Intensive and Critical Care Nursing (2008) 24, 78—89

ORIGINAL ARTICLE

Competence in intensive and critical carenursing: A literature review

Riitta-Liisa Aari a,∗, Suominen Tarjaa,b,1, Leino-Kilpi Helenaa,2

a University of Turku, Department of Nursing Science, 20014 Turku, Finlandb University of Kuopio, Department of Nursing Science, Box 1627, 70211 Kuopio, Finland

Accepted 28 November 2007

KEYWORDSCompetence;Critical care;Intensive care

Summary This literature review defines and describes the concept of competencein adult intensive care nursing, with special reference to clinical and profes-sional competence. The aim was to see whether and how the studies revieweddefined or described the concept of competence, and which domains of compe-tence have been investigated in intensive and critical care nursing research. Thereview focuses on empirical studies retrieved from the COCHRANE and MEDLINE(1994—2005) databases. The final analysis comprised 45 studies. The studies wereanalysed by inductive content analysis. Very few (n = 7) of the studies offered anydefinitions or descriptions of the concept of competence. Clinical and professionalcompetence in intensive and critical care nursing can be defined as a specific knowl-edge base, skill base, attitude and value base and experience base of intensive andcritical care nursing. Clinical competence can be divided into three and professional

competence into four constituent domains. In clinical competence, these are theprinciples of nursing care; clinical guidelines; and nursing interventions. In profes-sional competence, the domains are ethical activity; decision-making; developmentwork; and collaboration. More empirical research is needed to examine competencein intensive and critical care nursing.

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© 2007 Elsevier Ltd. Al

∗ Corresponding author. Tel.: +358 5036 52885;fax: +358 2333 8400.

E-mail addresses: riitta-liisa.aari@utu.fi (R.-L. Aari),tsuomine@messi.uku.fi (S. Tarja), helena.leino-kilpi@utu.fi(L.-K. Helena).

1 Tel.: +358 1716 2240.2 Tel.: +358 2333 8404; fax: +358 2333 8400.

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0964-3397/$ — see front matter © 2007 Elsevier Ltd. All rights reservdoi:10.1016/j.iccn.2007.11.006

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. Introduction

ntensive care nursing requires a high level of qual-fications and competencies (e.g. Hind et al., 1999;eino-Kilpi et al., 1998). Therefore, there has beenneed to examine and describe competence guide-

ines (Schribante et al., 1996), standards (Dunn etl., 2000) and frameworks of critical care nursingBench et al., 2003; Jones, 2002). Furthermore,ntensive care nurses have expressed their concerns

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ver the lack of knowledge and skills of graduatingurse students, saying that they are not necessar-ly equipped to work in intensive care units (ICUs)e.g. Aari et al., 2004). Further, there is a grow-ng need for systematic competence research andompetence assessment instruments in intensivend critical care nursing. It is important at theresent moment to develop basic, continuing edu-ation and internship programmes for the needs ofntensive care nurses. There is also a shortage ofualified intensive care nurses. This review makesn effort to cover the existing literature of clini-al and professional competence in intensive andritical care nursing. In addition, it illustrates theeed for knowledge of competence in intensive andritical care nursing.

Defining and measuring competence in nursing isifficult (McCready, 2006). In the literature, compe-ence in general has been defined as ‘‘the ability toerform the task with desirable outcomes under thearied circumstances of the real world’’ (Benner,982 p. 304), and as ‘‘the overlap of knowledgeith the performance components of psychomo-

or skills and clinical problem solving within theealm of affective responses’’ (Dunn et al., 2000 p.40). Competence has also been defined as the skillnd ability to practise safely and effectively with-ut the need for direct supervision (UKCC, 1999),nd as a level of performance demonstrating anffective application of knowledge, skill and judge-ent (ICN, 2003). Competence reflects knowledge,

nderstanding and judgement, a range of skills andrange of personal attitudes and attributes (ICN,

003).In the Medline-database the concept of compe-

ence is divided into the MeSH (Medical Subjecteadings), terms ‘‘clinical competence’’ and

‘professional competence’’. MeSH terms provideconsistent way to retrieve information that

ay use different terminology for the same con-epts (PubMed Services MeSH database, 2007). Itas assumed, for literature review, that compe-

ence can be divided into clinical and professionalompetence and the concept of competence wille examined according this assumption. The twoatabases consulted for this review (Medline, 2007;he Cochrane Library, 2007) define clinical compe-ence as the capability of a nurse to acceptablyerform duties directly related to patient care. Pro-essional competence is defined as the capabilityf a nurse to acceptably perform duties related tohe profession in general. This review uses these

efinitions of clinical and professional competence.

