The approved program standard for Registered Nurse Critical Care Nursing program of instruction leading to an Ontario College Graduate Certificate delivered by Ontario Colleges of Applied Arts and Technology (MTCU funding code 71423)

August 2017

Inquiries regarding specific programs offered by colleges of applied arts and technology in Ontario should be directed to the relevant college.

Permission to copy

For permission to copy this document, in whole or in part, for other purposes or by other institutions, or for any other general inquiries, please contact the ministry at:

Ministry of Colleges and Universities
Postsecondary Education Quality Assessment Branch
Program Standards Unit
315 Front Street West
16th floor
Toronto, Ontario
M7A 0B8

psu@ontario.ca

Introduction

This document is the Program Standard for the Registered Nurse Critical Care Nursing program of instruction leading to an Ontario College Graduate Certificate delivered by Ontario colleges of applied arts and technology (MTCU funding code 71423).

Development of system-wide program standards

In 1993, the Government of Ontario initiated program standards development with the objectives of bringing a greater degree of consistency to college programming offered across the province, broadening the focus of college programs to ensure graduates have the skills to be flexible and to continue to learn and adapt, and providing public accountability for the quality and relevance of college programs.

The Program Standards and Evaluation Unit of the Ministry of Colleges and Universities (formerly the Ministry of Advanced Education and Skills Development) has responsibility for the development, review and approval of system-wide standards for programs of instruction at Ontario colleges of applied arts and technology.

Program standards

Program standards apply to all similar programs of instruction offered by colleges across the province. Each program standard for a postsecondary program includes the following elements:

  • Vocational standard (the vocationally specific learning outcomes which apply to the program of instruction in question)
  • Essential employability skills (the essential employability skills learning outcomes which apply to all programs of instruction and
  • General education requirement (the requirement for general education in postsecondary programs of instruction)

Collectively, these elements outline the essential skills and knowledge that a student must reliably demonstrate in order to graduate from the program.

Individual colleges of applied arts and technology offering the program of instruction determine the specific program structure, delivery methods and other curriculum matters to be used in assisting students to achieve the outcomes articulated in the standard. Individual colleges also determine whether additional local learning outcomes will be required to reflect specific local needs and/or interests.

The expression of program standards as vocational learning outcomes

Vocational learning outcomes represent culminating demonstrations of learning and achievement. They are not simply a listing of discrete skills, nor broad statements of knowledge and comprehension. In addition, vocational learning outcomes are interrelated and cannot be viewed in isolation of one another. As such, they should be viewed as a comprehensive whole. They describe performances that demonstrate that significant integrated learning by graduates of the program has been achieved and verified.

Expressing standards as vocational learning outcomes ensures consistency in the outcomes for program graduates, while leaving to the discretion of individual colleges, curriculum matters such as the specific program structure and delivery methods.

The presentation of the vocational learning outcomes

The vocational learning outcome statements set out the culminating demonstration of learning and achievement that the student must reliably demonstrate before graduation.

The elements of the performance for each outcome define and clarify the level and quality of performance necessary to meet the requirements of the vocational learning outcome. However, it is the performance of the vocational learning outcome itself on which students are evaluated. The elements of performance are indicators of the means by which the student may proceed to satisfactory performance of the vocational learning outcome. The elements of performance do not stand alone but rather in reference to the vocational learning outcome of which they form a part.

The Development of a program standard

In establishing the standards development initiative, the Government determined that all postsecondary programs of instruction should include vocational skills coupled with a broader set of essential skills. This combination is considered critical to ensuring that college graduates have the skills required to be successful both upon graduation from the college program and throughout their working and personal lives.

A program standard is developed through a broad consultation process involving a range of stakeholders with a direct interest in the program area, including employers, professional associations, universities, secondary schools and program graduates working in the field, in addition to students, faculty and administrators at the colleges themselves. It represents a consensus of participating stakeholders on the essential learning that all program graduates should have achieved.

