The advancement of critical care nursing as a response to the current demands

Abstract

The current demand on health services requires that nurses play a key role, by adapting their competencies to different fields and complexity levels. The approach of situations presented by critically ill patients underpins the need for development of specialised competencies in specific areas such as patient safety, prevention and control of healthcare-associated infections, performance of specific techniques and interventions, autonomous medication management or the use of technology, among others. Spain relies on a specialist training programme that is unique worldwide. Training admission is managed through a contract as a “Resident Nurse Intern” (EIR, Enfermera Interna Residente), provided by regional healthcare services. Only 6 specialities have been established and developed, in an uneven manner and with a short provision of places, annually. Given that the specialization in critical care nursing does not exist, nurses usually self-fund their postgraduate training to enhance their opportunities career development. The development of a speciality for critical care nursing is a priority. The models proposed advocate for creating nursing roles that could cover the systemic gaps through the expansion of their competencies and the introduction of procedures that fit nursing into advanced practice, which could be achieved through Advanced Accreditation Diplomas. Simultaneously, it would be convenient to analyse how and why such a dynamic discipline in some countries became stuck in anachronistic models of the Spanish healthcare system. This analysis might contribute to move forward on the development of areas of improvement in terms of service access and quality of care.

Resumen

La actual demanda de servicios de salud requiere que sean las enfermeras quienes juegen un papel principal, adaptando sus competencias a diferentes ámbitos y grados de complejidad. El abordaje de las situaciones complejas que presentan los pacientes críticos justifica la necesidad de desarrollo de competencias especializadas, en áreas tan específicas como la seguridad del paciente críticamente enfermo, programas de prevención y vigilancia de la infección nosocomial, la realización de técnicas e intervenciones específicas, el manejo de medicación de forma autónoma o el uso de nuevas tecnologías, entre otras. Contamos en España con un sistema de formación de especialistas que es único en el mundo. Esta formación se realiza mediante un contrato como enfermera interna residente (EIR) por parte de los diferentes servicios de salud autonómicos. Tan solo 6 especialidades se han implantado y desarrollado, de forma desigual y con una oferta anual de plazas claramente insuficiente. Al no existir especialización de enfermería en cuidados críticos, los profesionales se autofinancian la formación posgrado para mejorar el desarrollo de su carrera profesional. El desarrollo de la especialidad de enfermería en cuidados críticos supone una prioridad. Los modelos propuestos abogan por la creación de figuras enfermeras que cubran las deficiencias del sistema actual mediante la expansión de sus competencias y la implantación de mecanismos de adecuación de los perfiles de enfermería a la práctica avanzada, las cuales pueden desarrollarse mediante los Diplomas de Acreditación Avanzada. Al mismo tiempo convendría analizar cómo y por qué una disciplina tan dinámica en otros países de nuestro entorno se ha quedado anclada en modelos anacrónicos en el sistema español. Este análisis contribuiría a avanzar en el desarrollo de nuevas formas de mejorar el acceso a los servicios y de proporcionar cuidados de calidad a las personas.

Introduction

The world’s health systems are facing new care challenges, caused by increasingly complex health problems, and changing population expectations. Population ageing is coupled with an increase in the prevalence of chronic diseases, multimorbidity, dependency problems, and community mental health disorders.^1,2 Analysis of the organisational structure of healthcare systems shows how the role of nurses can be pivotal, because their competency framework can be adapted to different areas and degrees of complexity.^3,4 However, Western healthcare systems have long been implementing austerity policies that have contributed to staff shortages and overwork in units, leading to evident signs of dissatisfaction and burnout, which negatively influence the individual’s expectations for the future and their motivation for professional development. In this context, a guaranteed person-centred care model and integrated services for continuity of care, which are multidisciplinary in nature, require a firm commitment to the adequate and stable provision of nurses and to professional development. This will be achieved by creating more professional profiles whose training in specific areas of care practice will help improve the system’s capacity to adapt and problem solve.^5–7

The wide variety of care activities and the competencies required to meet the needs of patients with conditions of varying levels of severity are key to the care process within these units and can vary markedly between units at different levels of care. Organisational and management measures as a whole are directly related to the safety of the critically ill patient with severe acute disease, such as programmes for the prevention and surveillance of nosocomial infection, integrated clinical communication systems (prescription, monitoring, and documentation), specific medication management, use of new technologies, high-risk therapies such as renal replacement therapy or extracorporeal circulation, etc.

