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International Journal of Nursing Studies 45 (2008) 1103–1109

www.elsevier.com/ijns

Critical care nursing education and practice in Canada andAustralia: A comparative review

L. Rosea,�, S. Goldsworthyb, L. O’Brien-Pallasa, S. Nelsona

aLawrence S Bloomberg Faculty of Nursing, The University of Toronto, Ont., CanadabDurham College/ University of Ontario Institute of Technology Collaborative BScN Program, Oshawa, Ont., Canada

Received 7 March 2007; received in revised form 4 June 2007; accepted 5 June 2007

Abstract

Critical care nursing is an area of policy concern with respect to staffing projections, skill mix and educational

preparation in both Canada and Australia. Despite many similarities between the health systems of these two countries,

differences exist in both undergraduate and graduate specialty nursing education. In Australia, specialist education is

primarily delivered via the tertiary sector as a formalised qualification, whereas the current Canadian model displays

significant variation in duration, content, and mode of delivery. This paper provides a comparative perspective on the

educational preparation of critical care nurses in these two countries. Consideration of alternative models of specialty

nursing education may provide a method to improve recruitment and retention of staff while maintaining quality of

care.

r 2007 Elsevier Ltd. All rights reserved.

Keywords: Nurse education; Critical care; Contextual influences; Nurse staffing; Critical care nurse

What is already known about the topic?

�

Worldwide shortages exist in the critical care nursing

workforce.

�

Formal education programs may promote authority

in decision-making, develop the role of the nurse and

improve recruitment and retention.

�

Differences exist in the structure and provision of

critical care nursing education internationally.

What this paper adds

�

Description of two alternative models of specialty

nursing education.

e front matter r 2007 Elsevier Ltd. All rights reserve

urstu.2007.06.006

ing author. Tel.: +1416 978 3492;

8222.

ess: louise.rose@utoronto.ca (L. Rose).

�

d.

Broader understanding of similarities and differences

in critical care nursing education and ICU organisa-

tional structure with in Canada and Australia.

�

Current initiatives underway that are designed to

promote and sustain the critical care nursing work-

force.

1. Introduction and Significance

Internationally, ineffective health human resource

planning has contributed to a current shortage of nurses

especially in the specialty areas such as critical care

(O’Brien-Pallas et al., 2001). The critical care nursing

workforce is currently under pressure to adapt to the

changing needs of the healthcare system and society. At

a time when health care systems are undergoing massive

transformation, combined with increasing demand and

greater expectations from consumers, health human

ARTICLE IN PRESSL. Rose et al. / International Journal of Nursing Studies 45 (2008) 1103–11091104

resource planning, which includes education and pre-

paration of nurses, becomes one of the most critical and

urgent of issues.

In Canada there has been a steady decline in the size

of the nursing workforce, with most provinces moving

from an oversupply to a serious shortage of nurses

(Dussault et al., 2000). Similarly, in Australia, nursing

shortages have resulted in reduced numbers of critical

care nurses due to both a reduced intake and increased

attrition (AHWAC, 2002).

One recruitment incentive for nurses is the provision

of formal education programs that may assist nurses

new to the specialty or provide life-long learning

experiences and opportunity in career advancement for

existing staff; factors identified as important retention

strategies (Yoder, 1995; Aiken et al., 2001). Education

programs increase nurses’ capabilities and accountabil-

ity and extend the scope of practice of nurses practising

in the critical care context (Rose and Nelson, 2006).

Further, a well-educated nursing workforce may pro-

mote authority in decision-making and assist in devel-

oping nurses’ role within the health professional team,

thus improving job satisfaction and therefore job

retention.

Overseas practices may serve as a guide for changing

existing practice (Clarke et al., 1999). The need to deliver

high quality care in the face of a decreasing nursing

resource pool is a challenge that transcends national

boundaries. The clinical field of critical care nursing

presents even further challenges in this regard due to the

complexity of care and the high level of clinical

competence required of health personnel in this field.

This paper takes two countries with similarities (Canada

and Australia) and compares and contrasts the educa-

tional preparation and context of practice for critical

care nurses.

2. Search strategy

The following databases were searched in September

2006 and May 2007: Medline, CINAHL, and Blackwell

Science using the keywords: critical care, nurse educa-

tion, higher education and nurse staffing both individu-

ally and in combination. Internet sites thought to

contain relevant information were also searched includ-

ing those of the Canadian Nurses Association, Austra-

lian Nursing Council respective government sites, the

Canadian Association of Critical Care Nurses

(CACCN) and the Australian College of Critical Care

Nurses (ACCCN).