Updating the program standard

The ministry will undertake regular reviews of the vocational learning outcomes for this program to ensure that the Registered Nurse Critical Care Nursing Program Standard remains appropriate and relevant to the needs of students and employers across the Province of Ontario. To confirm that this document is the most up-to-date release, please contact the ministry.

Vocational standard

All graduates of Registered Nurse Critical Care Nursing programs have achieved the vocational learning outcomes (VLOs) listed below, in addition to achieving the essential employability outcomes and meeting the general education (GE) requirement.

Preamble

*See Glossary

Critical care nurses* provide complex, specialized holistic care to patients and their families experiencing potential or actual life threatening illness and end-of-life situations. Critical care nursing* is delivered in a range of highly technologically supported health care settings including hospital critical care units, recovery rooms, emergency departments, catheterization labs, flight and transport care and outreach programs in hospitals as members of critical care response teams.

The RN Critical Care Nursing program confers an Ontario College Graduate Certificate and provides registered nurses, who hold a current Certificate of Competence from the College of Nurses of Ontario, advanced knowledge and specialized skills and abilities in critical care nursing*.

Graduates practice within the scope of professional, legal and ethical standards along with organizational policies and best practices in critical care nursing*. Working in partnership with patients, families and members of the inter-professional health care team*, critical care nurses* plan, coordinate, implement and evaluate individualized patient and family-centred care* across the critical care continuum.

Using advanced knowledge in physical and psychosocial sciences, pathophysiology and pharmacology, graduates apply clinical reasoning skills and judgement to continuously assess and manage patients with complex, multi-system problems and to select, implement and evaluate independent and interdependent specialized nursing interventions to achieve optimal patient outcomes. Graduates use evidence-based research and best practice guidelines to inform clinical decision making and critical inquiry* to examine and adapt critical care nursing* practice.

Framed within the therapeutic nurse-patient relationship, graduates advocate for and deliver patient and family-centred care* to diverse patients/families experiencing potential or actual life threatening illness and end-of-life situations. As members of the inter-professional health care team*, graduates of the RN Critical Care Nursing program collaborate with a wide range of health care providers and coordinate and implement the interdisciplinary plan of care to achieve continuity of care and optimal patient outcomes.

Clinical environments where critical care nursing* is practiced are complex, fast paced, dynamic and stressful. Graduates use strategies and available resources to manage, mitigate and respond positively to environmental, physical and psychosocial stressors affecting self and others in the workplace.

As members of a self-regulatory health profession, graduates engage in reflective practice and ongoing professional development to enhance competence in critical care nursing*.

There may be opportunities for graduates to pursue further educational, qualifications or professional certification through partnerships between the colleges and universities or professional associations. Graduates may be eligible to pursue specialty certification in critical care nursing through the Canadian Nurses Association (CNA) Certification Program. Students should contact individual colleges and professional associations for additional information.

Endnote: The Ontario Council on Articulation and Transfer (ONCAT) maintains the provincial postsecondary credit transfer portal, ONTransfer.

Synopsis of the vocational learning outcomes

Registered Nurse Critical Care Nursing (Ontario College Graduate Certificate)

*See Glossary

The graduate has reliably demonstrated the ability to:

  1. practice within the scope of professional, legal and ethical standards, organization policies and best practices in critical care nursing*
  2. establish and maintain therapeutic relationships with patients, families and/or substitute decision makers* to optimize patient and family-centred critical care*
  3. assess, analyze and monitor data for patients with complex, multi-system problems in order to anticipate early deterioration in patient’s condition, establish priorities and to plan interventions
  4. plan, implement, evaluate and document specialized nursing interventions to achieve optimal patient outcomes in potential or actual life threatening illness and end-of-life situations
  5. advocate for and deliver patient and family-centred care* to patients/families experiencing potential or actual life threatening illness and end-of-life situations
  6. collaborate with members of the inter-professional health care team* in providing care for patients experiencing potential or actual life threatening illness and end-of-life situations to achieve continuity of care and optimal patient outcomes
  7. use evidence-based research and best practice guidelines to inform and adapt critical care nursing* practice
  8. use strategies and available resources to respond to environmental, physical and psychosocial stressors affecting self and others in the critical care setting
  9. engage in reflective practice and ongoing professional development to enhance competence in critical care nursing*

Note: The learning outcomes have been numbered as a point of reference; numbering does not imply prioritization, sequencing, nor weighting of significance.

