patient’s condition can worsen quickly without warning, so critical care nurses must be able to immediately change a current care plan and provide emergency care.

The duties of a critical care nurse often include cleaning and bandaging a patient’s wounds, tracking life support equipment, and immediately responding to changes in a patient’s condition. These nurses may also serve as advocates, supporting and respecting the basic rights, values, and beliefs of critically ill or injured patients. Acting as patients’ representatives, critical care nurses find additional resources outside of the immediate care setting to assist in their patients’ recovery.

Critical care nurses work with patients and families experiencing extreme stress. Providing serious medical care for patients requires that these professionals be empathetic, sensitive, and compassionate while coping with major medical and life-or-death situations. Critical care nurses should be prepared to handle a wide range of emotions resulting from interactions with patients and their families. Often, critical nurses will have to make tough, objective decisions while remaining calm and caring.

Critical Care Nurse Education Requirements

Because working in a critical care department requires advanced skills, critical care nurse education requirements often include earning a bachelor’s degree in nursing. To become a critical care nurse, a health professional must first become a registered nurse, which requires a bachelor’s or associate degree. Registered nurses can advance to the critical care nursing profession after earning a critical care certification and state license and gaining one to five years of on-the-job experience caring for acutely or critically ill patients. After earning a bachelor’s degree, some critical care nurses may pursue a master’s degree to take on leadership positions in the critical care nursing field.

Critical Care Nurse Skills

Critical care nurses need strong decision-making and leadership capabilities to function in a high-stress, fast-paced environment such as an ICU or emergency trauma unit. Health professionals working in critical care settings also need to be familiar with complex medical equipment such as respirators and cardiac monitors. Some of the skills a critical care nurse needs include:

• Communication:  Critical care nurses are vital communication links for patients, families, and doctors.
• Critical thinking:  Emergency situations require nurses to make important medical decisions quickly to serve critical patient needs while paying close attention to detail to avoid errors.
• Physical endurance:  Nurses in critical care settings must perform strenuous tasks and often remain on their feet for entire shifts.

Other characteristics of a critical care nurse include:

• Resiliency:  Nurses need emotional strength, as nursing can be a mentally demanding and emotionally challenging profession.
• Confidence:  Nurses must be confident in their knowledge and decisions to ensure proper patient treatment.
• Compassion:  Nurses should maintain empathy for and sensitivity to patients and families.

Types of Critical Care Nurses

Critical care nurses can pursue certification in several specialties, including:

• Acute/Critical Care Nurse-Adult (CCRN-Adult) : Nurses provide direct care for acutely or critically ill adults in a variety of locations, including ICUs and cardiac care units.
• Acute/Critical Care Nurse-Pediatric (CCRN-Pediatric) : Nurses care for acutely or critically ill children in many settings, including ICUs and trauma units.
• Acute/Critical Care Nurse-Neonatal (CCRN-Neonatal) : Nurses care for newborns and premature infants in critical or acute conditions, typically in NICUs and other specialty care units.

Other career options open to critical care nurses include:

• TeleICU Nurse:  These nurses specialize in providing bedside remote care via audiovisual communication and computer equipment. TeleICU professionals typically work from a central or remote location.
• Transport/Flight Nurse:  These nurses provide care to critically injured or ill patients during ambulance, helicopter, or plane transports.
• Head CCU Nurse:  These nurses lead critical care departments such as ICUs, NICUs, and trauma units. Duties include staff supervision, quality monitoring, and inventory management.

Steps to Become a Critical Care Nurse

If a nursing career with an emphasis on taking care of severely ill or injured patients sparks your interest, you’ll need to know the education, certification, and experience requirements for becoming a critical care nurse.

The path toward becoming a critical care nurse begins with launching a career as a registered nurse. Because of the demands and complexity of administering critical care, many employers require a prospective critical care nurse to have a  RN to BSN online . Nurses often learn the advanced skills to become a critical care nurse through field training in a hospital setting.

Critical care nurses need to have the CCRN credential offered through the American Association of Critical-Care Nurses (AACN). The skills required to become a critical care nurse are similar to those required to become a registered nurse.

Step 1: Earn a Bachelor of Science in Nursing

You must have a formal nursing education to legally qualify for registered nursing positions.  Maryville University’s online BSN  may lead to a wide range of options for beginning or continuing a career in the healthcare industry. With a BSN, you can work for major hospitals, private practice clinics, home-care services, and nursing care facilities. It is possible to begin your nursing career with an associate degree, but your career options may expand with a BSN.

BSN graduates often work as nursing managers, nursing specialists, nurse educators, nursing informatics specialists, geriatric nurses, public health nurses, and critical care nurses. The bachelor’s degree in nursing is a launching point to start a career as a critical care nurse, working in intensive care units, emergency departments, and recovery rooms. Most employers will require you to have between one and two years’ experience prior to becoming a critical care nurse.

Step 2: Pass the National Council Licensure Examination (NCLEX)

After you have earned a  bachelor’s degree in nursing , you must pass the National Council Licensure Examination (NCLEX-RN), a requirement for any nurse who wishes to work in the United States. The NCLEX-RN is a computer-generated exam created by the National Council of State Boards of Nursing (NCSBN). The NCSBN works with nursing and regulatory boards to help maintain standards in nursing and promote the profession across the country.

The NCLEX-RN is designed to cover the processes that make up the foundation of the nursing practice. The test is divided into four categories, with six subcategories that span a range of topics designed to assess nursing competency.

Passing this exam is a mark of excellence. With board certification, you demonstrate to patients, employers, and the public that you have a high level of nursing knowledge that reflects national standards and demonstrates your commitment to patient safety. Passing the NCLEX-RN qualifies nurses for state licensing, which may have additional requirements such as a background check.

Once you earn a BSN, pass the NCLEX-RN, and earn a state license, you are a registered nurse. You may be able to find entry-level employment as an RN in the critical care unit of a hospital or trauma center. However, some employers prefer job candidates with prior nursing experience.

Step 3: Earn a Master of Science in Nursing

Critical care nurses who earn a  Master of Science in Nursing  (MSN) may significantly expand their career options and be prepared to take on a wider range of responsibilities in the workplace. The MSN curriculum includes additional theory- and evidence-based courses, building on the foundation established in a BSN program.

Master’s in nursing  students receive instruction and complete clinical hours, both of which offer the medical knowledge and skills they will need to treat critically ill patients. They learn how to take a leadership role in their positions, as well as how to apply theoretical learning in the real-life scenarios encountered in hospital settings.

An MSN provides critical-thinking, problem-solving, and communication skills and training that help you prepare for situations you will encounter on the job, including interactions with patients, families, and doctors. You will also learn how to effectively cope with the emotional and physical challenges that you will face as a critical care nurse.

Step 4: Get Certified by the AACN

An important step in pursuing this specialized area of nursing is becoming a certified critical care nurse through the American Association of Critical-Care Nurses. The CCRN certification from the AACN Certification Corporation establishes a baseline of knowledge for nursing critically ill or injured patients. CCRN is a service mark of the AACN and does not stand for “critical care registered nurse,” as AACN does not guarantee that a certification holder is an RN, which is a license regulated by each state — though nurses must have an RN license when they apply for CCRN certification.

Possessing the CCRN certification demonstrates your commitment to advancing your career and continually improving your skills and nursing expertise. Critical care nurses can be certified in various specialized medical areas. The specialized certification is valid for three years and must be periodically renewed.