The purpose of this article is to define andescribe competence, via an examination of clini-al and professional competence, in adult intensive

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are nursing in the light of previous empiricalesearch. This work will provide information forntensive care nurses, education professionals,dministrators and researchers who are interestedn improving the quality of care for intensive careatients. For example, European nursing educationystems are different from one another. Follow-ng registration, many European countries reportimited opportunities for continuing education andpecifically for postgraduate studies in intensiveare nursing (Tuning Educational Structures inurope, 2007). This present literature review maye useful in bringing new perspectives to researchn competence in intensive care nursing.

We set out to address the following researchuestions: (1) Do the studies reviewed define orescribe the concept of competence? (2) How dohe studies reviewed define or describe the conceptf competence? (3) Which domains of clinical androfessional competence have been investigated inntensive and critical care nursing research?

. Materials and methods

.1. Search and selection strategies

his literature review is based on a systematicearch carried out on two databases: COCHRANEnd MEDLINE (1994—2005). The search was con-ned to the past decade because during that periode have seen many reforms in nursing education

n Europe and much debate on questions of nurs-ng competence. The search pathway in COCHRANEas professional competence or clinical compe-

ence and intensive or critical care and nursing.he search was carried out using both MeSH termsnd title words. In MEDLINE, the pathway was pro-essional competence or clinical competence andntensive care or critical care and nursing. The lim-tations in MEDLINE were English language, focus ondults (19 years plus) and abstracts available.

In the first phase, the search yielded 5 clini-al trial abstracts in COCHRANE and 104 abstractsn MEDLINE. In the second phase, three abstractsrom COCHRANE were excluded: they were con-erned with intensive care in crisis situations, orot concerned with intensive care nursing at all. InEDLINE all studies concerning adult intensive careursing were included, while those dealing withducation methods, nursing students, neonatal oraediatric intensive care, and abstracts of reviews

r guidelines were excluded. We were thus left with4 relevant abstracts from MEDLINE. Two abstractsere double hits from these two databases. Thenal analysis included 45 abstracts, based on the

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following criteria: (1) empirical research and (2)focus on adult intensive or critical care nursing. Inthe third phase, the full texts (n = 45) were anal-ysed.

2.2. Studies included

Most (n = 36) of the studies had been carried outbetween 2000—2005; only nine (n = 9) dated from

1994 to 1999. Most of the studies were from theUnited States (n = 15), Australia (n = 8) and Sweden(n = 5). With respect to methodology, the sam-ple consisted primarily of surveys or questionnaire

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Table 1 Studies (n = 45) included in literature review

Reference Theme

O’Sullivan et al.(2000)

Equality and justness

Gramling (2004) Individuality and intimacy

Yeh et al. (2004a,b) Autonomy and safety

Watts et al. (2005) Continuity

Slomka et al. (2000) Adherence to practical guidelines

Crego and Lipp(1998)

Awareness of clinical guidelines

Egerod (2002) Awareness of clinical guidelinesLehwaldt and

Timmins (2005)Awareness of clinical guidelines

Peden-McAlpine(2000)

Recognition of abnormal situations

Reischman andYarandi (2002)

Recognition of abnormal situations

Santiano et al.(1994)

Biological—physiological functionof humans

McGhee and Woods(2001)

Patient monitoring

Giuliano andKleinpell (2005)

Patient monitoring

Wood (1998) Basic care

Day et al. (2001) Basic care

R.-L. Aari et al.

tudies (n = 25); in addition, it included quasi-xperimental studies (n = 3); applications of therounded theory method (n = 3); the focus groupethod (n = 3); phenomenography (n = 2); reviews

f medical records (n = 2); interviews (n = 2); semi-tructured interviews (n = 2); observation studiesn = 2); a focused interview (n = 1); an ethnographictudy (n = 1); a case study (n = 1); an application ofermeneutics (n = 1); a narrative inquiry (n = 1); and

written simulation (n = 1). The sample sizes and

esponse rates in the questionnaire studies rangedrom 5 (quasi-experimental study) to 906 and from7 to 93% (Table 1).

Method, previously tested instrument (if used),sample, response rate (if reported)

Questionnaire, Nurses Attitudes About AIDS Scale(NAAS) developed by Preston et al. (1995), n = 957(n = 61 critical care nurses, CCNs), 53%Narrative inquiry, n = 10 (intensive care unit, ICU,patients)Quasi-experimental study, questionnaires Knowledgeof Restraints Scale (KRS) based on the previous workby Houston and Lach (1990) and Janelli et al. (1992),Perception of Restraints Use Questionnaire (PRUQ)developed by Strumpf and Evans (1988), AttitudeToward Restraints Use Questionnaire (ATRUQ) andClinical Practice of Restraints Use Questionnaire(CPRUQ) based on work by Janelli et al. (1992), n = 37(novice nurses, NNs), 93%Questionnaire, n = 218 (CCNs), 43%, semi-structuredinterviews, n = 13 (CCNs)Survey, interview, review of medical records, n = 18(nurses)Questionnaire, n = 339 (registered nurses, RNs), 38%