Canada and Australia represent two equivalent

countries in terms of life expectancy and quality of the

health care system, economic standing and educational

systems (Flood, 2001; The Daily, 2003). In both

countries, critical care nursing has been an area of

policy concern with respect to staffing projections

and educational preparation over the last five years

(AHWAC, 2002; MOHLTC, 2005). Despite these

similarities there is a marked divergence in the educa-

tional preparation, staffing ratios and scope of practice

in Australia and Canada. The impact of these important

distinctions with respect to quality of care, recruitment

and retention warrants discussion. The aim of this paper

is to provide an Australian/Canadian comparative

perspective, with particular focus on the Province of

Ontario (Canada) and the State of Victoria (Australia),

to describe how nurses are prepared for work in critical

care settings and current educational strategies being

developed to improve quality of care and system

performance.

3. Basic education

To provide direct, unsupervised nursing care within

the critical care specialty, the minimum entry require-

ment is a Registered Nurse (RN). In Canada, nursing

education is university based and consists of either a

four-year program or a ‘direct entry’ course that

requires completion of an undergraduate science-based

degree prior to two years of nursing curricula. Since

1995, the entry to practice requirement to be a RN is the

Bachelor of Science in Nursing (BScN) credential.

Registration is then achieved by successfully passing

the Canadian RN exam. Canadian nursing programs

typically consist of a blend of theory and practicum

education with an increasing number of hours spent in

practice environments as the curriculum progresses.

Exposure to the critical care setting is minimal, if any,

and typically limited to preceptored observational

experiences in the final year.

Similarly, in Australia the government continues to

endorse a university-based bachelor degree as the

minimum level of qualification for entry to practice as

a RN, (Heath, 2002). In contrast to the four-year

Canadian BScN, the Australian counterpart is equiva-

lent to six full-time semesters (three years). This degree

consists of a comprehensive education program includ-

ing general and psychiatric content. While there is no

national undergraduate nursing curriculum within Aus-

tralia, programs are based on competency standards

developed by the Australian Nursing Council Incorpo-

rated (ANCI, 2000). Within the bachelor degree,

students complete a maximum of 1000 h of clinical

experience at a variety of hospital and community

settings (CDNM, 2005). Increasing undergraduate ex-

posure to critical care may be one method of improved

recruitment to the specialty, however, as is the case in

Canada, undergraduate clinical experience in critical

care is available to only a few students, and consists of

preceptored, observational placements.

ARTICLE IN PRESSL. Rose et al. / International Journal of Nursing Studies 45 (2008) 1103–1109 1105

In Australia, the transition from a hospital-based

apprenticeship model to the academic model was

finalised in 1994, from which point all RNs were

educated at the bachelor degree level (Heath, 2002).

Nurses who complete a university bachelor degree are

then required to gain registration with the appropriate

registering body according to the State or Territory they

wish to practice in. Registration is achieved through the

provision of academic transcripts that demonstrate the

student has met the academic and clinical requirements

of the registering board. Currently, there is no state or

national registration exam in Australia.

In 2004, there were 246,575 RNs in Canada. Among

these nurses 68.2% were diploma prepared, 30.3%

degree prepared, 1.4% had Master’s degrees or doctoral

preparation (CNA, 2006a). Of these nurses, 17,387

(7.1%) were practising within a critical care setting.

Only 1.2% of nurses working in critical care settings

have Master’s or doctoral preparation (CNA, 2006a). In

Australia, nurses are classified as RNs (usually holding a

degree) and enrolled nurses (ENs) (with either a

certificate or diploma). In 2004, there were 259,312

nurses in Australia, 80% practicing as RNs and 20% as

ENs (AIHW, 2006). Of these RNs, 24,492 (9.4%) were

employed within the critical care environment. Data on

the number of nurses with Master’s or doctoral

preparation is currently not available in published

Australian nursing workforce statistics (AIHW, 2006).

Table 1

Broad Curricula areas identified by the Declaration of Madrid

(1993)

Anatomy and physiology Psychological aspects

Pathophysiology Technology

Clinical assessment Patient and family education

Illnesses and alterations of vital

body functions

Legal and ethical issues

Plans of care and nursing

interventions

Professional nursing roles in

critical care

Medical indications and

prescriptions, with resulting

nursing care responsibilities

Use of current research

findings to plan and give care

4. Specialty Education

Significant differences exist in the provision of critical

care specialty education in Canada and Australia.