Critical care nurses can attain other types of certifications from different organizations. If you seek certification from another organization, check credentialing requirements before pursuing the endorsement. Requirements for renewal may differ from those stipulated by the AACN.

Continuing Education and Growth for Critical Care Nurses

Employers usually require that their critical care nurses attend continuing education classes to retain their positions. Continuing education helps critical care nurses perform effectively in the workplace, stay up to date with the most current teachings in the field, and master the latest technology. Keeping their skills current also helps critical care nurses perform as leaders and raises the bar to ensure excellent patient care at each facility.

Additional training and academic achievements can help facilitate career progression. For example, critical care nurses may want to consider enrolling in one of  Maryville University’s  graduate degree programs in healthcare and science.

Critical Care Nurse Salaries

The median salary of a registered nurse was $73,000 in 2019, according to the U.S. Bureau of Labor Statistics (BLS). The exact salary depends on level of education, years of experience, and size of the hospital or healthcare facility, among other factors.

Future Growth of Critical Care Nurses

The employment of registered nurses is projected to increase by 12% between 2018 and 2028, much faster than the average growth for all occupations, according to the BLS. There are numerous reasons for this growth, including an increased emphasis on preventive care; growing rates of chronic conditions, such as diabetes and obesity; and the demand for healthcare services from baby boomers as they live longer and more active lives.

Explore Advanced Nursing Careers

In today’s medical environment, patients are released from hospitals with complex medical needs that require the skills of critical care nurses with specialized training and experience. Critical care nurses frequently provide care to the critically ill and injured at patients’ homes and rehabilitation facilities. So in addition to helping critical nurses develop skills in hospital settings, an advanced nursing career also calls for skills in serving patients after they leave.

Begin your journey toward becoming a critical care nurse by enrolling in the  RN to BSN online  program offered by  Maryville University .

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Patient handouts, what is critical care.

Critical care is medical care for people who have life-threatening injuries and illnesses. It usually takes place in an intensive care unit (ICU). A team of specially-trained health care providers gives you 24-hour care. This includes using machines to constantly monitor your vital signs . It also usually involves giving you specialized treatments.

Who needs critical care?

You need critical care if you have a life-threatening illness or injury, such as:

• Severe burns
• Heart attack
• Heart failure
• Kidney failure
• People recovering from certain major surgeries
• Respiratory failure
• Severe bleeding
• Serious infections
• Serious injuries , such as from car crashes, falls , and shootings

What happens in a critical care unit?

In a critical care unit, health care providers use lots of different equipment, including:

• Catheters, flexible tubes used to get fluids into the body or to drain fluids from the body
• Dialysis machines ("artificial kidneys") for people with kidney failure
• Feeding tubes, which give you nutritional support
• Intravenous (IV) tubes to give you fluids and medicines
• Machines which check your vital signs and display them on monitors
• Oxygen therapy to give you extra oxygen to breathe in
• Tracheostomy tubes, which are breathing tubes. The tube is placed in a surgically made hole that goes through the front of the neck and into the windpipe.
• Ventilators (breathing machines), which move air in and out of your lungs. This is for people who have respiratory failure.

These machines can help keep you alive, but many of them can also raise your risk of infection.

Sometimes people in a critical care unit are not able to communicate. It's important that you have an advance directive in place. This can help your health care providers and family members make important decisions, including end-of-life decisions , if you are not able to make them.

• Arterial Catheterization (American Thoracic Society) - PDF
• Central Venous Catheter (American Thoracic Society) - PDF
• Chest tube insertion - series (Medical Encyclopedia) Also in Spanish
• Chest Tube Thoracostomy (American Thoracic Society) - PDF
• Tracheostomy - series -- Normal anatomy (Medical Encyclopedia) Also in Spanish

• Meet the Critical Care Team (Society of Critical Care Medicine)

Journal Articles References and abstracts from MEDLINE/PubMed (National Library of Medicine)

• Article: Incidence of post-extubation dysphagia among critical care patients undergoing orotracheal intubation:...
• Article: Catheter-associated urinary tract infections in critical care: Understanding incidence, risk factors,...
• Article: Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment:...
• Critical Care -- see more articles
• Implanted Ports (Nemours Foundation) Also in Spanish
• Peripherally Inserted Central Catheter (PICC Line) (Nemours Foundation) Also in Spanish
• Tracheostomy (For Parents) (Nemours Foundation) Also in Spanish
• Tunneled Central Lines (Nemours Foundation)
• When Your Baby's in the NICU (Neonatal Intensive Care Unit) (Nemours Foundation) Also in Spanish
• When Your Child's in the Pediatric Intensive Care Unit (Nemours Foundation) Also in Spanish
• Central venous catheter - dressing change (Medical Encyclopedia) Also in Spanish
• Central venous catheter - flushing (Medical Encyclopedia) Also in Spanish
• Peripherally inserted central catheter - dressing change (Medical Encyclopedia) Also in Spanish
• Peripherally inserted central catheter - flushing (Medical Encyclopedia) Also in Spanish
• Peripherally inserted central catheter - insertion (Medical Encyclopedia) Also in Spanish

The information on this site should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

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'Critical care' is now used as the term that encompasses 'intensive care', 'intensive therapy' and 'high dependency' units.

Critical care is needed if a patient needs specialised monitoring, treatment and attention, for example, after routine complex surgery, a life-threatening illness or an injury.

If someone needs critical care, they can be said to have a 'critical illness'.

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Original research

Towards definitions of critical illness and critical care using concept analysis, raphael kazidule kayambankadzanja,.

1 Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi

2 Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, Blantyre, Malawi

Carl Otto Schell

3 Global Public Health, Karolinska Institutet, Stockholm, Sweden

4 Centre for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden

5 Internal Medicine, Nyköping Hospital, Nyköping, Sweden

Martin Gerdin Wärnberg

6 Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden

Thomas Tamras

7 Internal Medicine, Södertälje Hospital, Stockholm, Sweden

Hedi Mollazadegan

8 Addiction Medicine, Sankt Goran Hospital, Stockholm, Sweden

Mats Holmberg

9 Centre of Interprofessional Collaboration within Emergency care, Linnaeus University, Växjö, Sweden

10 Health, Care and Social Welfare, Mälardalen University, Eskilstuna, Sweden

Helle Molsted Alvesson

11 Clinical Research, London School of Hygiene & Tropical Medicine, London, UK

12 Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania

Associated Data

bmjopen-2022-060972supp001.pdf

bmjopen-2022-060972supp002.pdf

Data are available upon reasonable request.

As ‘critical illness’ and ‘critical care’ lack consensus definitions, this study aimed to explore how the concepts’ are used, describe their defining attributes, and propose potential definitions.

Design and methods

We used the Walker and Avant approach to concept analysis. The uses and definitions of the concepts were identified through a scoping review of the literature and an online survey of 114 global clinical experts. We used the Arksey and O’Malley framework for scoping reviews and searched in PubMed and Web of Science with a strategy including terms around critical illness/care and definitions/etymologies limited to publications in English between 1 January 2008 and 1 January 2020. The experts were selected through purposive sampling and snowballing, with 36.8% in Africa, 25.4% in Europe, 22.8% in North America, 10.5% in Asia, 2.6% in South America and 1.8% in Australia. They worked with anaesthesia or intensive care 59.1%, emergency care 15.8%, medicine 9.5%, paediatrics 5.5%, surgery 4.7%, obstetrics and gynaecology 1.6% and other specialties 3.9%. Through content analysis of the data, we extracted codes, categories and themes to determine the concepts’ defining attributes and we proposed potential definitions. To assist understanding, we developed model, related and contrary cases concerning the concepts, we identified antecedents and consequences to the concepts, and defined empirical referents.