Case study, n = 14 (cases)Survey, questionnaire, n = 189 (nurses), 88%

Hermeneutic, multiple interviews, narrativeaccounts of critical incidents were audio taped andtranscribed, n = 15 (expert CCNs)Five CCCV (critical care cardiovascular) writtensimulations served as instruments, n = 23 expertnurses, ENs and n = 23 NNsQuestionnaire, Basic Knowledge Assessment Tool(BKAT) developed by Toth and Ritchey (1984), n = 35(RNs), 78%Questionnaire, n = 68 (CCNs), 17%

Survey, n = 517 (nurses)

Quasi-experiment study, nine patients (n = 9)assessed (intervention) before ETS (endotrachealsuction) and five patients (n = 5) having routine ETSQuasi-experimental study, n = 16 (intensive carenurses, ICNs)

Competence in intensive and critical care nursing 81

Table 1 (Continued )

Reference Theme Method, previously tested instrument (if used),sample, response rate (if reported)

Jones et al. (2004),UK

Basic care Questionnaire, n = 103 (ICNs), 65%

Yeh et al. (2004a,b) Basic care A questionnaire, n = 265 incidents of UEE (unplannedendotracheal extubation)

Potinkara andPaunonen (1996)

Care of significant others Focused interviews, n = 14 (significant others)

Fox and Jeffrey(1997)

Care of significant others Survey, was based on one developed by Hickey andLewandowski (1988), n = 47 (nurses), 54%

Hughes et al. (2005) Care of significant others Grounded theory, 8 relatives and 5 staffJohansson et al.,

2005Care of significant others Grounded theory, n = 29 (adult relatives of adult ICU

patients)Takman and

Severinsson (2005)Care of significant others Survey, Critical Care Family Needs Inventory

developed by Molter (1979), n = 243 (RNs), 74%Albert et al. (2002) Patient education Survey, n = 300 (nurses)Washburn et al.

(2005)Patient education Survey, Nurses’ Knowledge of Heart Failure

Education Principles developed by Albert et al.(2002), n = 51, n = 14 (nurses working in ICU)

Sjostrom et al.(1999)

Pain management Phenomenography interview and indicatingestimated pain intensity on a visual analogue scale(VAS 0-10 cm), n = 10 (CCNs)

Sjostrom et al.(2000)

Pain management A phenomenographic approach, tape-recordedinterview data, n = 30 (CCNs)

Erkes et al. (2001) Pain management Quasi-experimental study, questionnaire Nurses’Knowledge and Attitude Survey Regarding Paindeveloped by Ferrell and McCaffery (1998), n = 30(ICNs)

O’Brien et al. (2001) Patient comfort Questionnaire, Spielberger State Anxiety Index (SAI)developed by Spielberger et al. (1983), review ofmedical records, n = 101 (patients)

Puntillo et al. (2001) End-of-life care A questionnaire, developed and pretested by Puntilloet al. (2001), n = 906 (CCNs), 30%

Moss et al. (2005) End-of-life care Questionnaire, n = 473 (nurses), 66%Bunch (2001) Ethical sensitiveness Grounded theory, critical care unit observation one

yearHoll (1994) Factors that influence

decision-makingQuestionnaire based on modified items from Corwin’sinstrument (1960), n = 133 (RNs), varied by area from20 to 80%

Bucknall andThomas (1997)

Factors that influencedecision-making

Questionnaire, n = 230 (CCNs), 59%

Bucknall (2000) Factors that influencedecision-making

Observation, n = 18 (CCNs)

Manias and Street(2001)

Factors that influencedecision-making

Critical ethnography, n = 6 (nurses)

Bucknall (2003) Factors that influencedecision-making

Naturalistic observations and semi-structuredinterviews, n = 18 (CCNs)

Hicks et al. (2003) Critical thinking Questionnaires: Decision Analytic QuestionnaireDAQ; based on the work by Hughes and Young (1990),California Critical Thinking Disposition Inventory(CCTDI) Developed by Facione et al. (1994) andCalifornia Critical Thinking Skills Test (CCTST)developed by Facione (1992), n = 54 (CCNs), 47%

Bucknall et al.(2001)

Evidence-based practice Questionnaire, n = 274 (CCNs), 43%

Schribante et al.(1996)

Self-development Focus group, n = 7 (nurses)

82 R.-L. Aari et al.

Table 1 (Continued )

Reference Theme Method, previously tested instrument (if used),sample, response rate (if reported)

Suominen et al.(2001)

Self-development Questionnaire, Empowerment Questionnairedeveloped by Irvine et al. (1999), n = 814 (RNs), 77%

