AbstractIntensive care services have seen a radical increase in provision over the last four years. This,along with the disbanding of the English National Board (ENB), has allowed institutions ofhigher education to develop targeted, flexible pathways specific to critical care while still incor-porating national recommendations. Here, we set out our experience of developing a flexiblecritical care pathway that is fit for practice (UKCC 1999) and leads to a BSc (Hons) orHigher Education Diploma in Critical Care. We outline the reasons for the course devel-opment, the existing continuing professional development framework at NorthumbriaUniversity and the structure of the new pathway. The planning team endeavoured to incor-porate as many recommendations as possible from organizations such as the AuditCommission (1999), the Department of Health (DoH 2000; DoH 2001), and from Scholesand Endacott (2002). The membership of the planning team was also designed to incorporateas many views as possible—from both education and service. We believe that the targeted,flexible pathway offers a number of benefits, including a recognized qualification and a balanceof flexibility and standardization over course content. The pathway is open to all healthcarepractitioners working in critical care areas; it is competency-based, offers an opportunity foraccreditation for experienced practitioners, and students can either complete the wholepathway or access individual modules according to their, and their employer’s, needs.

Key words: accreditation, higher education, intensive care, targeted pathway

IntroductionIntensive care services have seen a radical increase in provision over the last four years.The ’flu epidemic in the winter of 1999, and a review of the services provided,

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A pathway to successInnovation in practice

Vanessa Gibson—Senior Lecturer, School of Health, Community and EducationStudies, Northumbria University, UK

Margaret Douglas—Senior Lecturer–Practitioner, School of Health, Communityand Education Studies, Northumbria University and the Newcastle upon TyneHospitals NHS Trust, UK

Alan Gregg—Principal Lecturer, School of Health, Community and EducationStudies, Northumbria University, UK

Practice Development in Health Care, 2(3) 129–138, 2003 © Whurr Publishers Ltd

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prompted a massive expansion of beds (DoH 2000), which inevitably led to arecruitment drive and the need to provide specific education for new staff. Thisexpansion, along with the English National Board for Nursing and Midwifery (ENB)being disbanded, has allowed institutions of higher education to develop targeted,flexible pathways specific to critical care, while still incorporating national recommen-dations. Here, we present our experiences of developing a flexible critical care pathwaythat helps to develop practitioners who are fit for practice (UKCC 1999). The reasonsfor developing the pathway are outlined, as is the existing continuing professionaldevelopment framework and the structure of the new pathway, as well as the benefitsand improvements over the old-style courses.

The main advantage of the targeted pathway over old-style courses lies in itsflexibility, which incorporates an opportunity for accreditation for experienced practi-tioners as well as the use of core and option modules so that students can tailor theircourse while ensuring that they gain fundamental information and have an opportunityto learn from and with other professionals. This is an exciting development and showswhat can be achieved when organizations work collaboratively rather than in isolation.

Reasons for developing the new pathwayThe overriding rationale for changing the existing programme was to enable practi-tioners to meet the challenging needs of their patients (DoH 2000). In addition wasthe requirement for flexible practice, which must be matched with flexible and acces-sible education (UKCC 1999; Scholes and Endacott 2002).

The intensive care unit (ICU) is a phenomenon of the last half of thetwentieth century. Despite the development and success of ICUs it soon becameapparent that there was a need for a ‘step down’ unit and, in the late 1990s, the estab-lishment of high dependency units (HDUs) became a reality. The proliferation ofHDUs led to the development of training courses that were specifically designed tomeet the needs of practitioners working in these areas and to complement the long-standing ICU courses.

The overriding rationale for changing the existing programmewas to enable practitioners to meet the challenging needs oftheir patients … flexible practice … must be matched withflexible and accessible education.

However, a recent review of adult critical care services (DOH 2000) revisitedthe definitions of ICU and HDU care, and this led some trusts to develop integratedcritical care units. It is vital that the education of practitioners in these areas reflectscontemporary practice.

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Most trusts report a shortage of critical care nurses, especially those trained toENB100 standard, and it is likely that this paucity is to also to be found in other profes-sions. Because the number of critical care beds is growing, trusts must recruit staffwithout experience and, in many cases, newly qualified staff are filling these vacancies.The Audit Commission (1999) recommends that a structured orientation andmentoring programme be provided for new nurses or staff, whereas the DoH (2000)recommends that a modular framework of continuous professional development shouldbe created, based on the continuum of critical care provision.