Within Australia, the Australian Health Workforce

Advisory Committee minimum standards for intensive

care units require that 50% of nursing staff employed

within an individual ICU must hold a graduate level

critical care qualification (AHWAC, 2002). The

ACCCN and Joint Faculty of Intensive Care Medicine

(JFICM) prefer 75% of nursing staff to hold a specialty

qualification (AHWAC, 2002). In the latest published

report of Australian ICU resources, the proportion of

nurses holding a graduate level specialty qualification

stands at 57% with the highest proportion (79%) being

in the State of Victoria (Higlett et al., 2005). Nurses who

wish to pursue a career in critical care are expected to

undertake a specialty qualification usually within the

first year of employment within an ICU. In addition, the

ACCCN has recommended that each ICU has a

designated clinical nurse educator (CNE) with a ratio

of one educator per fifty nurses. Currently, there have

been no similar recommendations made by comparable

associations in Canada. Moreover, little information is

available on the number of nurses holding a specialty

qualification.

Within Australia, specialist critical care nursing

education has transferred from the hospital-based

certificate model to various tertiary level programs

(ACCCN, 2006a). In this context, a critical care

qualification is clearly defined as: ‘‘a post-registration

award at a minimum of certificate level obtained by

successful completion of an accredited critical care

education program (Z 6 months duration) at a hospital

or tertiary institution’’ (ANZICS, 2005). In the State of

Victoria, all programs are delivered by the university

sector with multiple exit points (graduate certificate,

diploma or Masters) that normally are of 12 months in

duration. The bulk of graduates exit at the graduate

diploma level. In addition, employment within an ICU is

a prerequisite for entry into these programs. Nurses

receive both didactic and clinical education provided by

both the employing hospital and the education provider.

The programs are primarily taught by lecturing staff

employed by the universities, with additional clinical

education and support provided by CNEs in the

hospitals.

The ACCCN (2006a) recommends the curriculum for

these programs is based on the Competency Standards

for Specialist Critical Care Nurses (ACCCN, 2002) and

the Declaration of Madrid (WFSICCM, 1993; WFCCN,

2005) and demonstrates a balance between clinical

competence and sound theoretical knowledge. Broad

curricula areas recommended by The Madrid Declara-

tion and recently endorsed at the Buenos Aires

(WFSICCM, 1993; WFCCN, 2005) are listed in Table 1.

This combination of accredited teaching institutions and

a curriculum framework has resulted in a reasonably

consistent level of critical care specialist training

throughout Australia which still maintains flexibility

for individualised local needs.

In contrast to the formalised system prevalent within

Australia, specialty education in Canada displays

significant variation in duration, content and mode of

delivery (MOHLTC, 2006). Depending on the location,

critical care specialty education is usually offered as a

certificate via either a college-based or hospital-based

ARTICLE IN PRESSL. Rose et al. / International Journal of Nursing Studies 45 (2008) 1103–11091106

critical care nursing training program. In some Pro-

vinces, certificates are being offered in conjunction with

university based schools of nursing, however this is more

the exception rather than the rule (Robertson, 2000).

There are currently no statistics available on the number

of nurses holding critical care certificates in Canada.

Within Ontario, a recent survey identified the duration

of these courses range from two to more than nine weeks

(Goldsworthy, 2003; MOHLTC, 2006). Although this

survey was unable to directly assess the quality of these

programs, the presumption was made that this also

varied significantly between courses. Presently within

Ontario, there is a lack of formalised university

programs that offer critical care education at the

graduate level, although one University in Southern

Ontario has recently piloted a critical care under-

graduate stream in the BScN program.

Unlike the Australian model where employment

within an ICU is mandatory, nurses attending the

college-based courses may either be currently working in

critical care or planning to move into the specialty.

Courses are normally structured to reflect the CACCN

standards of practice (CACCN, 2004) and include topics

such as: advanced pathophysiology, arrhythmia inter-

pretation, hemodynamic monitoring, mechanical venti-

lation, critical care pharmacology, advanced cardiac life

support, ethical issues, neurological care, and care of the

critically ill surgical patient (Durham College, 2006).

Formalised education programs enable nurses to

develop clinical practice based on sound theoretical

principles which in turn fosters decision-making skills,

autonomy and professional practice, all key elements in

the recruitment and retention of nurses (Blanchfield and

Biordi, 1996; Charboyer et al., 2001; Finn, 2001).

Dissatisfaction with learning opportunities and limited

promotion options may have a greater impact on staff

turnover than poor pay or heavy workload (Shields and

Ward, 2001). Therefore, a well-educated, adequately

resourced workforce is essential in dealing with the

global nursing shortage.

