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Critical care nursing in CanadaCarol Ball

Carol Ball MSc,RGN, ENB100, StBartholomew’sSchool of Nursingand Midwifery,City University,Philpot Street,London E1 2EA

In September of this year, I was fortunate in beingable to attend the annual meeting of the CanadianAssociation of Critical Care Nurses (CACCN),held in Ottawa. There were numerous issuesraised at the conference which I thought wouldbe of interest to critical care nurses in other partsof the world, relating to both practice andeducation. To provide a context, I will alsoaddress the structure of the Canadian health caresystem (briefly!!) and the CACCN.

Canada has a public health care system, free atthe point of delivery on production of a ‘healthcard’, similar in size to a credit card. There is noprivate sector. Health care is administered by theFederal Government, but individual provincesare responsible for the administration of healthcare moneys. Therefore priorities, in terms ofspending, are established by each province.Provincial control is also evident in the pay ofcritical care nurses. Each province (andindividual hospital) can decide the level ofreimbursement. There is no national paystructure or bargaining. Nursing as a professionis beginning to increase its activity at FederalGovernment level and has just been awarded asubstantial sum of money to increase researchactivity. Four priority programmes have beenfunded: (1) nursing research chairs inuniversities; (2) training; (3) research funding;and (4) knowledge dissemination. In response tothis funding, CACCN has established a ResearchCommittee which will develop ideas to fostercritical care nursing research and produce anational proposal for a critical care nursing study.This is the first time money has been ‘ring fenced’for nursing, as opposed to medical research and itis seen to be a great step forward for theprofession in Canada.

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The CACCN represents 1031 nurses acrossCanada, as of 31 March 1999. The association isdivided into numerous chapters who facilitatelocal initiatives. The association has a webpagefor those of you who might wish to ‘browse’current activity. The address ishttp://www.caccn.ca and the E-mail address iscaccn@caccn.ca. Of particular interest on thewebsite are:

• Position statements on the Standards ofCritical Care Nursing Practice and the studyguide for Critical Care Nursing Certification,of which more later in this report;

• Critical Care Chatter – an informal venue toexchange ideas and findings with colleagues;

• Critical Care nursing research information anduseful links;

• Information concerning the journal of CACCN.

The CACCN is also very active in representingcritical care nursing issues to the Federalgovernment and recently presented a brief to theHouse of Commons Standing Committee onHealth outlining the CACCN’s position regardingthe role of critical care nurses in organ and tissuetransplantation. Other activities of the associationinclude Education, Partnerships, Research andthe future development of critical care nursing inCanada.

The education of critical care nurses occurs attwo levels. As in the UK, universities offer avariety of courses and these differ in terms oflength, content, teaching methods andassessment. An example of one such distance-learning package is that provided by MountRoyal College of Nursing, Calgary, Alberta. (Forthose interested in accessing information, the website is www.mtroyal.ab.ca). The second form of

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education involves certification in critical carenursing at a national level, providing a nationalstandard of the knowledge required to practise incritical care. This is very different from the UK,where not only do we have postcode prescribing,but also the possibility of postcode competence.This is an area which the United KingdomCentral Council should address, having as it doesa remit to protect the public.

The certification programme is administeredthrough the Canadian Nurses Association.However, the certification examination (multiplechoice – MCQ) is developed by CACCN throughthe establishment of Standards and Competencies(see the CACCN website for more informationregarding these). The Standards address both thestructure of critical care units and the process ofcritical care nursing. The former are important,recognizing as they do the responsibility of thehospital in facilitating optimal nursing care. Thestructure standards include:

• ensuring the physical environment isconducive to the delivery of nursing care tocritically ill patients and their families;

• opportunities are provided for critical carenurses to maintain knowledge and skills;

• the establishment of a critical care committeein each hospital, which includes nurses,doctors and other relevant health careprofessionals.

Process standards include:

• accurate collection of patient and family data;• knowledge of biological, physical and

behavioural sciences and the interpretation ofthese in practice;

• intervention and implementation of care;• evaluation of patient outcome;• development of therapeutic relationships with

patients and families.