Nine and 13 articles were included in the scoping reviews of critical illness and critical care, respectively. A total of 48 codes, 14 categories and 4 themes were identified in the uses and definitions of critical illness and 60 codes, 13 categories and 5 themes for critical care. The defining attributes of critical illness were a high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility. The defining attributes of critical care were the identification, monitoring and treatment of critical illness; vital organ support; initial and sustained care; any care of critical illness; and specialised human and physical resources. The defining attributes led to our proposed definitions of critical illness as, ‘a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility’, and of critical care as, ‘the identification, monitoring and treatment of patients with critical illness through the initial and sustained support of vital organ functions.’

The concepts critical illness and critical care lack consensus definitions and have varied uses. Through concept analysis of uses and definitions in the literature and among experts, we have identified the defining attributes of the concepts and proposed definitions that could aid clinical practice, research and policy-making.

Strengths and limitations of this study

• This concept analysis is the first study to systematically describe the uses and definitions of the concepts critical illness and critical care .
• The study uses a scoping review of the literature and input from over 100 clinical experts from diverse settings globally to identify the defining attributes and provide proposed definitions of the concepts.
• Some uses and definitions of the concepts in languages other than English, in unpublished grey literature and from clinical experts not included in the study may have been missed.
• As current usage of the concepts is diverse, the proposed definitions may not be universally accepted and are aimed to stimulate further discussion.

Introduction

The concepts critical illness and critical care are commonly used in healthcare. In PubMed, both concepts are Medical Subject Headings terms, and searches for ‘critical illness’ or ‘critical care’ return 40 000 and 220 000 articles, respectively. While it may seem evident that the concepts concern patients with very serious illness and their care, there is a lack of consensus around their precise definitions.

Critical illness is a concept concerning a patient’s condition that is distinct from the disease diagnosis. It has been argued that clinical practice is overly guided by diagnoses rather than prognoses. 1 We postulate that the lack of consensus around prognostic concepts such as critical illness may be one factor in this and could cause problems for clinical practice, research and policy-making. For the clinician, discordant interpretations of when a patient is critically ill could lead to differing clinical assessments and treatments despite similar states: for example, Doctor A interprets Patient B’s low blood oxygen level as critical illness, triggers an alarm and admits the patient to an intensive care unit (ICU), only for Doctor C to reverse the decision and discharge the patient as she interprets the illness as non-critical. For the researcher, it could be difficult to design a study or interpret findings: for example, studies into the effect of dexamethasone for critical COVID-19, or of another treatment for all patients with critical illness, require clear eligibility criteria and translating the findings to another patient group requires that the groups have similar clinical conditions. For the policy-maker, prioritising programmes and investments designed to improve care for very sick patients relies on comparisons between similar groups and clearly defined interventions.

Even quantifying the total global burden of critical illness has been challenging due to the lack of an agreed definition. 2 Proxies have been used instead, for example, summing up syndromes considered to comprise critical illness such as sepsis and acute lung injury—resulting in estimates of up to 45 million critical illness cases each year. 2 Low-income and middle-income countries are suspected to have the highest burden, 3 but the lack of a definition has hampered comparisons across settings. 4

Studying the care for critically ill patients has also been problematic. Studies have focused on care provided in hospital locations such as in intensive care or emergency units, which exclude both the care provided in hospitals lacking such units, and the care of critically ill patients in general hospital wards. 5–7 In the COVID-19 pandemic, there have been great efforts to describe, scale-up and improve care for critically ill patients throughout the world, 5 7 and a lack of agreement around the concept of critical care has hampered these efforts. 8 9

These examples illustrate how important concepts are as the building blocks of theories and communication. Ideally, concepts are clearly defined and their uses well described for unambiguous communication and an understanding about exactly what is being described or explained. 10 Concept analysis is a method for investigating how concepts are used and understood. Concept analyses have been conducted in diverse fields such as in teamwork, 11 postoperative recovery 12 and bioterrorism preparedness, 13 all with the aim of providing basic conceptual understanding and facilitating communication. In this paper, we have used concept analysis, following the stepwise approach described by Walker and Avant. 10 The first two steps in the approach are to choose the concept and determine the aim of the analysis. Our chosen concepts are critical illness and critical care and our aims are to explore the uses and definitions of the concepts in published sources and by global clinical experts, leading to a description of the defining attributes of the concepts and to proposed definitions.

Concepts are the basic building blocks in theory construction, research and communication. A concept analysis aims to define the concept’s attributes and facilitate decisions about which phenomena match the concept, and which do not. In this study, Walker and Avant’s method for concept analysis was chosen as a systematic approach used previously in similar studies. 10 The approach consists of eight steps: (1) select the concept; (2) determine the aim of analysis; (3) identify all uses of the concept that you can discover; (4) determine the defining attributes; (5) identify a model case; (6) identify borderline, related, contrary, invented and illegitimate cases; (7) identify antecedents and consequences; (8) define empirical referents. In this paper, steps 1 and 2 are described in the Introduction section, step 3 in the Method section and steps 4–8 in the Results section. Thus, the continuation of this article addresses steps 3–8 in Walker and Avant’s method. 10

Step 3: identifying the uses of the concepts

We identified the uses of the concepts of critical illness and critical care through a scoping review of the literature and a web-based survey of global experts.

Scoping review

We used the Arksey and O’Malley framework for scoping reviews. 14 Relevant studies published in English between 1 January 2008 and 1 January 2020 were identified in the PubMed and Web of Science databases. We began the search in 2018 and deemed that articles published prior to 2008 were more than 10 years old and would have less relevance. To include publications that were not found through the database searches, we hand-searched publication lists and grey literature of intensive care medicine and emergency medicine societies. Duplicates were removed using the software Rayyan. 15 The publications were examined through title, then abstract review and lastly by full-text review. The scoping review protocols were published in advance on the www.protocols.io database.

Critical illness

The search strategy used the terms terminolog*, etymolog*, nomenclatur*, OR definition*, AND emergency, critical*, acute*, OR sever*, AND ill OR illness. A total of 9323 articles were identified using these critical illness terms in the databases and an additional two articles were identified through hand searching. Of these, 1126 articles were identified as duplicates and the remaining 8199 articles were screened by title and abstract review by two of the authors (TT and HM). Eight thousand one hundred sixty-eight articles were excluded as they did not concern critical illness, were not written in English or were not available in full text online, leaving 31 articles for inclusion for full-text review. In the full-text review, 22 articles were excluded as they did not define critical illness, and so 9 articles were included in the analysis ( figure 1 and online supplemental table 1 ).

Study flow chart.

Supplementary data

Critical care.

The search strategy used the terms terminolog*, etymolog*, nomenclatur*, OR definition*, AND critical care, intensive care, emergency care, OR acute care. A total of 7286 articles were identified using these critical care terms in the databases and an additional 6 articles were identified through hand searching. Of these, 1964 were identified as duplicates and the remaining 5322 articles were screened by title and abstract review by two of the authors (TT and HM). Five thousand two hundred sixty-nine articles were excluded as they were not concerning critical care, not written in English or not available in full text online, leaving 59 articles for inclusion for full-text review. In the full-text review, 46 articles were excluded as they did not define critical care and so 13 articles were included in the analysis ( figure 1 and online supplemental table 2 ).