Since their inception, intensive care units (ICU) have been continuously evolving by incorporating new diagnostic procedures, treatments, and therapeutic possibilities. Furthermore, the new technologies have greatly improved patient monitoring and innovation in care. The competency domains of critical care nurses have not undergone major changes in their care, professional, managerial, or educational/developmental sub-domains. However, the aforementioned advances require professionals to update their knowledge, skills, and attitudes in the management of new devices and in person- and family-centred care planning.^8,9

The level of competency that nurses require to practice critical care is the most highly recognised by other professionals and the population. To respond to a level of demand that varies between critical care units, institutions, and the system itself requires a specific training agenda in critical care that is officially recognised and accredited, with training systems by care area (paediatric patient, neonatal, coronary critical care, etc.). The agenda must also be updated using a reaccreditation system based on continuous training, focussing on patient safety and scientific evidence-based practice that has been effective in reducing errors to ensure quality, as well as continuity of care. These premises are formally covered in the Belfast Declaration,¹⁰ where the various critical care nursing associations pledge to ensure the best standards of care by identifying opportunities to collaborate in further advancing critical care nursing education, practice, research, and development.

Given the above, this paper argues the need to address the problems present in the development of critical care nursing, exploring potential options for specialised and advanced training, along with viable official recognition in accordance with Spanish professional regulation.

Problems of the healthcare model

In Spain, for ICU nurses to reach the level of competency for safe practice, they must undergo a learning process that enables them to anticipate potential complications, which often occur in critical patients given their high vulnerability. In March 2020, when the COVID-19 pandemic was declared, Spanish healthcare professionals had to adapt quickly and decisively in their response to these new challenges. Spanish ICU facilities had to provide more than 13000 beds and acquire 3000 additional ventilators, without taking into account the number of professionals trained in managing these ventilators.⁴ However, these measures alone would not alleviate the pressure of care, as the lack of nurses with knowledge and skills in the care of critically ill patients meant care needs were not met. To address this problem, many nurses were redeployed from other non-critical care units, with widely varying levels of expertise. In these circumstances, nurses with expertise in critical care and those supporting the services expressed feelings of emotional stress caused by a situation in which all resources were scarce.^5–7

The course of the pandemic only highlighted the structural lack of nurses in our health system. Spain, with 6.1 active professionals/1000 population, is significantly below the average of the European Union member states, with 8.3 nurses/1000 population.^8,9 The patient: nurse ratio in Spanish hospitals (12.7:1) is higher than the average for hospitals in other European countries (8.3:1), according to the RN4CAST study of 2014.¹¹ A later multicentre study, conducted by Fernández-García¹² Andalusia, calculated an average ratio of 11:1 in medical and surgical inpatient units, taking shifts into account. In the specific case of Spanish critical care units, the average patient: nurse ratio is 2.2:1 for day shifts and 2.7:1 for night shifts.¹³ These figures are far from the standards published in other Western countries of 1:1 to 2:1, or 1:1 according to different levels of care complexity.^14,15 Such limited nurse staffing levels may result in overloading other team members to cover incidents, which also negatively affects the quality of care.^16,17 This is compounded by high levels of temporary nurse employment, which hampers the continuous practice considered essential for professional development and the acquisition of professional competencies. The lack of development and deficiencies in the recognition of an official training programme in Spain impede nurses’ professional advancement; this is a relevant factor in the flight of talent to other countries with more attractive professional development processes.^18,19 These circumstances not only form an inappropriate environment to ensure individuals better access to health services, but are also related to poor health outcomes in terms of care deficiencies, morbidity, and mortality.^17,19,20

Options for professional development in critical care

The training system for specialist nurses in Spain is unique in the world. Training is provided under a contract as a resident nurse intern (EIR) by the different autonomous health services (decentralised healthcare competences at autonomous region level), and lasts 2 years involving theoretical and practical training in the different teaching units. The training is clinical and real in the specific field of competency for each speciality. This training process is similar to the training of other healthcare professionals in their specialties, such as doctors, psychologists, pharmacists, etc., which is also delivered through a residency training system with access through a competitive process.^21,22