Jamieson et al.(2002)

Self-development Focus group, n = 26 (CCNs)

Kuokkanen et al.(2002)

Self-development Questionnaires, Qualities of Empowered Nurse Scale(QEN-S) and Performance of an Empowered NurseScale (PEN-S) developed by Kuokkanen et al. (2002),n = 121 (CCNs), 61%

Lindahl and Norberg(2002)

Self-development Tape recording of one clinical group supervisionsession for RNs and another one for ENs (enrollednurses), interviews with two RNs and two ENs,supervisor was interviewed, n = 10, 5 EN and 5 RN

Meretoja et al.(2004)

Self-development Questionnaire, Nurse Competence Scale developedand pretested by Meretoja et al. (2004), n = 513(n = 93 nurses from ICUs), 87%

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2.3. Analysis of studies

The first step was to see whether the studiesoffered any direct, explicit definitions or descrip-tions of competence. Secondly, the articles wereclassified as clinical studies if they were directlyrelated to patient care and as professional studiesif they were concerned with nurses’ professionalduties in general. Thirdly, the main domains ofclinical and professional competence were identi-fied using the method of inductive content analysis(Burns and Grove, 2001; Cavanagh, 1997). The unitof content analysis was a word, a number of wordsor a sentence. Fourthly, the subdomains of clini-cal and professional competence were separatelydescribed and analysed. Fifthly, the subdomainswere divided into several themes. Finally, the stud-ies and the subdomains and themes were revisitedwith a view to determining whether the study fittedinto a specific subdomain or theme (Fig. 1).

3. Results

3.1. Definition or description ofcompetence in the studies reviewed

Competence was rarely defined or described inempirical studies. Definitions or descriptions ofcompetence were offered in 16% (n = 7) of the

studies. Four main themes were identified inthe concept of competence: ‘‘competence ingeneral’’, ‘‘professional competence’’, ‘‘clinicalcompetence’’ and ‘‘expertise’’.

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Focus groups, four nursing groups (n = 27), tworesident groups (n = 6), one intensivist group (n = 4)

Competence in general, firstly, has been defineds functional adequacy and the capacity to inte-rate knowledge and skills into attitudes andalues in specific contextual situations of practiceMeretoja et al., 2004). Another general defini-ion described competence in critical care nursingn terms of a continuum from the novice throughdvanced beginner to competent, proficient andxpert level (cf. Benner, 1982). The conceptualramework of competence in general included pro-essional and cognitive competence, interpersonalkills and patterns of interaction. Critical careurses develop themselves within these categorieshen they practise in critical care (Schribante etl., 1996).

Professional competence has been defined,rstly, as the nurse’s attitude towards their jobs well as their skills and knowledge (Potinkarand Paunonen, 1996). Secondly, professional com-etence in critical care nursing has been defineds the calm surface under which a hidden drama isnfolding, fraught with difficult clinical and ethicalroblems. The actors (nurses and doctors) involvedn this drama face a range of difficult ethical issuesurrounding end-of-life questions, including deci-ions based on ambiguous clinical data in patientshose clinical course is erratic (Bunch, 2001). In

he context of post-operative pain assessment, clin-cal competence in intensive care nursing has beenescribed in three categories: ‘‘to be able to see’’,

‘to be able to differentiate’’ and ‘‘to be able toive’’ (Sjostrom et al., 2000).

Competence has also been defined in terms ofxpertise, as the ability to draw rapid and accurate

Competence in intensive and critical care nursing 83

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onclusions concerning the state of the patientReischman and Yarandi, 2002). Expertise is associ-ted with the esteem shown for the nurse’s job. Itanifests itself in competence and in a wide range

f knowledge (Kuokkanen et al., 2002).

.2. Domains of clinical and professionalompetence in intensive and critical careursing research

e identified four main domains of clinical and pro-essional competence: ‘‘knowledge base’’, ‘‘skillase’’, ‘‘attitude and value base’’ and ‘‘experiencease’’ of intensive and critical care nursing (Fig. 1).hus clinical and professional competence is a spe-ific knowledge base, skill base, attitude and valuease and experience base of intensive and criticalare nursing.

The clinical competence studies reviewedn = 30) could be divided into three clinical compe-ence subdomains and the professional competencetudies (n = 15) into four professional compe-ence subdomains. Furthermore, the subdomainsould be divided into several themes. The clin-cal competence subdomains were ‘‘principlesf nursing care’’; ‘‘clinical guidelines’’ and‘nursing interventions’’. The professional com-etence subdomains, then, are ‘‘ethical activ-

ty’’; ‘‘decision-making’’; ‘‘development work’’;nd ‘‘collaboration’’ (Fig. 1). Subdomains andhemes constitute the content of knowledgease, skill base, attitude and value base and

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xperience base of intensive and critical careursing.