Expert survey

The survey used open-ended questions to gather information about the experts’ definitions of critical illness and critical care, and how they see the relationship of the concepts to connected concepts in order to provide context. The survey included the questions: (1) How would you define critical illness ? (2) How would you define critical care? (3) Do critical care and intensive care differ ? If yes, in what way? (4) Do critical care and emergency care differ and if yes, in what way? (5) Do critical care and acute care differ and if yes, in what way ?

The inclusion criterion for an expert to be invited to participate in the survey was experience in any medical specialty that includes care of patients with acute, severe illness. Experts were identified from a stakeholder mapping of global critical care done by one of the authors (TB, unpublished), and those known to the researchers to be global experts in the field of critical care. Purposive sampling was used to invite experts with the aim of including 100 experts with a balance between specialties, geographical locations, health worker cadres and gender. In total 146 experts were invited to take part, and 114 completed the survey (78% response rate) ( figure 1 and table 1 ).

Characteristics of the experts who participated in the survey

*As the experts were asked to select all that apply, the sum may exceed 100%.

Step 4: analysis and determining the defining attributes

All the definitions and usages of critical illness and critical care from the scoping reviews and the expert survey were charted and analysed using a content analysis based on methods developed by Erlingsson and Brysiewicz. 16 First, the data from any parts of the literature and from the expert survey that concerned the uses or definitions of the concepts were extracted. The data were coded, and the codes analysed iteratively by the study team. Repeated and redundant codes were removed and similar codes were arranged into categories. The data were revisited when new categories arose or when diverse opinions with contrasting attributes were identified. Through the process, themes emerged that captured the defining attributes of the concepts. Using the defining attributes, definitions of the concepts were constructed by the research team to be coherent and useful.

Steps 5–8: presenting a model case, related and contrary cases, identifying antecedents and consequences, and defining empirical referents

The model cases, related and contrary cases were developed by the researchers to provide examples to illustrate the defining attributes of the concepts that emerged from the concept analysis. Model cases were developed to be clinically realistic and to include all the defining attributes. Related cases were developed that include some, but not all, of the defining attributes, and contrary cases that are clearly ‘not the concept’, containing none of the defining attributes. For simplicity in this study, we limited our cases to examples of patients with respiratory disease. Antecedents and consequences were identified as events that occur prior to the occurrence of each concept and as the outcomes of each concept, respectively. Empirical referents were identified as phenomena that demonstrate the occurrence of each concept ‘in real life’.

Ethical considerations

Informed consent was provided by all of the experts. The Research Ethics Committee of the London School of Hygiene and Tropical Medicine approved the study (reference number 22661).

Patient and public involvement

The results relate to steps 4–8 in the Walker and Avant approach, as steps 1–3 have been described in the Introduction and Methods.

Step 4: the defining attributes

A total of 48 codes were identified from the uses and definitions of critical illness from the scoping review and expert survey. The codes were analysed into 14 categories and 4 themes. ( table 2 ). The themes represent the defining attributes of critical illness: high risk of imminent death; vital organ dysfunction; requirement for care to avoid death; and potential reversibility ( figure 2 ).

Content analysis for the concept critical illness

NEWS, National Early Warning Score.

The defining attributes of critical illness.

Proposed operational definition

The proposed definition for critical illness is ‘Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility ’

Step 5: a model case of critical illness (a case including all the defining attributes)

A woman has a viral pneumonia. She is breathless and hypoxic with a low oxygen level in her blood (oxygen saturation) of 74%. Her lungs are dysfunctional, and she has a life-threatening condition that is likely to lead to her death in the next few hours. She requires care to support her lungs (oxygen therapy) and if she receives that care, she has a chance of recovery.

Step 6: a related case for critical illness (a case including some of the defining attributes but not the attribute of ‘imminently life-threatening’)

A man has a chest infection. He has a fever, is coughing up green sputum and feels short-of-breath when walking. He has an oxygen saturation of 91%. He has a serious condition, but it is not imminently life-threatening. He requires treatment, likely with antibiotics, but it is uncertain whether he requires any organ support such as oxygen. His condition is potentially reversible, and he can recover.

A contrary case for critical illness (a clear example of ‘not the concept’)

A woman has lung cancer. She is coughing up small amounts of blood but is able to walk to the hospital. She has an oxygen saturation of 94%. She is sick and she requires treatment. However, her illness is not imminently life-threatening, she has no dysfunctional vital organ and she does not require immediate care. Her condition may or may not be reversible.

Step 7: antecedents and consequences of critical illness

The antecedents of critical illness are the onset of illness, in mild or moderate form, with progressing severity. The consequences of critical illness are either recovery or death.

Step 8: empirical referents

There are an estimated 30–45 million cases of critical illness globally each year. 2 Many patients are cared for in hospitals with illnesses that are causing vital organ dysfunction and that are imminently life-threatening. There is much work done to identify patients with critical illness such as the use of single severely deranged vital signs, 17 or compound scoring systems such as the National Early Warning Score and The Sequential Organ Failure Assessment score. 18 19 In hospitals, the severity of patients’ conditions can be assessed using tools such as the Acute Physiology and Chronic Health Evaluation 20 and the Simplified Acute Physiology Score. 21

A total of 60 codes were identified from the definitions of critical care from the scoping review and expert survey. The codes were analysed into 13 categories and 5 themes ( table 3 ). The themes represent the concept’s defining attributes: identification, monitoring, and treatment of critical illness ; vital organ support; initial and sustained care; any care of critical illness ; and specialised human and physical resources ( figure 3 ).

Content analysis for the concept critical care

ICU, intensive care unit.

The defining attributes of critical care.

Proposed operational definition of critical care

The proposed definition for critical care is “Critical care is the identification, monitoring, and treatment of patients with critical illness through the initial and sustained support of vital organ functions.”

Step 5: a model case of critical care (a case including all the defining attributes)

A woman with a viral pneumonia is rapidly identified as critically ill when she arrives at the hospital. She is immediately admitted to a unit with supplies for managing critically ill patients and treatment is started. Nurses and doctors who have been trained in the care of critical illness monitor her regularly, and provide continuous care, titrating the treatments as needed. Continuous oxygen therapy is provided for her life-threatening hypoxia, supporting her respiratory dysfunction, until she has recovered and is no longer critically ill.

Step 6: a related case of critical care (a case including some of the defining attributes but not the attribute of ‘vital organ support’)

Care in a hospital is provided to a man with a chest infection. A nurse assesses him at arrival to hospital. A doctor admits him to the ward, prescribes antibiotics and decides he is not critically ill and does not require support for any of his vital organs. After 4 days, the doctor discharges him from hospital.

A contrary case of critical care (a clear example of ‘not the concept’)

In the outpatient department, care is provided to a woman with lung cancer. A doctor and a nurse do some investigations and prescribe some medications. She is sent home with a follow-up appointment 2 weeks later.

Step 7: antecedents and consequences of critical care

The antecedents of critical care are the contact of the patient with the healthcare system and may include other care of a patient who has not deteriorated to the point of becoming critically ill. The consequences of critical care are either the patient’s recovery or death.

Many hospitals have wards or units for the provision of critical care, such as emergency units, high dependency units or ICUs. 22 Critical care can also be provided in general wards, and a recent global consensus specified the care that should be included for all patients with critical illness in any hospital location. 23 Rapid Response Teams or Medical Emergency Teams have been introduced into some hospitals, often consisting of staff from the ICU responding to calls from the wards when a critically ill patient has been identified, and providing either critical care on the ward, or transferring the patient to the ICU. 24

We have described how the concepts critical illness and critical care are used and defined in the literature and by a selection of global experts using a concept analysis approach.