The vocational learning outcomes

1. The graduate has reliably demonstrated the ability to

practice within the scope of professional, legal and ethical standards, organizational policies and best practices in critical care nursing*.

*See Glossary

Elements of the performance
  • accept accountability for professional practice in the critical care setting
  • maintain professional boundaries within role as a critical care nurse*
  • perform the critical care nurse* role in accordance with the Regulated Health Professionals Act, 1991; the Nurses Act, 1991; the Public Hospitals Act, 1990 and the College of Nurses of Ontario standards for nursing practice
  • participate in quality assurance processes and uses quality improvement findings to inform change for nursing practice and health care delivery
  • differentiate level 2 and level 3 critical care environments
  • identify safety indicators associated with delivery of critical care e.g., ventilator associated pneumonia (VAP) rates, central line-associated infections (CLI) rates, instances of unplanned extubation and hand hygiene compliance
  • participate in a positive culture of quality critical care, patient safety and risk prevention
  • ensure patient and family privacy and confidentiality within the critical care setting
  • implement and adheres to required organizational practices
  • follow guidelines for reporting data to appropriate agencies e.g., Critical Care Information Systems, Office of the Chief Coroner
  • identify potential organ and tissue donors through adherence to Trillium Gift of Life Network, End of Life Care guidelines and complete organ procurement documentation
  • apply relevant legislation related to consent, capacity and assisted dying i.e., Health Care Consent Act, 1996; the Substitute Decisions Act, 1992 and the Medical Assistance in Dying Act, 2016
  • propose and use resource tools to guide ethically complex situations e.g., ethical decision making frameworks, ethics committee
  • act as a resource person for students, peers, health care providers patients and patients’ family members

2. The graduate has reliably demonstrated the ability to

establish and maintain therapeutic relationships with patients, families and/or substitute decision makers* to optimize patient and family-centred critical care*.

*See Glossary

Elements of the performance
  • develop therapeutic relationship with the patient, family and\or substitute decision maker* reflecting cultural sensitivity and social justice
  • form a partnership with patient, family and\or substitute decision maker* and collaborate in the planning, delivery and evaluation of critical care*
  • use effective communication skills including active listening, touch and non-verbal communication, empathy, clarification and conflict resolution
  • preserve the patient’s dignity by respecting personal privacy, autonomy, preferences and individual diversity including age, ethnicity, spiritual beliefs, gender, marital status, sexual orientation, life and socioeconomic status
  • provide frequent, honest and realistic exchanges of information with patient, family and\or substitute decision maker*
  • use language that is consistent with level of understanding, education, culture and circumstances of patient and family
  • provide opportunities for patient and family to verbalize understanding, feelings and concerns using interpretation services where needed
  • assess patient’s current communication status by using all techniques available and involving the family in interpreting the patient’s efforts to communicate
  • provide augmentative and alternative communication methods to support patients and families with impaired communication e.g., gestures, Passy-Muir valve, cuff deflation, communication board, sign language, pictures etc

3. The graduate has reliably demonstrated the ability to

assess, analyze and monitor data for patients with complex, multi-system problems in order to anticipate early deterioration in patient’s condition, establish priorities and to plan interventions.

Elements of the performance
  • assess thorough physiological, psychosocial, cultural, developmental and spiritual data based on the patient’s condition
  • complete a comprehensive health history using available resources and appropriate sources of information
  • interpret and incorporate relevant medical history, laboratory and diagnostic information into holistic assessment data
  • use validated assessment tools where indicated in the critical care setting
  • analyze and validate data from patient, family and other sources to inform decisions about patient and family needs
  • make decisions about priorities of care in life-threatening and non life-threatening situations in collaboration with patient, family and the inter-professional health care team
  • use clinical reasoning and judgement to identify and/or predict early deterioration in patient’s condition
  • prepare for emergencies and sudden deterioration in patient’s condition and communicate changes in a timely manner
  • anticipate patient’s responses to planned interventions and monitor/re-assess as required

4. The graduate has reliably demonstrated the ability to

plan, implement, evaluate and document specialized nursing interventions to achieve optimal patient outcomes in potential or actual life threatening illness and end-of-life situations.

