In the growing sea of nursing specialties, critical care is actually one of the oldest. It was established in the 1950s and 1960s as the specialized care provided for the first intensive and cardiac care units. Seriously ill patients with complex health issues needed qualified nurses with unique skill sets. The same remains true today.
Critically ill patients who were once mostly cared for in ICUs can now be found throughout health care facilities, in emergency departments, post-anesthesia recovery units, interventional radiology, cardiac catheter labs, pediatric and neonatal intensive care units, burn units, progressive care units such as step-down and telemetry units, and even inpatient general care areas.
"The needs of the patients and their families determine whether they require a critical care nurse. It's not based on the name of the unit or its location," says Reynaldo Rivera, D.N.P., R.N., C.C.R.N., N.E.A.-B.C., A.N.P. Among his responsibilities as Director of Nursing in Medicine Services at New York-Presbyterian Hospital/Weill Cornell Medical Center in New York, Rivera works with recent nursing graduates as they transition into their first professional role. "People are admitted into the hospital with more serious conditions and complex co-morbidities than patients in the past. The role of the critical care nurse continues to adapt to meet the challenges of a changing health care system," he says.
More than half a million acute and critical care nurses comprise this specialty, which continues to grow. These nurses also teach, research, manage departments, and lead in the quest to create a health care system that is driven by the needs of patients and families.
A career in critical care has taken Cuban-born and U.S.-educated Maria Shirey, Ph.D., M.B.A., R.N., N.E.A.-B.C., F.A.C.H.E., from an internship program for new nurses at the Baptist Hospital of Miami to educator, manager, and executive positions in Florida, Texas, Louisiana, and Indiana. She is now an associate professor in the Doctor of Nursing Practice program at the University of Southern Indiana's College of Nursing and Health Professions in Evansville. "I have been a nurse for 33 years, and the skills gained at the bedside have been useful at every stage of my career," she says. "Critical care nurses must make quick decisions constantly, and those decisions need to be based on evidence and data. You have someone's life in your hands, and that's not a responsibility to be taken lightly."
Nurses may enter critical care immediately after licensure, or they transition into the specialty after gaining experience in other areas. Patients depend on these highly knowledgeable and skilled nurses to make accurate assessments, prioritize needs, and recognize the difference between an exception and a problem.
Linda Martinez, M.S.N., R.N., A.C.N.S.-B.C.-C.M.C., says critical care nurses begin with the basics, but soon realize textbook cases exist only in the classroom. A critical care nurse for 31 years, she works as a clinical nurse specialist for Presbyterian Heart Group at Presbyterian Hospital in Albuquerque, New Mexico. "First you learn the basics. Then, you learn the exceptions. As nurses gain experience, they start to individualize normal by putting into context what's going on with each patient," she says. "Assessment skills have to be very sharp in critical care. You have to be able to quickly assess a patient's situation in case there's a life-threatening change. You put everything you've learned into context."
Rivera serves as president of the Philippine Nurses Association of America, where he advocates for diversity in the workforce, ethical recruitment practices, and professional development and standards. "Nurses in high acuity and critical care must have the competencies and requisite skills to do the job with an underlying sense of compassion and sensitivity. It's the combination of all these attributes that inspire patients and their families to trust us," Rivera says. "We practice as whole persons, using our hearts, the mind, and the hands. It's also the soul of who we are."
Shirey and Martinez have also become national leaders in nursing and critical care. Martinez serves on the national board of the American Association of Critical-Care Nurses (AACN), the world's largest specialty nursing organization, representing the interests of more than 500,000 nurses who care for acutely and critically ill patients. Shirey chairs the AACN Certification Corporation, the association's credentialing arm that certifies bedside and advanced practice nurses in high acuity and critical care. It also certifies nurse managers in a joint program with the American Organization of Nurse Executives.
Shirey cites complex patient conditions, the fast pace, and pressure-packed environment as reasons why critical care nurses must commit to continuing professional development. "Things happen so quickly that you don't have time to always research before acting. I either need to know it or know where to turn for help," she says.
Shirey says she first joined AACN because of her desire to take better care of patients and their families. "I started studying the AACN core curriculum to hone my skills. I then joined AACN so I could receive the journals and earn my CCRN certification. All so I could be the best nurse for my patients."
Armenian-born Anna Dermenchyan, B.S.N., B.S., R.N., C.C.R.N., agrees. She's a clinical nurse in the cardiothoracic ICU at the Ronald Reagan UCLA Medical Center and an adjunct instructor at Mount St. Mary's College, both in Los Angeles. "If we're not learning, we're not moving forward. Outdated skills affect patient care, especially with new medications and technology, changing policies, and procedures," she says. "We have to be the best for our patients. We learn the most from them. Each case presents lessons for the next case."
Ryan Cavada, R.N., a staff nurse at the UCLA Medical Center Santa Monica campus, says nurses in critical care need strong critical-thinking skills, the ability to work under pressure in a fast-paced environment, and a continual desire to learn. "Critical care is at the forefront of evidence-based nursing practice where we apply new medical research, adapt ever-changing procedures, and use the latest technology. Our patients can't afford care that doesn't meet this benchmark standard," he says.
Patient advocacy is a vital responsibility of critical care nurses, as acutely and critically ill patients often can't express how they feel or what they need. "As a nurse, I am the main representative for my patients and their families," Dermenchyan says. "Many times, patients can't communicate for themselves, describe symptoms, or tell me something is wrong. I need to be on the lookout on their behalf and communicate their needs to the ICU team."
Martinez adds, "Critical care nurses must hone their communication skills, because a lack of understanding or miscommunication can have life or death implications." She recalls the night she realized the importance of good communication. "I was speaking with the intern on call about a patient in pain and it hit me that I am the voice of this patient. My role as a patient advocate became crystal clear. If I couldn't communicate what was needed, that patient would suffer through the night."
Critical care nurses collaborate with other nurses and health professionals with a single focus on caring for the patient. Filipino-American nurse Cavada points to critical care's unique intimacy. "We really get to know our patients," he said. "Nurses are more than an active part of a team. We become the team's hub. Doctors, nutritionists, respiratory therapists, everyone involved in a patient's care come to us for the most current information." He says competent critical care nurses are concerned about their own patients and stand ready to assist their colleagues. "Good teamwork allows more to be done for the patient in less time. In critical care, that can make a big difference; time is of the essence."
"When we get patients who are extremely sick, we all have to work together. It's our patient, not my patient. We all want good outcomes," Dermenchyan says. "Collaboration is key, or patients suffer." Critical care nursing demands a healthy work environment and true collaboration, in which each professional's knowledge and abilities are respected.
Collaboration in critical care also goes beyond health care professionals. "Family members are an important element to caring for the patient," Shirey says. "Critical care nurses learn to integrate them into the care, keep them informed, and we know how to be sensitive to changes in the patient's condition that might cause turmoil in the family."
The willingness to work collaboratively toward a common goal has benefits beyond the bedside.
Nurses learn early on how to work well in teams," Martinez says. "And teams are vital to improving the system of health care, not just in the delivery of care."