Our proposed definition for critical illness of, “a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility”, is similar to those in some key publications. Chandrashekar et al state that, “Critical illness is any condition requiring support of failing vital organ systems without which survival would not be possible”. 25 Painter et al write that, “A critically ill or injured patient is defined as one who has an illness or injury impairing one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition”. 26 Indeed, we found widespread agreement in the literature and expert sources that critical illness concerns the attributes ‘life-threatening illness’ and ‘organ dysfunction’.

However, we found diverse and varied usage of the concept concerning the attribute of reversibility and the interface between critical illness and the natural process of dying. Some uses included only illness that was potentially reversible—these sources regarded that for critical illness there should be a possible chance of recovery. Without this, critical illness would be a concept that encompasses the dying process—everyone would be critically ill immediately before death—which would conflict with many clinical uses and understandings of the term. Others had a wider interpretation including all life-threatening illness and did not include reversibility in the definition as it is difficult to identify in the clinical setting, and the concept risks becoming context dependent (high-resource interventions may reverse some critical illness which would not be possible in low-resource healthcare). Our iterative content analysis method led to our interpretation that reversibility should be included as one of the defining attributes and to make a distinction between critical illness and illness at the end of life. 27 This conclusion should be seen as one possible interpretation that can stimulate further discussion.

It is hoped that the proposed definition of critical illness assists communication in the field. Previously, studies about critical illness have focused on patients in certain hospital units, or with diseases or syndromes as proxies for critical illness that exclude some critically ill patients. 2 5 Our definition of critical illness is not diagnosis or syndrome specific and can be due to any underlying condition. The definition could facilitate the specification of clinical criteria for the identification of critical illness, estimates of the overall burden of critical illness, assessments of outcomes for patients with critical illness across centres and settings, and interventions to improve outcomes.

For critical care, there was greater diversity around its use and definition. There was widespread agreement that critical care included the attributes of, ‘care of critically ill patients’, and the ‘support of vital organs’. However, there were differing uses around the location of the care and the need for specialised resources. Some sources considered critical care to be only the care provided in certain locations (such as ICUs or critical care units) or to be care that is always highly specialised or resource intensive. The World Federation of Societies of Intensive and Critical Care Medicine have suggested that critical care is synonymous with intensive care and is, “a multidisciplinary and interprofessional specialty dedicated to the comprehensive management of patients having, or at risk of developing, acute, life-threatening organ dysfunction. [Critical care] uses an array of technologies that provide support of failing organ systems, particularly the lungs, cardiovascular system, and kidneys.” 22 In contrast, other sources used critical care to be inclusive of any care for patients with critical illness, irrespective of location or resources. The Joint Faculty of Intensive Care Medicine of Ireland state that critical care units are those that, “provide life sustaining treatment for critically ill patients with acute organ dysfunction due to potentially reversible disease”, 28 and in Belgium, critical care beds have been defined as any beds “for patients with one or more organ functions compromised” 4 Hirshon et al strike a balance between these two contrasting views, “[Critical care is] the specialized care of patients whose conditions are life-threatening and who require comprehensive care and constant monitoring, usually in intensive care units.” 29

Our proposed definition of, “the identification, monitoring, and treatment of patients with critical illness through the initial and sustained support of vital organ functions”, aims to be inclusive. Critical care may include the use of specialised resources, but it is not a requirement. We see this as a strength in the definition, as it maintains a patient-centred rather than setting-dependent focus. Critical care when defined in this way can be provided anywhere, and does not have to be resource intensive—it includes both high-resource care in ICUs and lower resource care in other settings. Indeed, critical care can be provided in general wards, in small health facilities, in the community or in ambulances. High-resource intensive care may not be possible in low-resource settings, but such settings care for many critically ill patients who require critical care. 6 30 31 The proposed definition focuses on supporting vital organ functions, emphasising that critical care’s primary focus is treating the critical condition of the patient rather than definitive care for the underlying condition. 9 32 Critical care, as we have defined it, can be seen as a system of care of patients with critical illness throughout the course of their illness, from the time of their first contact with healthcare through to resolution of the critical illness or death. Critical care is part of the wider concept of acute care which also includes prehospital care, emergency care, trauma and surgery care, as well as inpatient care in medical, surgical, paediatric, obstetric and other wards. 29

The word ‘crisis’ is the root for the word critical and has its origin from the Greek word ‘krisis’ referring to a ‘turning point’ or ‘act of separation’, and later in English in a medical context when a crisis refers to the decisive point at which a patient either improves or deteriorates. 33 The concepts critical illness and critical care could be regarded as remaining true to these origins as they refer to the point in a patient’s ‘journey’ through their illness where they are so severely ill that the situation has become a crisis, and managing the crisis is necessary to direct the patient towards improvement rather than towards deterioration.

Strengths and limitations

To our knowledge, this is the first study attempting to describe the uses and definitions of the concepts critical illness and critical care , and to identify the defining attributes leading to proposed definitions of the concepts. A strength is the use of both a scoping review of the literature and the inclusion of over one hundred clinical experts as sources. The findings of the analysis should be seen as a first step towards consensus and we recognise that the use of concepts is fluid and changes over time. 10 We were limited to including literature in English between 2008 and 2019 and to published studies and guidelines and we may have missed relevant publications in other languages or in other grey literature. Our sample of experts was purposively selected and had global representation but was not perfectly symmetrical to continents, specialty, cadre or gender. There are many more experts than we were able to include, and we are likely to have missed experts who could have provided valuable contributions. Our proposed definitions, while based on a content analysis of scoping reviews and an expert survey, are the outputs of one possible interpretation of the data and may not be universally accepted. We hope our analysis and findings move the conversation forwards, providing input about how to communicate and collaborate around these vitally important concepts, and ultimately how to improve the care and outcomes for critically ill patients.

The concepts critical illness and critical care lack consensus definitions and are used in varied ways in the literature and among global experts. Through a concept analysis of scoping reviews and an expert survey we identify common themes in the uses and understandings of the concepts. We propose definitions for the concepts: “Critical illness is a state of ill health with vital organ dysfunction, a high risk of imminent death if care is not provided and the potential for reversibility” and “Critical care is the identification, monitoring, and treatment of patients with critical illness through the initial and sustained support of vital organ functions.” The proposed definitions could aid clinical practice, research and policy-making.

Supplementary Material

Acknowledgments.

We thank all the experts who participated in the study.

Twitter: @MatsHolmberg9

Contributors: TB and COS designed the study. RKK, TT, HM and TB collected and analysed the data. COS, HMA, MH and MGW contributed to analysing the data. TB is responsible for the overall content as the guarantor. RKK and TB wrote the first draft of the manuscript. All authors critically reviewed the manuscript and approved the final version.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review: Not commissioned; externally peer reviewed.

Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Data availability statement

Ethics statements, patient consent for publication.

Not applicable.

Ethics approval

This study was approved by London School of Hygiene and Tropical Medicine (Reference number 22661). Participants gave informed consent to participate in the study before taking part.

Critical Care

Critical care is also referred to as intensive care. It is a type of care that involves treating and managing injuries and illnesses that are very serious and may be life-threatening. Surgical complications, accident injuries, severe infections, and serious respiratory issues are examples of conditions that may require critical care. Patient receiving this level of care may get better and transition to other types of care, but many people die in critical care.