*See Glossary

Elements of the performance
  • anticipate, prevent, prepare for, recognize and intervene in critical and life-threatening situations
  • analyze and integrate all assessment findings to develop a collaborative and/or an independent plan of care
  • establish and revise immediate and longer-term patient-centred goals in collaboration with the patient, family and the inter-professional health care team*
  • coordinate and implement the plan of care within the individual’s scope of practice and in collaboration with other members of the inter-professional health care team*
  • select and safely implement the appropriate evidence-informed independent and interdependent interventions to manage the following acute patient problems;
    • ineffective airway clearance – e.g., positioning, managing secretions, oral, pharyngeal and tracheal suctioning, managing airways (endotracheal tubes, laryngeal mask, tracheostomy)
    • respiratory failure secondary to impaired gas exchange or mechanical failure – e.g., administering pharmacological agents (analgesics, reversal agents, sedatives, paralytics), mechanical ventilation, oxygen therapy, weaning from ventilatory support
    • shock and\or hypotension, arrhythmias and alteration in cardiac output – e.g., fluid management, administering pharmacological agents (vasodilators, vasopressors, thrombolytics), invasive hemodynamic monitoring, cardiac pacing, cardiopulmonary resuscitation and assisting with cardioversion/defibrillation and hemodynamic catheter insertion
    • alterations in cerebral perfusion – e.g., positioning, invasive monitoring of cerebral perfusion pressures, administering pharmacological agents (anticonvulsants, diuretics, barbiturates, calcium channel blockers, sedatives), fluid management, strategies to minimize stimulation
    • gastrointestinal tract abnormalities and altered nutrition – e.g., administering pharmacological agents (motility enhancers, GI prophylaxis), gastric drainage, gastric lavage, enteral/parenteral nutrition
    • acute renal failure with fluid, electrolyte or acid-base imbalance – e.g., administering and managing fluids, administering pharmacological agents (diuretics, vasodilators), continuous renal replacement therapy, intermittent hemodialysis and peritoneal dialysis
    • ineffective thermoregulation – e.g., administering pharmacological agents, using invasive cooling devices and non-invasive cooling/heating devices
    • skin breakdown, loss of skin integrity – e.g., skin care and positioning to prevent breakdown, complex wound care (negative pressure wound therapy, packing, burn dressing)
    • motor and/or sensory deficits – e.g., early mobilization and range of motion exercises, maintaining spinal cord integrity, monitoring for spinal shock, neurogenic shock, autonomic dysreflexia and compartment syndrome
    • alteration in immunological function – e.g., administering pharmacological agents (anti-infectives, immunomodulators), asepsis, infection prevention and control
    • alteration in hematologic function – e.g., administration of blood and blood components
    • alteration in endocrine function – e.g., administering hormones and synthetic substitutes, managing antidiuretic hormone, hyper/hypoglycemia, hyper/hypothyroidism and adrenal insufficiency associated with critical illness
    • pain and alteration in comfort – e.g., sedation and pain scales, comfort measures, administering pharmacological agents (analgesics, sedatives, regional blocks, epidural anesthesia/analgesia, patient controlled analgesia), non-pharmacological interventions to promote comfort
    • alteration in mentation – e.g., delirium-screening tools, mobilization, reorientation, minimizing sensory overload, pharmacological management, removal of lines as soon as possible
    • end-of-life care – e.g., providing palliative care, preparing for organ donation, maintaining hemodynamic stability, comfort care, pain and symptom management
  • manage multiple interventions and continuously monitor and evaluate the effectiveness and timeliness of planned interventions to achieve patient goals
  • complete timely, accurate and ongoing documentation of patient responses to independent and interdependent interventions using critical care flow sheets, narrative notes and/or care mapping in written and/or electronic medical record systems in accordance with organization’s documentation policies and the Documentation Standard of College of Nurses of Ontario
  • implement evidence-informed and/or best practice in relation to clinical care and patient safety

5. The graduate has reliably demonstrated the ability to

advocate for and deliver patient and family-centred care* to patients/families experiencing potential or actual life threatening illness and end-of-life situations.