.3. Clinical competence

.3.1. Principles of nursing carehe implementation of the principles of nursingare is an integral part of clinical competencecf. e.g. Hendersson, 1961). Empirical studiesn = 4) identify seven themes within this subdo-ain: ‘‘equality’’ and ‘‘justness’’ (O’Sullivan et

l., 2000), ‘‘autonomy’’ and ‘‘safety’’ (Yeh etl., 2004a,b), ‘‘individuality’’ and ‘‘intimacy’’Gramling, 2004) and ‘‘continuity’’ (Watts et al.,005) (Fig. 1).

Every patient has the right to be treated andared for as equals. Patients with infectious dis-ases, such as AIDS (Acquired Immune Deficiencyyndrome) present a special challenge to upholdinghis principle. O’Sullivan et al. (2000) examined theelationship between critical care nurses’ attitudesowards AIDS and their willingness to provide careo AIDS patients. In intensive care nursing adher-nce to the principles of autonomy and safety maye particularly difficult due to the state of theatient, their restlessness and the inability to takeart in decision-making about their care. In relationo these principles, Yeh et al. (2004a,b) examined

he use of restraints in ICU.

Respecting the patient’s individuality and theirntimacy are principles of nursing care thatome under the domain of clinical competence.

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According to Gramling’s (2004) description of inten-sive care nursing from the patients’ point ofview, ‘‘intimacy’’ and ‘‘honouring the body’’ and‘‘knowing the other’’ are themes that representpatients’ experience of nursing in critical care. Pro-tecting and ensuring the continuity of nursing careis another principle of nursing care and part of anintensive care nurses’ clinical competence. In ICUsthe discharge of patients to another unit may bea critical point in their pathway that reflects thecontinuity of care. Watts et al. (2005) identifiedfactors that enhance or impede critical care nurses’discharge planning practices.

3.3.2. Clinical guidelinesThe implementation of clinical guidelines is partof clinical competence. The empirical studiesreviewed (n = 4) identified two themes in thesubdomain of implementing clinical guidelines:‘‘adherence to practical guidelines’’ (Egerod, 2002;Slomka et al., 2000) and ‘‘awareness of clinicalguidelines’’ (Crego and Lipp, 1998; Lehwaldt andTimmins, 2005) (Fig. 1).

Clinical guidelines help nurses to provideevidence-based nursing care. Slomka et al. (2000)and Egerod (2002) described nurses’ adherenceto practice guidelines regarding the sedation ofpatients receiving mechanical ventilation. Nurses’awareness of clinical guidelines related to intensivecare is also part of their clinical competence. Cregoand Lipp (1998) described nurses’ knowledge ofadvanced directives. Lehwaldt and Timmins (2005)studied ICU nurses’ knowledge regarding the careof patients with chest drains.

3.3.3. Nursing interventionsThe implementation of nursing interventions is partof nurses’ clinical competence in intensive and crit-ical care nursing. Based on the empirical studiesreviewed (n = 22) we can identify four themes inthis subdomain: ‘‘recognition of abnormal situa-tions’’ (Giuliano and Kleinpell, 2005; McGhee andWoods, 2001; Peden-McAlpine, 2000; Reischmanand Yarandi, 2002; Santiano et al., 1994), ‘‘basiccare’’ (Day et al., 2001; Jones et al., 2004; Wood,1998; Yeh et al., 2004a,b), ‘‘care of significant oth-ers’’ (Fox and Jeffrey, 1997; Hughes et al., 2005;Johansson et al., 2005; Takman and Severinsson,2005; Potinkara and Paunonen, 1996) and ‘‘specialissues of intensive care’’ (Albert et al., 2002; Erkeset al., 2001; Moss et al., 2005; O’Brien et al., 2001;Puntillo et al., 2001; Sjostrom et al., 1999, 2000;

Washburn et al., 2005) (Fig. 1).

The recognition of abnormal situations in inten-sive care nursing is part of nurses’ clinicalcompetence. Peden-McAlpine (2000) explored the

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R.-L. Aari et al.

nconscious activity of early recognition of patientroblems with a view to better understand-ng the thinking of expert critical care nurses.eischman and Yarandi (2002), for their part,xamined and compared novice and expert crit-cal care cardiovascular nurses’ diagnostic cuetilization. The recognition of abnormal situ-tions is according to the studies related tohe ‘‘biological—physiological function of humans’’Santiano et al., 1994) and ‘‘patient monitoring’’Giuliano and Kleinpell, 2005; McGhee and Woods,001). Understanding the biological—physiologicalunction of humans and patient monitoring are partf the intensive care nurse’s clinical competence.antiano et al. (1994) evaluated the existing basiciological—physiological knowledge of RNs workingn ICUs, while McGhee and Woods (2001) describedritical care nurses’ knowledge related to directonitoring of arterial blood pressure. Giuliano andleinpell (2005), for their part, assessed nurses’ andhysicians’ perceptions and practices with regardo their use of common continuous monitoringarameters in the care of patients with sepsis.