This type of care is usually given in what is called an intensive care unit, or ICU. The ICU is staffed by trained professionals and equipment needed to provide life support. ICUs may be specialized for children or infants or may be for adults or for people of all ages; another specialty is post-operative intensive care. Most hospitals have an ICU and are staffed by a critical care team.

What is Critical Care?

Critical care is a type of medicine that is dedicated to evaluating, diagnosing, treating, and managing life-threatening illnesses and injuries. This type of care often requires more advanced technologies than are available in an emergency room or other medical setting. Patients may be transferred from an emergency room to the critical care unit once they have been sufficiently stabilized or when the emergency team has done all it can in terms of treatment and diagnosis. Patients may also be transferred from other hospital units or after surgery.

According to statistics, nearly six million people are given critical care in the U.S. each year. More than half of people admitted to emergency rooms will be transferred to an ICU. The most common reasons for admission are for neurological conditions, cardiac conditions, and respiratory conditions. Some reasons people go to the ICU for care are poisoning, kidney failure, gastrointestinal hemorrhages, and diabetes complications. The average length of stay in the ICU is just under four days.

The Intensive Care Unit

Critical care is administered in an intensive care unit, which in some places is called the critical care unit. The ICU is reserved for patients who are very sick and need critical care. The staff in an ICU is specially trained to work with these kinds of patients. Care and monitoring of patients in the ICU is, as the name describes, intensive. Staff members observe patients closely and each nurse is typically responsible for just one or two patients at a time.

In addition to the close care, the available equipment in the ICU sets this department apart from other areas of a hospital. Many patients in this kind of care need organ support to prevent failure. Commonly, these patients need ventilators to assist with breathing. Patients in the ICU are also connected to monitoring equipment to keep tabs on heart rate, blood pressure, and respiration.

ICU equipment is typically categorized by organ systems. The equipment is used to support the organ systems in patients and keep them from failing: cardiovascular system, central nervous system, gastrointestinal system, endocrine system, respiratory system, and the renal system are the major organ systems supported by ICU equipment. Patients may also receive care for blood issues, infections, and the skin.

Patients Needing Critical Care

Patients admitted to an ICU may be there for varying reasons, but what they all have in common is that they need close attention and monitoring and they need advanced equipment, often life and respiratory support. The main criteria for admitting a patient for critical care are serious and life-threatening conditions, but also the possibility that with intensive treatment and monitoring that the patients can recover. Many patients do not recover in critical care, but as long as there is that possibility, the ICU is usually the choice for care. Some examples of conditions that may send a patient to the ICU are:

• Various types of shock, including septic shock from severe infection.
• Acute respiratory failure.
• Chronic respiratory failure.
• Cardiovascular diseases, such as heart failure.
• Kidney failure.
• Bleeding and clotting disorders.
• Multiple organ dysfunction.
• Neurological conditions.
• Complications of chronic illnesses.

Types of ICU

Many intensive care units are general, and can provide critical care for most patients. Others are more specialized. For younger patients there are pediatric intensive care units and neonatal intensive care units. For mental health crises, there are psychiatric intensive care units. These are mostly used when patients are at risk of harming themselves and need close monitoring.

Other specialized types of intensive care units include those that focus on cardiac care, neurological care, and trauma. Surgical intensive care units provide care for patients before and after surgery and are typically staffed by surgeons. Post-anesthesia care units are devoted to providing close monitoring for patients after surgery and anesthesia.

Critical Care Teams

The medical professionals that staff ICUs and provide care have specialized in this type of care. Critical care as a specialization is relatively new. An ICU staff will include critical care doctors, critical care nurses, both specially trained, as well as specialists like neurologists, surgeons, pulmonologists, respiratory therapists, nutritionists, physical therapists, pharmacists, social workers, and radiography technicians.

What to Expect in Critical Care

If you or a loved one is admitted to critical care, you can expect to be updated regularly as patients in ICUs are monitored around-the-clock. You can also expect to see a lot of equipment that you don’t understand, and this can be intimidating or frightening, but it is important for providing quality critical care. It is also important to understand that patients in critical care are very seriously ill. While the specialized medical staff here will do everything possible to help patients recover enough to be released, not all patients can be cured or helped.

Another expectation to have in the ICU is that family members may be asked to make some important decisions, as patients are often unable to speak. If you have a loved one in critical care, be sure that you have the right people in place to make difficult choices about continuing care or removing life support. It helps to have more than one person to discuss these decisions, even if one person is ultimately responsible.

Critical care is a very important part of medical care. It is used to help treat patients who need advanced technology for supporting organs and who need constant care and monitoring. This crucial component of overall care helps save lives, although the people in the ICU are very sick and not all will survive. Critical care staff are expected to provide specialized care and to keep family members informed regularly so that important decisions can be made in the best interests of the patients.

• https://medlineplus.gov/criticalcare.html
• http://www.cpmc.org/learning/documents/icu-ws.html
• https://www.fraserhealth.ca/media/Factsheet - ICU Care.pdf
• Understanding Care
• Healthcare Resources
• Your Rights

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Definition and principles of nursing

Eight principles that apply to all nursing staff and nursing students in any care setting

Nursing is the largest safety critical profession in health and social care. The nursing team is diverse and includes the nursing support workforce.

The RCN last published a definition of nursing in 2003. This resource includes a new definition that depicts the change and increased complexity that the nursing profession has seen over the last two decades. 

The Principles of Nursing are mapped to and complement the NMC Code (for registrants).

Definition of Nursing

Nursing is a safety critical profession founded on four pillars: clinical practice, education, research, and leadership. Registered nurses use evidence-based knowledge, professional and clinical judgement to assess, plan, implement and evaluate high-quality person-centred nursing care.

Definition of Nursing (expanded version)

The work of registered nurses consists of many specialised and complex interventions. Their vigilance is critical to the safety of people, the prevention of avoidable harm and the management of risks regardless of the location or situation.

Compassionate leadership is central to the provision and co-ordination of nursing care and informed by its values, integrity and professional knowledge. Responsibility includes leading the integration of emotional, physical, organisational, and cognitive nursing work to meet the needs of people, organisations, systems, and populations.

Registered nurses are decision makers. They use clinical judgement and problem-solving skills to manage and co-ordinate the complexity of health and social care systems to ensure people and their families are enabled to improve, maintain, or recover health by adapting, coping, and returning to live lives of the best quality or to experience a dignified death. They have high levels of autonomy within nursing and multi professional teams, and they delegate to others in line with the NMC Code.

Footnote The leadership pillar for some nurses will include management responsibilities.

• RCN New Definition of Nursing: Background research and rationale . This summary explanation aims to provide the background to developing the revised RCN definition of nursing in support of the professional framework. It explains the reasons for the choice of language terms and the emphasis placed on the definition.
• RCN position on preserving safety and preventing harm: Valuing the role of the registered nurse

The Principles of Nursing

The Principles of Nursing are applicable to all of the nursing workforce. The Principles describe what everyone, from nursing staff to people and populations, can expect from nursing to deliver safe and effective nursing care. They cover the aspects of behaviour, attitude and approach that underpin good care and they are mapped to and complement the NMC Code .

Principle A - Equality, Diversity and Inclusion

Principle B - Accountability

Principle C - Safety Critical, Safe Care

Principle D - Personalised Person-Centred Care

Principle E - Communication and Informatics

Principle F - Knowledge and Skills

Principle G - Professional Standards

Principle H - Leadership

The term ‘nursing staff’ includes the nursing support workforce who work with the registered nurse to support the provision of nursing care. This term, as defined in the RCN Nursing Workforce Standards encompasses a wide range of roles and titles which may include nursing associate (England only), assistant practitioner, health care assistant, health care support worker, and nursing assistant.