*See Glossary

Elements of the performance
  • seek out, listen to and honour patient and family perspectives when planning and delivering critical care nursing* care
  • advocate for family presence in the critical care environment
  • involve family in direct patient care e.g., assisting with basic care
  • support, facilitate and respect the patient’s and family's right for information and participation in the plan of care and decision making
  • promote patient and family privacy and autonomy within a highly technological critical care* environment
  • use and adapt digital technology in the delivery of patient centered care and support the patient and family to be a partner with the use of technology
  • identify patient and family learning needs throughout the critical care experience and incorporate changing learning needs into the ongoing plan of care
  • use and adapt teaching strategies consistent with the acuity, complexity, readiness, ability and needs of the patient and family
  • provide patient and\or family members the opportunity to demonstrate learning e.g., repetition and return demonstrations
  • advocate for and support patient and family decision making related to planning care, advance directives, organ donation, informed consent, privacy and allowing natural death
  • enable and support transition to end-of-life care e.g., communication, advocating for patient and family wishes, conflict resolution
  • support family with referrals to internal and/or external resources e.g., social work, ethics consult, discharge planning, community supports, hospice, palliative care
  • advocate for patient and family participation in the evaluation of critical care services

6. The graduate has reliably demonstrated the ability to

collaborate with members of the inter-professional health care team* in providing care for patients experiencing potential or actual life threatening illness or end-of-life situations to achieve continuity of care and optimal patient outcomes.

*See Glossary

Elements of the performance
  • explain and promote one’s own role and responsibilities to patients, families and other members of the inter-professional health care team
  • shares relevant information with patient, family or substitute decision maker* and appropriate member of the inter-professional health care team*
  • formulate the inter-professional plan of care within a culture of quality, safety and risk reduction
  • use effective interpersonal communications, negotiation and conflict resolution skills to promote collegial relationships and to support optimal patient care
  • support the roles of shared leadership and decision making with respect to patient care in the critical care setting
  • facilitate communication among patient, family, inter-professional health team* members and external resources
  • consider the goals of care and consult with appropriate individuals to establish/review the plan of care and to promote continuity of critical care

7. The graduate has reliably demonstrated the ability to

use evidence-based research and best practice guidelines to inform and adapt critical care nursing* practice.

*See Glossary

Elements of the performance
  • promote research, evidence-based practice and dissemination of nursing knowledge
  • gather information from a range of sources including experts, research, professional standards and best practice guidelines and organizational practices
  • use a critical inquiry* process characterized by purposive thinking and reflective reasoning, to examine questions and changes in critical care practice
  • apply knowledge of relevant theoretical concepts and principles to guide critical care nursing* practice
  • integrate the best available evidence-informed care into critical care nursing* practice
  • identify issues, trends and clinical questions in the critical care setting that would benefit from research investigation
  • participate in research and incorporate research findings into practice where applicable

8. The graduate has reliably demonstrated the ability to

use strategies and available resources to respond to environmental, physical and psychosocial stressors affecting self and others in the critical care setting.

*See Glossary

Elements of the performance
  • contribute to and support initiatives that reduce stressors in the critical care setting and enhance the quality of work life
  • manage the environment to mitigate the effects of noxious stimuli
  • assess and facilitate the patient and family’s ability to cope with stressors related to illness and the environment and support access to resources for coping
  • identify common stressors impacting health care professionals in the critical care environment e.g., rapidly changing and high patient acuity levels, highly technological environment, ethical distress and conflict etc.
  • use and recommend available resources e.g., critical incidents reviews, debriefings, employee assistance program, to respond to stressors affecting the members of the inter-professional health care team*
  • manage stress to support personal health and well-being through various strategies e.g., self-care, mindfulness, behaviour/cognitive therapy

9. The graduate has reliably demonstrated the ability to

engage in reflective practice and ongoing professional development to enhance competence in critical care nursing*.