The document, Modernising Heath and Social Services: Developing the Workforce(DoH 1999), identified that the NHS has a responsibility to develop effective workingrelationships with education providers and to participate when decisions are madeabout the education available to current and future staff. In particular, training anddevelopment plans for health professionals need to be supported by well-managedcontinuous professional development programmes that are targeted to meet localservice objectives and the needs of individuals, the implication being that thegovernment programme to build modern and integrated systems of health and socialcare depends upon the development of a skilled and highly motivated workforce withrelevant education, training and experience.

In addition to these national recommendations, in April 2002 the ENB wasdisbanded. Walker (2001) suggests that the demand for education and training is likelyto continue given the growth in critical care services and the ever increasing complexityof care intervention. Consultation with local trusts highlighted not only that thedemand for education is great but also that practitioners want a recognized qualificationin critical care. Northumbria University, in line with governmental recommendations,believes that this education should not only be aimed at new staff but should be amodular pathway, leading to a diploma or degree in critical care practice.

The continuous professional developmentframework

Northumbria University already had a well-established continuous professional devel-opment framework and a good track record of developing critical care courses (Gibsonand Douglas 2000). The continuous professional development framework offersflexible and accessible programmes of learning to all professionally trained practi-tioners in nursing, palliative care, cancer care and mental health. The new pathway incritical care practice was an addition to this and is accessible to all registered practi-tioners working in critical care.

The continuous professional development framework is delivered on a part-time basis and is fully modular, with students having access to a large portfolio ofmodules of learning. However, for the critical care pathway the portfolio was limited toa shortlist of modules relevant to critical care (Scholes and Endacott 2002) (Figure 1).

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Development of the new pathwayAs with any new project, a great deal of planning and negotiation was needed.Nothumbria University is the main education provider for a number of acutehealthcare trusts in the northern region. The senior lecturer from the universityworked closely with the senior lecturer–practitioner, which is a joint appointmentbetween one of the larger trusts and the university. This close working relationship wasvital to ensure key individuals were kept informed and a rigorous consultation processwas undergone. In addition to the senior lecturer–practitioner, fourpractitioner–lecturers had also recently been appointed to deal with growing educa-tional demands in critical care areas. These five posts are vital to maintainingcommunication between the university and local trusts. With the senior lecturer forcritical care, these individuals form a cohesive team and meet the numerous educa-tional demands of practitioners in the area.

Figure 1 Structure of the critical care pathway.

Gibson et al.

20 core pointsContemporary Issues in Professional Practice (Degree) 20 points

Enquiry & Research for Practice (Diploma) 20 points

40 specialist pointsCRITICAL CARE PRACTICE

Foundations in Critical Care 20 pointsAdult Critical Care 20 points

30 core pointsTheorizing Practice (Degree) 30 points

Promoting Change in Practice (Diploma) 30 points

BSc (Hons) Critical Care Practice

Dip. HE Critical Care Practice

30 option points(Two examples are

given here, taken fromrelevant critical care

modules within the CPDframework menu)

Example 2Cardiac Surgery Acute and Critical Care

10 pointsThe Critically Ill Trauma Patient

10 pointsPractice Development in Critical Care

10 points

Example 1Foundations of Neuroscience Nursing

10 pointsNeuroscience Nursing

20 points

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The planning teamStaff from various disciplines from all the critical care units and a number of acutewards in the region were invited to a presentation, as a result of which several membersof the audience volunteered to join the planning team. A representative group wasformed from these volunteers. The university was represented by lecturers whodelivered the critical care modules. Nursing representation came from six acutehospital trusts in the region, and ranged from nurse consultants to staff nurses. Alliedhealth professions, such as physiotherapy and occupational therapy, were also represented on the planning team. Some planning team members were employed injoint roles as practitioner–lecturers or lecturer–practitioners. Altogether there were 14members of the planning team. Although this was a large team, it was felt important tohave wide representation to facilitate communications with the various clinical areasand within the university. In retrospect, membership of the planning team should havebeen even broader as we have subsequently had students who are midwives andoperating department practitioners.

Various issues were identified before validation of the pathway, including:

● the development of critical care modules that would provide the knowledgeand experience required by practitioners

● links between the modules needed to be explicit● the aims of the modules needed to reflect the needs of current practitioners

within critical care● the assessment process should be designed to enable practitioners to explore

and demonstrate knowledge and skill development pertinent to critical care● flexible access to the pathway was needed to accommodate the different

requirements of critical care practitioners● logical and user-friendly documentation was needed, not only to support both

practitioners and their clinical supervisors but also to inform the universityvalidation panel

● agreement of clinical outcomes for the modules was needed; this would becompetency-based

● delivery of the modules—block, day or evening?● supervisor preparation● accreditation for experienced staff.