The implementation of basic care is part of clin-cal competence in intensive care nursing. Jonest al. (2004) described ICU patients’ oral care anday et al. (2001) and Wood (1998) examined andescribed endotracheal suctioning. Planning andntegrating basic care interventions into the caref ICU patients is part of clinical competence. Yeht al. (2004a,b) described the roles of nursing caren the occurrence and consequences of unplannedndotracheal extubation in ICU.

The care of significant others is part of clinicalompetence in intensive care nursing. ICU patientsre, by definition, seriously ill and are often unpre-ared for admission to the ICU. In these situationsignificant others will also need counselling, sup-ort and care. Potinkara and Paunonen (1996) andohansson et al. (2005) have identified factorshich help to alleviate significant others’ anxi-ty or strengthen their sense of security. Takmannd Severinsson (2005) described the perceptionsf nurses and physicians regarding the needs ofignificant others in ICUs. Hughes et al. (2005)escribed relatives’ overall experiences of the criti-al care environment and how staff perceived thesexperiences, while Fox and Jeffrey (1997) investi-ated critical care nurses’ role expectations anderceived role performance with respect to theatient’s family.

Clinical competence comprises a wide range of

pecial issues, such as ‘‘patient education’’ (Albertt al., 2002; Washburn et al., 2005), ‘‘pain manage-ent’’ (Erkes et al., 2001; Sjostrom et al., 1999,

000), ‘‘patient comfort’’ (O’Brien et al., 2001)

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nd ‘‘end-of-life care’’ (Moss et al., 2005; Puntillot al., 2001). Patient education is part of the ICUurse’s clinical competence. ICU patients are oftenncertain, worried, in need of information aboutheir situation and may have difficulties communi-ating because of respiratory care, for example.lbert et al. (2002) and Washburn et al. (2005)escribed nurses’ knowledge of the principles ofeart failure education. ICU patients’ pain manage-ent is an important part of clinical competence.ll ICU patients suffer from different types of pain.ith respect to pain management, Erkes et al.

2001) described critical care nurses’ knowledgebout and attitudes to pain management. Sjostromt al. (1999, 2000) examined critical care nurses’ost-operative pain assessment.

Patient comforting is an integral part of clinicalompetence. ICU patients are anxious and often ineed of support. With respect to patient comfort,’Brien et al. (2001) have determined the extento which clinicians assess anxiety in patients withcute myocardial infarction. End-of-life care is alsoart of clinical competence in intensive care. Thor-ugh multiprofessional deliberation may lead to theecision to discontinue intensive care and beginnd-of-life care. With respect to end-of-life care,untillo et al. (2001) investigated nurses’ knowl-dge and beliefs of end-of-life issues. Moss et al.2005) described the barriers to quality end-of-lifeare in ICU.

.4. Professional competence

.4.1. Ethical activitythical activity is part of professional competence.ccording to one empirical study (Bunch, 2001), oneheme can be identified in the subdomain of ethi-al activity; ‘‘ethical sensitiveness’’. Bunch (2001)xplored the ethical dilemmas faced by health careroviders in ICUs and how they deal with themFig. 1).

.4.2. Decision-makingecision-making is part of professional compe-ence. According to empirical studies (n = 6) twohemes can be identified in the subdomain ofecision-making: ‘‘factors that influence decision-aking’’ (Bucknall, 2000, 2003; Bucknall andhomas, 1997; Holl, 1994; Manias and Street,001) and ‘‘critical thinking’’ (Hicks et al.,003). Nurses’ decision-making is influenced by

wide range of factors, which also impact on

heir professional competence. Manias and Street2001) explored how nurses and doctors con-truct their practices through knowledge to informheir decision-making. (Bucknall and Thomas, 1997)

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tudied nurses’ perceptions of the problems asso-iated with their decision-making in critical careettings, the decision-making of critical nursesithin natural clinical settings (Bucknall, 2000)nd environmental influences on nurses’ real deci-ions (Bucknall, 2003). Holl (1994) described variousurse characteristics to estimate their influence onrofessional beliefs and decision-making. Criticalhinking is part of decision-making and professionalompetence. Hicks et al. (2003) investigated theelationship of the ability of critical thinking to con-istency in clinical decision-making among criticalare nurses (Fig. 1).