The standards are written in considerabledepth and clearly itemize the expectations of theCACCN. From these Standards, Competencieshave been established and it is upon these that thenational certification examination is based. TheCompetencies are system-related. A nine-categoryclassification scheme covers: Neurological,Cardiovascular, Respiratory,Immunology/Haemotological, Musculoskeletaland Psychosocial issues. A total of 147competencies have been established within the

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nine categories. As can be seen, the competencieshave a ‘strong’ physical bias and identify coreknowledge which can be examined in the MCQformat. Examination of psychosocial issues ismore difficult and thought is being given to theconstruction of verified portfolio evidence in theassessment of this category. Interestingly, at theCACCN conference a presenter from the USAdescribed the development of ‘The SynergyModel’ which attempts to restore some balance inthe physical and psychosocial equation. TheSynergy Model attempts to match Patient andNurse Characteristics, with the aim ofdemonstrating nursing’s unique contribution topatient outcome. The fundamental premise of theSynergy Model is that patient characteristics drivenursing competencies. For more informationregarding the model, see Curley (1998) andEdwards (1998). The model will be used to assessthe competence of nurses working in critical carein the USA, but the emphasis will change as thenurse progresses from competent to expert. Forexample, in the early stages, assessment willconcentrate on clinical judgement, reasoning andcaring practices. However, in the later stages of anurse’s development, assessment increasinglyfocuses on collaboration, response to diversity(the sensitivity to recognize, appreciate andincorporate different responses to nursing care),clinical inquiry and facilitating learning in bothpeers and patients. Therefore, the model can beused to assess both competent and expert practice.

The majority of concurrent papers given at theconference related to many and varied practiceissues. It was, of course, not possible to attend allthe presentations but those which attracted myattention were:

‘Haemodynamic Waveform andInterpretation’ and an associated paper, ‘Fromglobal to regional haemodynamic assessment:what is on the horizon?’ Both these papers weregiven by Bobbie Leeper, a Clinical NurseSpecialist from Baylor University Medical Centrein the USA. Of particular note in the firstpresentation was the use of case studies todemonstrate the effectiveness, or otherwise, ofnursing interventions. The second paperreviewed the limitations of pressuremeasurement, such as central venous orpulmonary artery occlusion pressures (CVP andPAOP), when compared to volume measures, forexample, right ventricular end diastolic volume,

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in the manipulation of preload. For furtherinformation on this subject, see Safcsak andNelson (1999). The problem of assessing regionalperfusion and flow using global measures, suchas PAOP or CVP, was raised and the futureintroduction of regional measures particularly forthe appraisal of oxygen delivery in thegastrointestinal tract and brain was described.

Other practice-based presentations included a‘Review of the Respiratory System’, the‘Interpretation of Heart and Breath Sounds’, ‘12-lead ECG Interpretation’ and ‘Cardiac Pacing’.

More unusual aspects of critical care werepresented as case studies. These included:

• Streptococcal toxic shock syndrome;• Abdominal compartment syndrome;• The dangerous side of Heparin: allergy and

HIT (heparin-induced thrombocytopenia);• Traumatic amputation and reattachment;• Acute iron poisoning.

The case studies presented were extremelyinteresting to listen to and the format provided‘real-life’ understanding of patient-centredsituations rather than the more usualpresentation of physiology, pathophysiology andtreatment.

Research papers were patient-centred andincluded:

• ‘The Effects of Therapeutic Touch onContinuous EEG Waveforms’

• MI in Women: Precursors, Presentation,Process and Recovery’

The former study demonstrated thattherapeutic touch is able to induce relaxation inpatients with cortical dysfunction, followingtrauma, as observed by EEG. The secondhighlighted the fact that heart disease has notbeen traditionally considered as a women’sdisease. However, women appear to be at higherrisk than men of experiencing emotional distress

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and a lower quality of life. Despite this, they areless likely to be referred to, or participate in,cardiac rehabilitation programmes. Women alsoexperience difficulty relinquishing homemakingand family responsibilities and often resumethese roles early after discharge despite physicaland psychological symptoms.

Poster presentations addressed recent practicedevelopment in the implementation ofanalgesic/sedation scoring systems; critical carenurses’ satisfaction with the process ofwithdrawing life-support; aortic valvereplacement in women: recovery patterns andissues; alcohol withdrawal: a community hospitalexperience; music therapy; the development of atracheostomy team: a strategy for quality careand the development of a protocol for use of theprone position.

The conference provided an interesting insightinto the practice of critical care nursing inCanada. It revealed many similarities with theUK and demonstrated huge potential for futurecollaboration, particularly in the area of researchand practice development. I would encouragethose of you with the appropriate technology tovisit the website and promote dialogue on issuespertinent to your own practice in critical care. Forany further information concerning the above orcontacting the CACCN Board of Directors, pleasefeel free to contact me at: St Bartholomew’sSchool of Nursing and Midwifery, CityUniversity, Philpot Street, London E1 2EA.

References

Curley M A Q 1998 Patient Nurse Synergy: optimisingpatient outcomes. American Journal of Critical Care 7:64–72

Edwards D F 1998 The synergy model: linking patientneeds to nurse competencies. Critical Care Nurse 19:88–90, 97–99

Safcsak K, Nelson L D 1999 Right heart volumetricmonitoring: measuring preload in the critically illpatient. AACN Clinical Issues 10: 22–31

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