The RCN Nursing Workforce Standards  support achieving the principles of nursing.

For registrants, the principles are mapped to the Nursing and Midwifery Council Code of Conduct .

How you can use the principles

As a nursing professional or nursing student you can use the principles to:

• understand what patients, colleagues, families and carers can expect from nursing 
• help you reflect on your practice and develop as a professional
• generate discussions with your colleagues or if you are student with your mentor, tutor or fellow students on the aspects of behaviour, attitude and approach that underpin good nursing care
• identify where the principles are being practised within your organisation, and to identify instances where you think they are not being practised
• see how they relate to a trust’s own set of nursing values.   

Further reading

• The NMC Code for nurses and midwives

The RCN has started a programme of work to co-create an overarching UK wide professional framework for nursing. This is led by the Professional Nursing Committee and in collaboration with forums and fellows.

It will bring together the vast variety of career and competency frameworks across all settings to show the opportunities our profession has, which will support recruitment and retention of the nursing workforce.

Glossary of terms

Absences - Agreed and non-agreed non-attendance at a workplace. Absenteeism is habitual absence from work.

Direct care - Care provided personally by a member of staff. May involve any aspect of health care including treatments, counselling and education regarding people who use services. Indirect care - Nursing interventions that are performed to benefit people who use services but do not involve direct contact with these individuals and communities. Independent employer - Any independent contractor, employer organisations that may or may not be commissioned by the public sector. This will include private health care providers, most social care providers; GP practices; out of hours/call centres; social enterprises and community interest companies; charities, private surgical, mental health and learning disability hospitals; independent treatment centres; public/private schools; private industry. Missed care - Required care for people who use or need services that is omitted in part or fully, or care that is delayed. Nurse-patient/staff ratios - Number of people who need or use services assigned to an individual or team of nurses; based upon the acuity and/or dependency of the service user for nursing care. Nurse retention - A strategy which focuses on preventing nurse turnover and keeping nurses in an organisation's employment. Nursing establishment - The total number of staff to provide sufficient resource to deploy a planned roster that will enable nurses to provide care to people who need or use services that meets all reasonable requirements in the relevant situation. This includes: a resource to cover all staff absences, and other staff functions that reduce the time available to care for people who need services. Supernumerary persons such as students and sisters/charge nurses/managers should not be included in the planned roster. Nurse staffing - Rota and whole time equivalent (WTE) for a nursing team. The nurse staffing level refers to both the required establishment and the actual staffing level per shift/allocated workday. The maintenance of the nurse staffing level should be funded from the organisation’s revenue allocation. Nursing workforce - The total number of nursing staff, of all levels of experience and qualification, currently working within an organisation, sector or country. Patient acuity - Acuity can be defined as the measurement of the intensity of nursing care that is required by a person in need of service. An acuity-based staffing system regulates the number of nurses on a shift according to the individual's needs and not according to numbers of people who use or need services. Patient/client dependency - Measuring the differing reliance of individual people who use services on nursing staff, a means to classify patients in order to predict staffing needs. Patient safety - Patient safety is the prevention of errors and adverse effects to patients associated with health care. It is closely correlated to safe staffing levels. Public sector - Refers to employers that are publicly provided – either as an arm’s length body of the department of health and social care, or via another government department or directorate such as education, home office, and criminal justice. Examples include local authorities, statutory agencies such as inspectorates and regulators.

Registered Nurse  - "Nursing is a safety critical profession founded on four pillars: clinical practice, education, research and leadership. Registered nurses use evidence-based knowledge, professional and clinical judgement to assess, plan, implement and evaluate high-quality person-centred nursing care."

Seasonal variation in nursing workload - Variations and fluctuations in demands for care by people who need or use services, such as differing attendance rates. Shift patterns - Is the organising of shifts to ensure patients have continued access to nursing care whatever the day or time of day. The shifts could be rotational between day, night and weekend working, or fixed or a continuous working pattern. Skill mix - Percentage of different health care personnel involved in provision of care, for example between registered nurses and nursing support workers, or between different health care professions. Social care - Is 60% publicly funded by local authorities. However, most UK residential and domiciliary care and employment is provided by independent employers, which include private care home companies, domiciliary care agencies, charities, private care management companies. Staff rosters/schedules - A list of staff and associated information such as working times, responsibilities and locations for a given time period. Staffing levels - To ensure effective staffing there needs to be the right numbers of the right people, in the right place at the right time. It is not just a matter of having enough staff, but also ensuring they have suitable knowledge and experience. Substantive position - An employee's permanent position of employment. Team - A group of staff brought together to achieve a common goal. Often associated with a multidisciplinary approach to care for people who use services. Understaffing - A situation where there are insufficient numbers of staff to operate effectively, such as to impact upon service user safety. Uplift - Adding an allowance when calculating staff numbers for planned and unplanned staff absence. Vacancies - Paid posts which are newly created, unoccupied, or about to become vacant and the employer is actively searching for suitable staff. Temporary staff may be able to fulfil posts during the recruitment of permanent staff. Whole-time equivalent - This is a standardised measure of the workload of an employee. Workforce planning – The process of analysing the current workforce and determining future needs, including identifying any gaps between current and future provision.

Page last updated - 12/08/2024

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8.7: Critical Thinking, Clinical Judgment and the Nursing Profession

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Figure 8.12 Image by Moondance from Pixabay

Critical thinking involves the skillful analysis of information to make informed judgments. To engage in critical thinking, it's crucial to recognize and address personal biases and assumptions when encountering information, and to consistently apply standards for evaluating sources.

Critical Thinking in Nursing

Critical thinking is indispensable in nursing as it empowers caregivers to make decisions that optimize patient care. During education, educators and clinical instructors introduced critical-thinking examples in nursing, emphasizing tools for assessment, diagnosis, planning, implementation, and evaluation.

The cultivation of these skills continues into practice. Critical thinking is pivotal in delivering quality patient care and evolves throughout a nursing career, eventually becoming instinctive. Critical thinking in nursing involves identifying problems, determining optimal solutions, and executing effective resolutions through clinical decision-making. Reflection follows action to assess outcomes and consider alternative approaches where necessary.

Nurses play a crucial role as primary patient advocates, often the first to detect changes in status. Critical thinking enables unbiased interpretation of these changes based on evidence rather than conjecture. Anticipating patient needs through critical-thinking skills significantly influences care quality and outcomes.

Key elements of critical thinking in nursing include:

• Clinical judgment: Prioritizing patient needs, interpreting data, and anticipating complications.
• Patient safety: Recognizing deviations and taking preventive actions.
• Communication and collaboration: Fostering interdisciplinary teamwork.
• Problem-solving skills: Analyzing issues and implementing effective solutions.

Developing critical-thinking skills involves continuous learning, reflection on practice, openness to diverse perspectives, and structured problem-solving approaches like SWOT analysis. These skills mature with experience, enabling nurses to navigate complex healthcare scenarios effectively.

In conclusion, critical thinking is indispensable for safe, patient-centered care in nursing. Its ongoing development equips nurses to navigate challenges and uphold standards of excellence in an evolving healthcare landscape.