For the last 18 years, and after the publication of Royal Decree 450/2005,²³ regulating 7 nursing specialities, only 6 specialities have been implemented and developed in the different autonomous regions, unequally and with a clearly insufficient number of annual places (2108 places for more than 330000 registered nurses). Furthermore, some of the professional categories of specialist nurse have not yet been implemented in the autonomous systems, which makes it impossible to include specialist nurses in care teams (Fig. 1). This means an investment in the training of specialist nurses that is not effectively reflected in the provision of services to the population. The deficiencies in establishing specialist nurse categories not only limit improvements in care quality, but also lead to inter-regional inequalities in the health services available to the population.^24,25 Similarly, the fact that few specialist nurses are employed means that access to specialist training is no longer seen as a feasible opportunity for professional development. This, coupled with an increased supply of jobs for generalist nurses during the COVID-19 pandemic, may have contributed to the marked decline in the number of applications for EIR training, from 13515 applicants in 2017 to 9152 in 2024.²⁵ The lack of planning and inequality in establishing specialist nursing categories has an impact, and can be discouraging and frustrating for the profession, with consequent demotivation in terms of professional development, which can cause irreparable damage to the healthcare system.

Figure 1.

Implementation of the different categories of specialist nurses by autonomous region. In several autonomous regions the category of Specialist Nurse has been created without specific mention or recognition of each speciality, which is ambiguous. Compiled in house.

Given the obvious difficulties of an approach that involves staffing units with specialist critical care nurses trained in a residency system, it is difficult to envisage the development of other advanced care roles, where professional competencies can be matched to specific care needs. These advanced roles already exist in some of our neighbouring countries, with the advanced practice nurse (APN). The APN is a designated nursing role or level focused on the provision of care in direct and indirect services at an advanced level, a broader scope of care practice than that of the general nurse. One of the capabilities of the APN is to manage complex care processes with a high level of autonomy, integrating evidence-based practice, education, and leadership. They should be the first point of contact or healthcare reference for individuals and their families. In addition, their leadership is a major component in managing nursing teams and in their training, and in promoting evidence-based practice in them.^26,27 The benefits of the APN role are already appreciable in other systems, where in addition to managing care with an expert level of competency, the APN contributes significantly to promoting research, training, and the continuous improvement of the quality of care in units.^28,29

The APN does not yet have a clearly defined role in Spain, although in some autonomous regions such as Catalonia and Andalusia, APN positions are starting to be created without their having a recognised professional category.^29–32 In comparison to other countries, the profile of the Spanish specialist nurse could be equivalent to the “specialised nurse”, with a level of qualification similar or slightly lower than that of the APN, and whose minimum training includes extensive clinical experience combined with undertaking courses, internships, or specialised clinical modules. The level of qualification is also comparable to that of the “clinical nurse specialist”, whose training is completed at university, at Master’s level or above, and whose scope of practice is limited to advanced roles in the care of patients with specific health problems or in specific clinical units.^26,27,33

There are current European initiatives to develop advanced practice nursing, with new roles and scopes of action that are more in line with today’s demand of health services. These could be achieved by adapting new training pathways recognised by the European Higher Education Area (EHEA) and the EQF to facilitate their official recognition. However, plans are already being made in Europe to harmonise nursing specialities, and create and standardise advanced practice nursing profiles.^27,34,35

A potential option in Spain could be that covered by Royal Decree 639/2015,³⁶ regulating accreditation diplomas and advanced accreditation diplomas, the nature of which is continuing education, and recognised through the Commission for Continuing Education of Health Professions. According to this regulation, "Advanced accreditation diplomas certify that the professional has attained the advanced competencies and continuing training requirements established in a specific functional area that admits and requires a more highly qualified professional practice, for a specific period of time". Advanced accreditation diplomas are valid nationally for a standard duration of five years. An expert knowledge base, complex decision-making skills, and clinical competencies must underlie advanced nursing practice.³⁵ The title of this legal regulation could imply that advanced practice nursing is accredited through a system of continuing education, outside the European Qualifications Framework (EQF). However, the EQF does not regulate specific roles and competencies that can be applied in the context of creating new professional categories.

