Intensive and Critical Care Nursing
Volume 23, Issue 4 , Pages 183-186, August 2007

Master's level critical care nursing education: A time for review and debate

Department of Intensive Care Medicine, Middlemore Hospital, Private Bag 93311, Otahuhu, Auckland, New Zealand

Article Outline

 

Critical care nursing knowledge and skills have been identified as important factors in achieving improved patient outcomes (Thorens et al., 1995). Since the development of critical care in New Zealand in the early 1960s great advancements in nursing education have occurred. In those early years, when no formal education was available, doctors and nurses worked together learning from each other (Cribb, 1992). In 1970, as the need for more formal nursing knowledge increased, the first formal critical care programme began, and by the 1980s these programmes were firmly established around the country. Most of these programmes were hospital-based, consisting of the theoretical content provided by critical care medical and nursing staff, and clinical experience and assessment being completed within the critical care unit (Cribb, 1992). The early 1990s saw critical care nursing education move into the tertiary education sector as graduate certificate programmes, providing access to critical care nursing education for nurses who did not have programmes offered in their own units. These post registration education programmes became accepted as effective methods in providing the required specialty knowledge and skills (Hardcastle, 2006). Over recent years, most critical care nursing programmes have moved to master's level. This move has been influenced by the migration of all pre-registration nursing education to undergraduate degree level. As registered nurses are now entering practice with a bachelor's degree, many nurses and educators have the view that further education following registration should be aimed at master's level (Hardcastle, 2006). The popularity of master's level programmes is further compounded by New Zealand's government funding policies currently supporting master's level programmes for registered nurses. Hence, nurses willingly enter master's level programmes as they currently create less personal financial burden.

It has long been accepted that master's level clinical nursing education programmes reflect the established standards of the nursing specialty (ANA, 1980, as cited by Dunn, 1996). This requires firstly, the critical care profession to have educational standards and guidelines that reflect both clinical and academic requirements (Roberts et al., 1986, Russel, 2001) and secondly, a collaborative relationship between both the academic and clinical providers (CCNS, 2000, CCNS, 2007a, Endacott and Dawson, 1997, Howard and Steinberg, 2002, Prowse, 2003, Prowse and Lyne, 2000, Pugh, 2002).

To ensure appropriate critical care specialty practice content continued with this move of specialty education to the tertiary education sector, the Critical Care Nurses’ Section (CCNS), formerly known as the Intensive Therapy Section, developed and has since revised standards for critical care nursing education (Pirret, 1994, CCNS, 2000, CCNS, 2007a). These standards outline required academic and clinical collaborative processes, recommended programme content, and assessment guidelines. These standards are now accepted by New Zealand critical care nurses as the minimum standards for critical care nursing education (Intensive Care Advisory Group, 2005). Hence, clear professional guidelines are available to curriculum planners of critical care nursing programmes to ensure appropriate specialty knowledge and competency assessment is included.

However, although some critical care units are reporting good clinical outcomes from master's level critical care programmes, there are others that are not (CCNS, 2007b). Recent years have seen the emergence of an increasing number of anecdotal reports related to poor clinical outcomes from some master's level critical care nursing programmes. These anecdotes include: critical care specialty content as outlined in the New Zealand Standards of Critical Care Nursing Education (2000) not being adequately covered; no requirements for nurses to work in critical care clinical practice; inadequate assessment of clinical competence by appropriately qualified critical care clinicians; and nurses’ completing the programmes without being able to demonstrate the expected clinical competencies (CCNS, 2007b). Anecdotal evidence also highlights the increased difficulty critical care unit's have in meeting the standards requiring 50% of critical care staff to be intensive care trained (CCNS, 2002, JFICM, 2003), due to the cost, and time required to complete a master's level programme (CCNS, 2007b).

An advanced level of knowledge of pathophysiolgy is required to enable accurate assessment of the critically ill patient and effective implementation and evaluation of both medical and nursing care (Dunn, 1996). Although not solely focussing on New Zealand trained critical care nurses, recent New Zealand research identifies critical care trained nurses articulate a low to medium level of respiratory physiology when providing rationale for their clinical decision-making (Pirret, 2007) suggesting nurses do not have an advanced level of respiratory physiology. This research also identified that 22% of nurses perceived that some of the concepts of respiratory physiology were inadequately covered in their critical care education programme.

Guided experience within clinical practice is designed to provide the student with specialist competence and is an integral component of any master's level critical care programme (Dunn, 1996). Therefore, ensuring nurses have the required clinical experience within the practice environment is essential. The emergence of nurses being able to complete critical care master's level programmes with no or minimal clinical practice requirements is a concern, and is not unique to New Zealand. In an Australian study of critical care nursing education, Aitken et al. (2006) found some programmes had no minium requirements for clinical practice.