Structure of the new pathwayCore modules

The continuous professional development framework has two core modules commonto all the degrees or diplomas within it, these being ‘Contemporary Issues inProfessional Practice’ (degree) and ‘Enquiry and Research for Practice’ (diploma), as astarting point, and ‘Theorising Contemporary Practice’ (degree) and ‘PromotingChange in Practice’ (diploma), as a finishing point. We were keen to have core critical

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care modules so that all practitioners shared some common essential knowledge ofcritical care. The two modules that were developed are described below.

‘Foundations in Critical Care’

This module was designed for practitioners new to critical care; for those who wished toupdate their critical care skills and knowledge, or for those working with acutely orcritically ill patients in ward areas. It introduces practitioners to recent developmentsin critical care and the main themes of this area of practice. Themes covered in themodule include: assessment and monitoring of the critically ill patient; support andtreatment of patients with respiratory failure; support and management of other organfailure; and the psychological care of the critically ill patient. This module should givepractitioners the knowledge to assess and manage the early phases of critical illness.

Students who have completed the foundation module value the opportunity torevise or consolidate their experience, as shown by the following evaluation comments:

‘Most of the module was relevant to my practice …’

‘It backed up and built upon my knowledge …’

‘… more confident at looking after the critically ill.’

‘Adult Critical Care’

This module was designed to build on and develop the knowledge gained from‘Foundations in Critical Care’. Its main themes include: advanced respiratory support;advanced haemodynamic monitoring; and the support and management of patients inmulti-organ failure. The psychological impact of the intensive care environment isexplored through student-led seminars. The aim of this module was to give practi-tioners the knowledge to manage effectively patients with advanced critical illness.Typical comments from students suggest that our expectations were realized and thatstudents were thinking more deeply about their practice and its effect on patients:

‘I feel more knowledgeable and able to base my practice on theory more effec-

tively.’ ‘I also feel I have a greater appreciation of the patient experience’

Practitioners are expected to achieve learning outcomes or ‘competencies’ in caring forLevel 3 patients (DoH 2000). This requires them to work in a suitable clinical area(that is, intensive care) or to gain a placement in that area. Assessment takes the formof a case presentation that is assessed using a viva voce.

It was important to include as many new recommendations as possible in thepathway. The Audit Commission (1999) recommends that a structured orientationand mentoring programme be provided for new nurses or staff and we feel that this hasbeen achieved with the ‘Foundations in Critical Care’ module. This module isdelivered in the university and is open to all practitioners, but in addition, part of theremit of the four practitioner–lecturers is to run the module for their trusts as aninduction for staff new to critical care.

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The DoH (2000) recommends that a modular continuous framework of coursesshould be developed, based on the continuum of critical care provision. The ‘AdultCritical Care’ module, and the choice of option modules, allows for a continuousframework while still offering practitioners some flexibility.

As with all university programmes the critical care pathway is examined exter-nally. Early feedback from external examiners has been very positive; commentsincluded:

‘The topic that has been set for the assessment is well thought out and clearly

expressed. It allows the students to reflect on and identify ways of developing

their practice.’

FlexibilityThe course team was keen to include essential content for all students while providingsome flexibility for individual needs. The pathway offers the following options.

Option modules

Not all critical care areas are the same. As well as expansion, critical care has also seendiversification. In the north-east of England there are critical care units that specializein neurosciences, cardiac surgery, liver surgery, and burns and plastics as well as anumber of general units. The critical care pathway so far offers students 90 core pointstowards a qualification that requires 120 points. The planning team therefore decidedthat the remaining 30 points could be made up from a number of option modules.However, critical care courses have been criticized in the past for trying to incorporatetoo much general material and not enough specific content on aspects of critical care(Scholes and Endacott 2002).

With a rapidly developing, technological service it is important that educationhelps to produce practitioners who are fit for purpose. The existing continuous profes-sional development framework offered more than 150 modules. However, the planningteam felt that not all of these were relevant to critical care and narrowed the choice ofoptions down to 37. For example, there are option modules that are very specificallyfocused to a clinical patient issue, such as ‘Care of Clients with Altered RenalFunction’, and there are modules that adopt a ‘tool-kit’ approach, for example the‘Practice Development in Critical Care’ module, which aims to facilitate critical carepractitioners’ capacity to develop practice.

