Training of nurses in intensive care: essential for the critical patient

For several decades now, various European institutions have supported specialist training for intensive care nurses (ICU). Specialties provide the knowledge, skills, and aptitudes necessary to fully develop nursing competencies and to provide patients and their families excellent quality care, which results in increased responsibility, professional recognition, and better financial reward. ICU nurses have different training requirements from other nurses due to the specific characteristics of the critical patient, involving advanced skills and competencies that are continuously evolving.^1,2

The scientific evidence has shown that the quality of nursing care for critically ill patients and the workload often mean the difference between their survival or death, and between a good quality of life or severe sequelae on leaving the ICU.^3,4

In English-speaking countries such as the United Kingdom, a nurse without ICU experience needs one year's experience as an ICU nursing assistant to start working in this unit. Furthermore, in the UK and other countries such as France, Sweden or Belgium, nurses undergo a mentoring period of 3 to 6 months, depending on the country, before they start to work autonomously.

In the United Kingdom and Israel, nurses must complete a specialisation course in the first three years of ICU experience, and this is a requirement for career advancement. However, in other countries such as Estonia, Finland or the UK, nurses starting to work in ICU receive an induction course provided by the hospital and even financial support to study the speciality. In Germany, Switzerland, and Sweden it is not compulsory by law for nurses to specialise, but more than 80% do, which ensures that professionals meet minimum and standard requirements.

This proves that nurses in Spain being able to work in ICU having received only virtual and rapid training to explain “everything necessary about these units” is a form of negligence.⁵

With respect to workload, countries such as the United Kingdom and Sweden have a nurse/patient ratio of 1:1 which, although not compulsory by law, is recommended by the national critical care associations and is sufficient for it to be applied in practically all units in these countries. This consensus is supported in different countries, as shown in the literature review by Gullick et al., by the need to reduce clinical care variance, structuring training in all the parties involved (nurses, healthcare institutions, and scientific associations) to improve healthcare through clinical practice standards that will increase quality of care in critical patients and their families.⁶

Meanwhile, a standards and recommendations guideline has been published in Spain that defines the ratio for a level III ICU as one patient per nurse and states: “In addition to nursing, the intensive care nurse has been trained in intensive care and is competent to apply the nursing care process to the critical patient”.⁷ This statement is also a recommendation, not regulatory in nature, but not followed as can be observed in hospital settings. The same text defines the ICU as a unit in which “patients with pathophysiological conditions that have reached a level of severity such that they pose a current or potential threat to life but from which they may recover” (p.13)⁷ are cared for. Despite the changes in nursing education in Spain,⁸ no specific programmes for critical care nurses have been developed.^9,10 Research has focused for several years on the number of nurses and their maximum manageable workload, ignoring the importance of the qualities, and training that nurses receive throughout their professional lives, which make them key assets of the national health system.

For more than 10 years, there has been a widespread need for healthcare structures to have the recruitment resources to find a specific professional profile. The profile of the critical care nurse is recognised in several autonomous communities, which constitutes official recognition of the need for specific ICU nurse training.

Training in care, management and research skills adapted to the current needs of each professional are required.¹¹

In the current pandemic, this experience has not been acquired in a regulated manner due to the great demand for critical care nurses.^12,13 We were pleased to observe that the media echoed the need not only for more ICU beds, but also for nurses trained in the care of critical patients. This subject has been raised for many years at different scientific meetings and in the critical care units themselves. This situation, already expressed in society through the media, should prompt health institutions to reflect on the specific training in critical care needed by nurses to develop their full potential for the benefit of the patient and the health system. The search for staff to ensure nursing care in the ICU in times of nurse shortages has been a concern for managers. However, at present all previous forecasts have been insufficient and finding nurses with adequate training has proved a challenge.¹⁴ These contingency plans that focus on the skills of ICU nurses demonstrate the complexity of critical care; requiring prior experience that can support the learning curve through ad hoc training.¹³

Healthcare safety is a concern for all healthcare professionals. We have observed how professionals who have had to work in ICU during the pandemic without previous experience have been aware of their many limitations, only delivering the care in which they considered themselves competent.^15,16 Clinical safety requires control of the care situation by knowing the setting, the healthcare team, and the instruments in that setting. However, specific communication within the work team, in situations of risk and stress, is a cross-cutting element throughout the care process and closely linked to clinical safety that must be developed through experience and training.¹⁷ The lack of control of the healthcare situation, due to the pandemic, has put a strain on healthcare teams, causing difficulties in healthcare; this has empowered expert nurses within the entire team.¹⁸

It should be highlighted that ICU nurses should receive specific continuing education throughout their careers. This is evidenced by their high active participation in continuing education related to the critically ill patient and in the numerous research studies that have been undertaken that impact care outcomes. This implies a call to critical care nurses, with the support of the Spanish Society of Intensive Care Nurses and Coronary Units, to create a common framework so that we can develop a homogeneous professional identity within Spanish nursing. The minimum requirements shared by all critical care nurses constitute a bond that guarantees recognition as specialist professionals, ensuring a critical professional mass to face future healthcare challenges.

The absence of the elements mentioned above is a source of complete frustration for Spanish ICU nurses. We must negotiate with governments (of whatever colour) that do not want to listen to what we have to say, even when presented with scientific evidence of the need for specific education in critical care. At government level, an immobile strategy is maintained that is diametrically opposed to the needs of a nineteenth-century national health system that is not meeting today's challenges. ICU nurses are dynamic, innovative, and fully aware of their responsibilities to society. The failure to develop specific training in the care of the critically ill patient with every safeguard has not been considered either before or after repeated waves of a pandemic where the healthcare system has struggled to ensure quality care. This was clearly only possible because nurses have always perceived the need to continue updating and developing tools to care effectively for the critical patient, hence many of our ICU nurses have outstanding training. Because of this, developing a specialisation in critical care is so necessary that we must continue to work with a clear and positive objective: to guarantee the best training for ICU nurses to ensure equity of care for all the country’s critical patients. We certainly know how all healthcare leaders would answer the question: If you were to be admitted to an ICU, who would you prefer to care for you, a nurse specialised in critical care or an unqualified nurse?