Clinical Judgement

Clinical judgment is the application of critical thinking to the clinical setting, which includes assessing, analyzing, and synthesizing complex patient data to develop and implement effective patient care plans. It involves interpreting patient information, drawing conclusions, and making decisions about patient care. Clinical judgment centers on interpreting and synthesizing patient data to make informed decisions about nursing interventions. It aims to make accurate and timely clinical decisions that positively impact patient outcomes. Nurses use clinical judgment to prioritize patient needs, anticipate complications, and adapt care plans based on patient responses. It integrates critical thinking skills into real-time clinical situations.

Clinical Decision Making

Clinical decision making refers to the process of choosing the best course of action among various alternatives to achieve a desired patient outcome. It involves selecting appropriate interventions based on a synthesis of clinical judgment, evidence-based practice, patient preferences, and available resources. Clinical decision making is focused on choosing the best action to meet specific patient needs and goals. It aims to provide safe, effective, and patient-centered care. Nurses engage in clinical decision making to determine treatment plans, prioritize care activities, and manage patient responses. It relies on critical thinking and clinical judgment to weigh options and select the most appropriate intervention.

In nursing practice, critical thinking, clinical judgment, and clinical decision-making are interrelated and essential:

• Critical thinking underpins both clinical judgment and decision-making by guiding the analysis and evaluation of information.
• Clinical judgment utilizes critical thinking to interpret patient data and make informed decisions about care priorities and interventions.
• Clinical decision-making integrates critical thinking and clinical judgment to choose effective interventions and strategies for achieving positive patient outcomes.

While critical thinking focuses on the process of reasoning and evaluating information, clinical judgment applies this thinking to clinical situations to interpret and prioritize patient needs. Clinical decision-making then uses critical thinking and clinical judgment to select the best course of action for optimal patient care. Together, these elements form the foundation of professional nursing practice, ensuring safe, effective, and patient-centered care delivery.

Differentiating Between Critical Thinking and Clinical Judgment in Caring for a Patient with Pneumonia

Instructions:

Review the patient scenario provided below. For each action taken by the nurse, determine whether it demonstrates critical thinking or clinical judgment. Write "CT" for critical thinking and "CJ" for clinical judgment next to each action. Explain why you classified each action as either critical thinking or clinical judgment.

Patient Scenario:

Mrs. Johnson, a 68-year-old woman, is admitted to the hospital with pneumonia. She presents with a fever of 101.8°F, productive cough, shortness of breath, and chest pain. Her medical history includes hypertension and type 2 diabetes.

1.Reviewing Mrs. Johnson’s Medical History and Lab Results: - Action: The nurse reviews Mrs. Johnson’s past medical history and her recent lab results to understand her overall health status. - Classification: ___ - Rationale: ___

2. Administering Prescribed Antibiotics: - Action: The nurse administers the prescribed antibiotics as ordered by the physician. - Classification: ___ - Rationale: ___

3. Monitoring Vital Signs: - Action: The nurse frequently monitors Mrs. Johnson’s vital signs, including temperature, blood pressure, respiratory rate, and oxygen saturation. - Classification: ___ - Rationale: ___

4. Evaluating the Effectiveness of Interventions: - Action: After administering antibiotics, the nurse assesses Mrs. Johnson’s response, including a reduction in fever and improvement in breathing. - Classification: ___ - Rationale: ___

5. Prioritizing Care: - Action: The nurse prioritizes interventions, ensuring that Mrs. Johnson receives oxygen therapy before other less urgent tasks. - Classification: ___ - Rationale: ___

6. Educating the Patient and Family: - Action: The nurse educates Mrs. Johnson and her family about pneumonia, its treatment, and how to manage symptoms at home. - Classification: ___ - Rationale: ___

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Barriers in providing quality end-of-life care as perceived by nurses working in critical care units: an integrative review

Affiliations.

• 1 Department of Nursing Sciences, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. [email protected].
• 2 Princess Aisha bint AL-Hussein College of Nursing and Health Science, Al-Hussein Bin Talal University, Maan, Jordan. [email protected].
• 3 Department of Nursing Sciences, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. [email protected].
• 4 Department of Nursing Sciences, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
• 5 Department of Nursing, School of Medical and Life Science, Sunway University, Bandar Sunway, 46200, Malaysia.
• 6 Faculty of medicine, Yarmouk University , Irbid, Jordan.
• 7 Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
• 8 Department of Nursing, School of Nursing and Midwifery, Torbat Heydariyeh University of Medical Sciences, Torbat Heydariyeh, Iran.
• PMID: 39210456
• PMCID: PMC11363454
• DOI: 10.1186/s12904-024-01543-y

Background: Despite increasing interest in quality end-of-life care (EOLC), critically ill patients often receive suboptimal care. Critical care nurses play a crucial role in EOLC, but face numerous barriers that hinder their ability to provide compassionate and effective care.

Methods: An integrative literature review was conducted to investigate barriers impacting the quality of end-of-life care. This review process involved searching database like MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, EBSCO, and ScienceDirect up to November 2023. Search strategies focused on keywords related to barriers in end-of-life care and critical care nurses from October 30th to November 10th, 2023. The inclusion criteria specified full-text English articles published between 2010 and 2023 that addressed barriers perceived by critical care nurses. This integrative review employs an integrated thematic analysis approach, which combines elements of deductive and inductive analysis, to explore the identified barriers, with coding and theme development overseen by the primary and secondary authors.

Results: Out of 103 articles published, 11 articles were included in the review. There were eight cross-sectional descriptive studies and three qualitative studies, which demonstrated barriers affecting end-of-life care quality. Quality appraisal using the Mixed Method Appraisal Tool was completed by two authors confirmed the high credibility of the selected studies, indicating the presence of high-quality evidence across the reviewed articles. Thematic analysis led to the three main themes (1) barriers related to patients and their families, (2) barriers related to nurses and their demographic characteristics, and (3) barriers related to health care environment and institutions.

Conclusion: This review highlights barriers influencing the quality of end of life care perceived by critical care nurses and the gaps that need attention to improve the quality of care provided for patients in their final stages and their fsmilies within the context of critical care. This review also notes the need for additional research to investigate the uncover patterns and insights that have not been fully explored in the existing literature to enhance understanding of these barriers. This can help to inform future research, care provision, and policy-making. Specifically, this review examines how these barriers interact, their cumulative impact on care quality, and potential strategies to overcome.

Keywords: Barriers; Critical care units; Nurses; Quality end-of-life care.

© 2024. The Author(s).

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Conflict of interest statement

The authors declare no competing interests.

PRISMA search flow diagram

• World Health Organization W. palliative care key facts 2022, 2022(8 aug 2022).
• Ransea K, Yatesb P, Coyer F. Modelling end-of-life care practices: factorsassociated with critical care nurseengagement in care provision. Intensive Crit Care Nurs. 2016;33:48–55. 10.1016/j.iccn.2015.11.003 - DOI - PubMed
• Haji Ali Beigloo R, Mohajer S, Eshraghi A, Mazlom SR. Self-administered medications in Cardiovascular Ward: a study on patients’ Self-efficacy, knowledge and satisfaction. Evid Based Care. 2019;9(1):16–25.
• Ghasemi A, Karimi Moonaghi H, Mohajer S, Mazlom SR, Shoeibi N. Effect of self-management educational program on vision-related quality of life among elderly with visual impairment. Evid Based Care. 2018;8(1):35–44.
• Kisorio LC, Langley GCJI, Nursing CC. Intensive care nurses’ experiences of end-of-life care. 2016, 33:30–8. - PubMed

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