*See Glossary

Elements of the performance
  • maintain critical care and professional competency by engaging in reflective practice and self-assessment of learning needs
  • participate in in-service training/certification, educational activities and organizational requirements related to the critical care setting
  • seek out opportunities to enhance knowledge, skills and competencies in critical care nursing*
  • use constructive feedback, performance evaluation/appraisals and peer review to improve critical care practice
  • remain current with emerging trends in the critical care field
  • develop a professional network to support ongoing professional development and access to resources in critical care nursing*
  • articulate the benefits of professional associations/bodies in critical care nursing* e.g., Canadian Association of Critical Care Nurses (CACCN), Critical Care Services Ontario (CCSO), Canadian Nurses Association (CNA) – Critical Care Certification and Advanced Critical Life Support (ACLS) certification

Glossary

Critical Care Nurse(s) – The critical care nurse works collaboratively within the inter-professional team and is responsible for coordinating patient care to meet patient and family needs. The critical care nurse is an advocate for the patient, family and inter-professional health care team in ethically, emotionally and morally challenging situations. The critical care nurse possesses and uses critical thinking skills to identify and respond to rapidly changing patient, family and environmental situations. The critical care nurse maintains professional competence through ongoing education, research and skill development. (Adapted from the Canadian Association of Critical Care Nurses, 2010. Standards for Critical Care Nursing Practice, 4th ed., and the Canadian Nurses Association, 2010. Critical Care Nursing Certification.)

Critical Care Nursing – Critical care nursing is a specialty which exists to care for patients who are experiencing potential or actual life-threatening health crises and end-of-life situations within a patient/family centred model of care. Nursing the critically ill patient is continuous, intensive and may be aided by technology. Critical care nursing requires advanced problem-solving abilities and specialized knowledge to assess, plan, intervene and evaluate care in potential or actual life-threatening health crises and end-of-life situations. (Adapted from the Canadian Association of Critical Care Nurses, 2010. Standards for Critical Care Nursing Practice, 4th edition.)

Critical Inquiry – Expands on the meaning of critical thinking to encompass critical reflection on actions. Critical inquiry means a process of purposive thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs and actions in the context of nursing practice. The critical inquiry process is associated with a spirit of inquiry, discernment, logical reasoning and application of standards (College of Nurses of Ontario, 2014. Competencies for entry-level Registered Nurse practice).

Inter-professional health care team – A range of health care professionals who provide health services to patients, working collaboratively to plan and deliver comprehensive, quality care in partnership with the patient, family and/or substitute decision maker within the critical care setting.

Patient and family-centred care – An approach to the planning, delivery and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients and families. It redefines the relationships in health care by placing an emphasis on collaborating with people of all ages, at all levels of care and in all health care settings. In patient and family-centered care, patients and families define their “family” and determine how they will participate in care and decision making. A key goal is to promote the health and well-being of individuals and families and to maintain their control (Institute for Family-Centred Care, 2017).

Substitute decision maker (SDM) – Individuals who are sometimes required to assist with decision making for a patient/client in hospital who is considered incapable to make care or treatment decisions. The Health Care Consent Act contains a guide for identifying who the legally authorized SDM is, based on hierarchy of people. The highest-ranking person on the hierarchy who is willing and able to make decisions regarding health care for the patient/client becomes the SDM (Health Care Consent Act, 1996).

Acknowledgements

The ministry acknowledges with thanks the significant contribution of the many individuals and organizations who participated in the development of this program standard. In particular, the ministry would like to acknowledge the important roles of:

  • all individuals and organizations who participated in the consultations
  • the faculty, coordinators and deans of the Registered Nurse Critical Care Nursing (Ontario College Graduate Certificate) programs for their assistance throughout the project
  • the project officer who led the development of the vocational standard, Christine Foster

ISBN 978-1-4868-0592-1