The critical care pathway, therefore, gives practitioners the vital coreknowledge and skills that are required in a changing critical care environment. In-builtflexibility allows students to meet the needs of their patients, of their own professionaldevelopment and the requirements of their employers. Two examples of the way optionmodules can be used can be seen in Figure 1: one would be appropriate to nursesworking with neuroscience patients, whereas the other would meet the needs of nursesworking with a broader range of patients.

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Accreditation of prior experiential learningThe new critical care pathway used ‘Foundations in Critical Care’ as a core module,which then enabled staff who had undertaken it as an induction programme to gainaccess to the rest of the pathway without having to repeat any study unnecessarily.However, the critical care pathway is not only open to new staff, but also to existingstaff, many of whom had been on the waiting list for the old ENB awards in highdependency or intensive care. The planning team recognized that these practitionersmay have gained considerable knowledge and clinical expertise from their practice andmay not wish, or need, to undertake a foundation module. This led to the developmentof an accreditation of prior experiential learning (APEL) exercise, which enables appli-cants who wish to be accredited for their experience to articulate their practiceknowledge and to be awarded academic credits for this. This process is explained indetail in the following article.

Accreditation of work-based learningThe existing continuous professional development framework includes an option fordegree-level students to gain up to 60 CATS point via accreditation of work-basedlearning (AWBL). The planning team felt that, where possible, it was important for thenew pathway to follow existing structures. Equally, it was felt that AWBL offered avehicle by which practitioners could demonstrate the learning that occurs in andthrough practice. An important differentiation between APEL and AWBL being thatthe learning emphasis rests in the ‘now’ of the working environment and not throughreflection on previous events. The AWBL process seeks to recognize that workplacelearning may be derived from any number of sources, and that the knowledge and skillsacquired through doing can be made visible and open to academic assessment (Clarkand James 1997; Waddington and Marsch 1999; Parish 2001).

The AWBL process within the continuous professional developmentframework was originally designed to provide students who had previously undertakenspecialist modules at diploma level with an opportunity to continue their studies atdegree level. (Standard university regulations prevent students re-registering for thesame or similar modules at a higher level.) The initial concept being that such studentswould be able to demonstrate application of their diploma-level learning to practiceand to articulate the new learning that occurs as part of this process. Initial evaluationsindicate that the AWBL process enabled students to capture their learning, regardlessof previous exposure to specialist modules, and the process is now open to all degreestudents.

One of the greatest strengths of this process is its relevance to practice and theevident synergy between theoretical and professional development. Concerns at theflexible and individual nature of AWBL are outweighed by the heightened self-confi-dence gained through personal and peer recognition of the benefits of practice(Swallow et al. 2000a; Swallow et al. 2000b; Swallow et al. 2001).

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ConclusionThe last few years have seen the expansion and diversification of critical care services.This growth, along with the disbanding of the ENB and its awards, has led to a re-examination of educational provision. Institutions of higher education are able tocombine national recommendations with the flexibility to develop new programmes incritical care education. Northumbria University has taken account of these anddeveloped a higher education diploma and BSc (Hons) in critical care practice. Theseawards encompass a structured orientation and mentoring programme for new staff(Audit Commission 1999) and a modular continuous framework, based on thecontinuum of critical care provision (DoH 2000). In addition, the university has incor-porated the recommendations of both the DoH (2001) and Scholes and Endacott(2002) in providing competency-based assessment and relevance of the contentspecific to critical care (UKCC 1999). The assessment strategy involves bothacademics and clinical experts.

Flexibility is offered through the inclusion of a relevant choice of optionmodules so that students can tailor the pathway to meet the needs of their patients aswell as themselves and their employers. Experienced nurses, and those who haveobtained an old-style critical care qualification, can opt for APEL or AWBL. Studentsare also given an opportunity to learn with and from other professionals, as thepathway is open to all practitioners in critical care. This programme is an excitingdevelopment and we believe is a pathway to success in critical care practice.

AcknowledgementsThe authors would like to acknowledge the valuable contributions of all members ofthe planning team: Lesley Bolding, Sarah Carr, Debbie Cheetham, Anne Gray, ElaineHenderson, Karen Imrie, Mike Kelleher, Liz Klein, Leigh Mansfield, Alan Platt,Annette Richardson, Iain Rutherford, John Stephens and Beverly Wilkinson.

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Swallow V, Chalmers H, Miller J. Learning on the job: accredited work based learning (AWBL).Emergency Nurse 2000a; 8: 35–9.

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Address correspondence to: Vanessa Gibson, Senior Lecturer, Room H217,Northumbria University, Coach Lane Campus, Coach Lane, Benton, Newcastle uponTyne NE7 7XA, UK (E-mail: vanessa.gibson@unn.ac.uk).

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