.4.3. Development workevelopment work is part of professional compe-ence. According to empirical studies (n = 7) twohemes can be identified in the subdomain of devel-pment work, i.e. ‘‘evidence-based practice’’Bucknall et al., 2001) and ‘‘self-development’’Jamieson et al., 2002; Kuokkanen et al., 2002;indahl and Norberg, 2002; Meretoja et al., 2004;chribante et al., 1996; Suominen et al., 2001).he pursuit of evidence-based practice is partf the professional competence of intensive careurses. Bucknall et al., 2001 identified critical careurses’ research skills, the barriers encountered inarticipation and implementation and the currentvailability of resources (Fig. 1).

Self-development is also part of professionalompetence. Ongoing advances in technology andesearch are contributing to the development ofntensive and critical care nursing. The hecticempo of intensive care and the difficult situa-ion of patients are further potential sources oftress to ICU nurses. This requires an effort on theart of ICU nurses to develop themselves. Lindahlnd Norberg (2002) have illuminated this processnd described the content of clinical group super-ision in an intensive care unit. Clinical groupupervision supports interpersonal skills and man-ging in ICU work. Suominen et al. (2001) anduokkanen et al. (2002) described the empower-ent of intensive care nurses. Schribante et al.

1996) formulated and described guidelines for theompetency requirements of critical care nurses,nd Meretoja et al. (2004) described ICU nurses’erceptions of their competence. Furthermore,amieson et al. (2002) explored the role of ICUurses with a view to determining the need for andvanced role for their specialty.

.4.4. Collaborationollaboration is part of professional competence.ccording to one empirical study (Lingard et al.,004) one theme can be identified in the subdo-

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main of collaboration: ‘‘teamwork’’. Lingard et al.(2004) explored how team members in the ICUinteract to achieve daily clinical goals, delineateprofessional boundaries and negotiate complex sys-tems issues (Fig. 1).

4. Discussion

In this article we have sought to define and describecompetence in intensive and critical care nursingin the light of previous empirical research. Many ofthe studies reviewed offered no clear and coherentdefinition or description of the concept of com-petence. Competence was defined or describedthrough the following themes: ‘‘competence ingeneral’’, ‘‘professional competence’’, ‘‘clinicalcompetence’’ and ‘‘expertise’’. There is literatureon expertise in ICU, e.g. Christensen and Hewitt-Taylor (2006) explored the concept of expertise inintensive care nursing practice. Further King andMacleod Clark (2002) examined ICU nurses‘clinicalexpertise and use of intuition in intensive care set-tings.

According to the presumption of this study,competence can be examined via clinical and pro-fessional competence. Clinical and professionalcompetence is ‘‘knowledge base’’, ‘‘skill base’’,‘‘attitude and value base’’ and ‘‘experience base’’of intensive and critical care nursing. Our reviewwas based on the definition of databases that com-petence is ‘‘the capability of a nurse to performduties that generally or directly are related topatient care . . .’’ Based on our analysis, this capa-bility refers to nurses’ knowledge base, skill base,attitude and value base and experience base on thestrength of which they can perform their duties inintensive and critical care nursing. The definitionof clinical and professional competence in inten-sive and critical care nursing shares similaritieswith previous definitions of competence: knowl-edge base (Dunn et al., 2000; ICN, 2003; Kuokkanenet al., 2002; Meretoja et al., 2004; Potinkara andPaunonen, 1996; Schribante et al., 1996), skill base(Dunn et al., 2000; ICN, 2003; Meretoja et al.,2004; Potinkara and Paunonen, 1996), and attitudeand value base (ICN, 2003; Meretoja et al., 2004;Potinkara and Paunonen, 1996). Experience basewas not mentioned in definitions of competence inthe empirical studies reviewed, but it does sharesimilarities in common with the idea put forwardby Benner (1982) and Schribante et al. (1996) that

competence is closely related to the critical carenursing experience.

Previous studies’ guidelines for competency ofthe critical care nurse (Schribante et al., 1996),

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ompetency standards for specialist critical careurse (Dunn et al., 2000) and competency frame-ork for critical care (Bench et al., 2003) do notpproach the concept of competence with the helpf the concepts of clinical and professional com-etence. They have approached the concept ofompetence and identified the categories, domainsnd statements with the help of experts’ empiri-al qualitative data. In this literature review it waseasonable to examine the concept of competenceith the help of the MeSH-term concepts clinicalnd professional competence. However, the resultsf this literature review share similarities on theontent level of competence with previous empiri-al studies.