Assessment of clinical competency by appropriately qualified clinicians is clearly outlined in critical care education standards (CCNS, 2000, CCNS, 2007a, WFCCN, 2005) and seems such an obvious requirement for any critical care programme, yet some universities are failing to meet this requirement. Aitken et al. (2006) identified that only 60% of programmes in Australia used personnel with a combined clinical and education role to assess competency of the nurses completing master's level critical care nursing programmes. Having both no minimal clinical practice requirements and inadequate assessment of clinical competency suggests that a master's level academic qualification in critical care nursing can be awarded to nurses with very limited relevant clinical critical care experience (Aitken et al., 2006).

Hardcastle (2006), in challenging the view that master's level critical care nursing education meets the needs of all New Zealand critical care nurses, suggests many master's level programmes assume students have already learned and mastered the application of specialist knowledge to practice. This view is supported by Aitken et al. (2006) who found little consistency in specialty content covered in critical care nursing programmes, with graduate certificate courses concentrating more on critical care specialty content, and master's level courses concentrating on generic nursing issues. Hence, in our desire to achieve professional advancement of critical care nursing through master's level education, we now have to question firstly, whether master's level education is consistently able to provide nurses with the required specialist theoretical knowledge and clinical competencies that meet the needs of the critical care clinical areas, and secondly, have we “thrown the baby out with the bath water.”

Historically, the aim of master's level education was to provide critical care nurses with theoretical knowledge and supervised clinical practice in their specialty area (Roberts et al., 1986). The minimal aim of all critical specialty practice programmes, whether it be at graduate certificate or master's level, is to develop good bedside nurses, who are able to provide a high standard of nursing care to critically ill patients (CCNS, 2000, Roberts et al., 1986, WFCCN, 2005). Without specialty specific content and supervised clinical practice, masters prepared nurses will not have the foundations to enable development of advanced nursing practice knowledge and skills within the critical care specialty area, and therefore will not develop to be effective leaders of critical care clinical practice.

So as a profession, we need to ask why are we having such problems with some master's level critical care programme’ outcomes? One of the reasons is no doubt the increasing financial pressures on both the academic and clinical providers. Since the development of master's level specialty education there have been ongoing problems associated with inadequate funding for the provision of clinical teachers (Dunn, 1996). These fiscal pressures, on both the academic and clinical providers are increasing, with academic providers increasingly reluctant to finance the cost of clinician involvement in programmes, and clinical providers increasingly reluctant to provide a service for free.

Another reason for poor master's level critical care programme outcomes are the ongoing alterations made to tertiary programmes. Tertiary programmes are known to change from year to year, and as a consequence programme content is also likely to change (Aitken et al., 2006). Hence, there needs to be an ongoing monitoring process by the critical care professions to ensure that programmes continue to meet the established critical care standards. This requires critical care professional bodies to be politically active, ensuring an effective critical care nursing voice is heard at government regulatory level. This is not easy task, as like New Zealand, most professional critical care national bodies are made up of nurses who although are elected, fulfil this role in a voluntary capacity. These nurses are often very senior nurses, who along with performing their national CCNS responsibilities, have their own employment, educational and personal commitments. Hence, creating a political voice has the potential to create an immense burden on an already professionally stretched group.

A further factor that could be influencing this ongoing problem of poor master's level programme outcomes is the tendency for hospitals to have an affiliation with one single tertiary provider. This significantly limits the nurse to choose a programme based on reputable programme outcomes. Many nurses beginning their specialty critical care education, are unfamiliar with specialty requirements, and hence may not make an informed choice that ensures they enrol in a critical care programme that best meets their needs. So do the critical care nursing professional bodies have a responsibility to identify and support education programmes that meet our established standards?

The New Zealand CCNS has recently updated the education standards (CCNS, 2007a). However, unless measures are taken to ensure these established standards are met, the review of these standards becomes only a paper exercise with no benefits to critical care nurses and the patients they care for. To ensure our education standards are utilised and adhered to, the New Zealand national CCNS has established an educational working party to firstly, identify the depth of the problem related to master's level critical care education, and secondly recommend strategies to resolve this problem (CCNS, 2007b). However, as discussed, the problems associated with poor outcomes from some master's level critical care nursing programmes, are not unique to New Zealand. Hence, sharing of educational problems and successes is essential if we want to adequately prepare critical care nurses for the future. As an international critical care nursing profession, it is now time to revisit and internationally debate how we ensure appropriate clinical outcomes from education programmes. If we wish to continue to pursue master's level critical care education, how do we ensure critical care education and clinical experts are actively and consistently involved in critical care programme curriculum planning and competency assessment, and are financially reimbursed for this involvement? It is only by debating these issues, will we be best able to identify successful learning models to provide our future critical care nurses with the necessary knowledge and skills to care for our critical care patient population.

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PII: S0964-3397(07)00052-3

doi:10.1016/j.iccn.2007.05.001

Intensive and Critical Care Nursing
Volume 23, Issue 4 , Pages 183-186, August 2007

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