Doctors settled their specialisation in 1978, (Spain) being one of the few countries in the world where the speciality of intensive care medicine exists independently from the speciality of anaesthesia. The situation of nurses in Spain remains unresolved; we do not have a speciality in critical care, and although there is a pending speciality in medical-surgical care, it has been blocked since 2005 and there is no clear indication that critical care can be included within it.²² Being an expert nurse in the care of critical patients requires experience and training with postgraduate courses related to care in the ICU or critical situations.³⁷

Problems and solutions in specialising in critical care

As there is no official specialisation in order to be a nursing team member in special services, such as ICU, the operating theatre, or ED, nurses must be self-motivated and self-financed in pursuing postgraduate studies to provide the safest nursing care, with greater autonomy and with the best quality standards. This is also a way to widen their opportunities to gain professional experience in these units. Added to the vacuum in training recognition for nurses working in critical care is the aforementioned difficulty in building stable teams. This cocktail of “instability + non-recognition” is a perfect breeding ground for increased undesired variation in clinical practice, which is closely related to increased risk to patient safety.³⁸ The most coherent models, under the current legal framework, would advocate the creation of an EIR-type critical care specialty and subspecialties through specific training areas. This could be complemented by other profiles that could serve through advanced practice, through advanced accreditation diplomas. Other options for developing advanced critical care roles would include the creation of master’s type university programmes, as proposed by the International Council of Nursing (ICN), which would include a practical training load comparable to a two-year residency system. However, the creation of specific categories in the Spanish health system, under the university model, would require a change in the regulatory and developmental model of specialised nursing. It should also be considered whether to include a competitive system of access with this model, as with the examination for EIR places. However, there could be concerns in the development of advanced accreditation diplomas because they are considered part of continuing education, in some way distancing themselves from that proposed by the ICN.

The first step towards analysing the viability and development of a new speciality in nursing is to gain the approval of seven autonomous communities (as they finance the teaching units and the costs of resident nurses), and the scientific societies of each area of knowledge are responsible for putting their argument and convincing the different autonomous health service managers in order to obtain their approval. Once this support has been obtained, it must be passed on to the Ministry of Health, specifically to the Directorate General for Professional Organisation, which covers the National Commissions for healthcare professional specialities. We are aware that the SEEIUC is already taking these steps and we are convinced that the necessary support will be obtained. The Directorate General for Professional Organisation will then inform of the need and ask the opinion of different professional bodies, including the General Council of Nursing as legal representatives of the nursing profession in Spain, and then ultimately inform the Minister of Health of the need to create a new speciality and obtain their approval.

At the organisational level, specifically defining critical care positions and implementing a periodic accreditation system to enable practice in certain technical areas are interesting proposals that should be explored.

Conclusion

Undoubtedly, critical, or intensive care nursing is a necessary speciality, and an urgent approach is a priority, because this is an area where nursing care is particularly complex. The General Council of Nursing is not in favour of a model with multiple specialities like the medical discipline, although we believe that 6 do not cover the current demands of the system and that we should opt to create 4 or 5 new specialities. However, there are great differences between the characteristics of the patients cared for in critical care units, which may give room for profiles with specific training areas within the speciality, such as profiles for paediatric or neonatal critical care. Profiles for undertaking high-risk therapies such as renal replacement therapy or extracorporeal circulation would require advanced accreditation because their management directly impacts patient safety and the quality of care provided. Therefore, we believe that accreditation diplomas and advanced practice nurses can fit into this model with specialist and generalist nurses, who must continue to form the nursing workforce.

While efforts are being made to create much-needed nursing specialities such as critical care, it would be useful to analyse how and why a discipline that is so dynamic in other countries around us has remained stuck in anachronistic models in the Spanish system, where not only are international nurse staffing recommendations not being met, there is also no commitment to specialisation and advancement, nor to the continued professional development of nurses. This analysis would help us to advance in creating new ways of improving access to services and providing care for people. The greatest beneficiary of a more agile and seamless structure will always be the population that places its trust in the system.

Funding

The authors declare that no funding was received for this manuscript.

Conflicts of interest

The authors have no conflict of interests to declare, and the manuscript is not under review by other publications or journals, apart from Enfermería Clínica.