The critical care competency framework (Bencht al., 2003) identifies four competency state-ents: a competent nurse integrates comprehen-

ive patient assessment and interpretative skillso achieve optimal patient care, s/he managesherapeutic interventions and regimes; a com-etent nurse evaluates and responds effectivelyo rapidly changing situations, and s/he developsnd manages a plan of care to achieve optimalatient outcome and considers implications forischarge. The framework shares similarities withhe classification of competence of this literatureeview, especially the clinical competence subdo-ains ‘‘clinical guidelines’’ and ‘‘nursing interven-

ions’’.The subdomains ‘‘nursing interventions’’ and

‘clinical guidelines’’ share similarities withhe ‘‘enabling’’ domain of competence stan-ards for specialist critical care nurse (Dunnt al., 2000). The subdomains ‘‘ethical activ-ty’’, ‘‘decision-making’’, ‘‘development work’’nd ‘‘collaboration’’, share similarities withhe ‘‘professional practice’’, ‘‘clinical problem-olving’’, ‘‘reflective practice’’, ‘‘leadership’’ and‘teamwork’’ domains of competence standardsor specialist critical care nurse (Dunn et al.,000).

There were no clear similarities on the con-ept level with the conceptual framework forritical care nurse competency requirementsSchribante et al., 1996) but the content was sim-lar with the classification of competence of thiseview.

The results of this review — classification of com-etence — can form the basis of a competencessessment instrument in intensive care nursing andhe content of education programmes both locally

nd internationally.

Within the field of clinical competence, mostf the empirical research thus far has focused onhe implementation of nursing interventions. This is

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Bench S, Crowe D, Day T, Jones M, Wilebore S. Developing a com-petency framework for critical care to match patient need.Intensive Crit Care Nurs 2003;19:136—42.

Benner P. Issues in competency-based testing. Nurs Outlook

ompetence in intensive and critical care nursing

nderstandable in view of the fact that the imple-entation of nursing interventions is an importantart of nurses’ work and their competence. InCUs, nurses carry out nursing interventions inde-endently. Most professional competence studies,or their part, have focused on the domain of devel-pment work, which is an important part of theCU nurse’s competence. This refers to the abilityf ICU nurses to develop themselves, to empowerhemselves at work and to develop evidence-basedursing.

The kind of literature review presented herenvolves some inherent problems. Firstly, the anal-sis itself was highly problematic. The review wasased on a search of the COCHRANE and MEDLINEatabases. The studies reviewed were categoriseds clinical or professional competence studies inhe databases, even though many of them madeo mention or offered no description or defi-ition of clinical or professional competence atll. The studies reviewed described intensive andritical care nurses or their actions in ICUs. There-ore, we finally came to the decision that thetudies investigated have to describe the clinicalr professional competence needed in intensivend critical care nursing. Secondly, the searchnd analysis was carried out by one author only.owever, to strengthen the validity and reliabil-

ty of the literature review, the search was firstonducted in January 2005 and then updated inay 2006. Likewise, the first version of the anal-sis was done in 2005 and elaborated upon in006.

There are some other limitations in this reviewhat warrant attention. Firstly, the articles andtudies were screened from two databases only,.e. COCHRANE and MEDLINE. We considered thesewo databases to cover the most relevant empir-cal research in this field (cf. Brazier and Begley,996). Secondly, the search pathway and ournderlying assumptions may have influenced theutcomes of our search, which furthermore wasonfined to English language studies, adult inten-ive or critical care nursing, clinical or professionalompetence and to the period 1994—2005. How-ver, these restrictions and the search pathwayere reasonable in view of the specific interestf this review, which was to define and describeompetence, via an examination of clinical androfessional competence, in adult intensive careursing in the light of previous empirical research.hirdly, the studies included in the review alsoave their own limitations. For example, theample sizes and response rates of the quantita-ive studies reviewed were often quite low (see

able 1).

87

. Conclusion

hat does the existing empirical research tell ushen about competence in intensive and criticalare nursing? Overall, this relatively large body ofesearch seems to be lacking in coherence. Theoncept of competence in intensive and criticalare nursing is multidimensional. The domains ofompetence identified in our review do not yetuffice to produce a clear and coherent overallicture of competence in intensive care nursing.ore systematic research is still needed in thisrea. A concept analysis of competence in inten-ive care nursing would also be useful. Competencen intensive care nursing differs from overall com-etence in nursing. Therefore, work is also neededo develop the assessment of competence in inten-ive care nursing. This would yield importantnformation for intensive care nurses, educationrofessionals, administrators and researchers e.g.mprovements in the quality of patient and fam-ly care, justification of further training beyondasic nurse education and arguments by tradenions for improved work conditions. A valid andeliable competence assessment instrument whichs based on a literature review and supplemen-al studies would be useful in nursing educationnd administration to ensure qualified nurses inCUs.

cknowledgements

e wish to thank library technicians Helenaahtinen from the University of Turku Medicalibrary and Hannele Mikkola from the library ofurku Polytechnic for their invaluable assistanceuring the search process. We would also like tohank Mr. David Kivinen and Ph.D. Mike Nelsonor their valuable help with English language revi-ion.

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