5. Ongoing competency assessment

In Canada, nurses working in critical care may also

choose to become certified to a national standard

through an exam process. The ‘Certified Nurse in

Critical Care-Canada’ (CNCC (C)) credential is pro-

vided by the Canadian Nurse’s Association (CNA) and

endorsed by the CACCN. To obtain certification, a

candidate must successfully complete a national certifi-

cation exam. This credential, which is actively promoted

by both the CNA and the CACCN is currently

voluntary for critical care nurses. In 2005 1263 nurses

have successfully completed the credentialing process

(CNA, 2006b).

Within Australia, a credentialing process is also

offered by the ACCCN. This process, which involves

the completion of a practice portfolio, has been available

since 1998. Currently, of the 48 nurses who have applied

for credentialing, only 12 have successfully completed

the program (ACCCN, 2006b). Unlike Canada few

nurses within Australia have taken up the credentialing

process. This may be due to the emphasis on formal,

standardised graduate level specialty qualifications,

though currently no studies have investigated the

reasons for the poor uptake in critical care credentialing

within Australia.

6. Work environment and staffing

Despite the highlighted differences in specialty educa-

tion for nurses, ICUs in Canada and Australia have

some similarities. In both countries, ICUs are structured

using a closed medical model in which exclusively

rostered medical staff hold overall responsibility for

key decision-making as well as admission and discharge

of patients to the ICU. A notable difference between the

organisational structure of units in the two countries are

staffing ratios and skill mix. In Canada, the usual nurse-

to-patient ratio for ventilated patients is 1:2, though this

may vary depending on patient acuity. In contrast,

Australian ICUs are staffed with a minimum of a 1:1

nurse-to-patient ratio for ventilated and other critically

ill patients as stipulated by the ACCCN and the JFICM

(Robertson, 2000; Ball and McElligot, 2003; JFICM,

2003). Further, the ACCCN states nursing staff may be

required in a higher ratio in patients requiring complex

management.

One of the main reasons for this difference in nurse

staffing ratios is the role of the respiratory therapist

(RT). In addition to nursing staff, most Canadian ICUs

will also be staffed by RTs. However, this professional

group is not utilised in the Australian context; rather

critical care nurses adjust and titrate ventilation and

weaning. Therefore, the absence of RTs in the Aus-

tralian setting significantly influences the scope of

nursing practice.

Several studies have identified variation in the profile

and role of the critical care nurse in different settings.

Within European ICUs, significant variation of nurse

participation exists in procedures including: initiation of

mask ventilation and cardiac massage, peripheral and

arterial line insertion, pulmonary capillary wedge

pressure measurements and weaning (Depasse et al.,

1998; Benbenishty et al., 2004). Currently, the scope of

nursing practice within Canadian and Australian ICUs

has been inadequately described. One survey of ICUs

within South-western Ontario found, in smaller hospi-

tals which employed fewer RTs, nurses performed

ventilator parameter changes more frequently providing

ARTICLE IN PRESSL. Rose et al. / International Journal of Nursing Studies 45 (2008) 1103–1109 1107

evidence of the influence of organisational structure and

skill mix on the role of the critical care nurse (Keenan

et al., 1998).

Nurses’ roles may be difficult to quantify both locally,

nationally and internationally due to the influence of

contextual and organisational issues such as differences

in skill mix, education, unit profile, unit culture, and

professional roles and boundaries (Rose and Nelson,

2006). Further, while it is acknowledged ICUs differ

both locally and internationally, it is important to

identify those factors that may influence patient out-

comes and quality of care. Some such factors include

organisational structures and the delivery of nursing

care (Tourangeau et al., 2007).

Increasingly, evidence suggests staffing ratios and

skill-mix have an effect on patient outcome in a number

of clinical settings including critical care. A higher

proportion of care delivered by RNs has been shown to

decrease a number of patient complications and length

of hospital stay (Clarke et al., 1999; Dimick et al., 2001;

Aiken et al., 2002; Dang et al., 2002; Needleman et al.,

2002; Aiken et al., 2003). More recently, Tourangeau

et al., (2007) found both a higher proportion of RNs and

baccalaureate-prepared nurses were both independently

associated with lower 30-day mortality rates for acute

medical patients.

In Australian ICUs, direct patient care is delivered

exclusively by RNs, with minimal use of ENs (role

similar to licensed practical nurses (LPNs)), in contrast

LPNs have an established role in Canadian ICUs. In

2001, only 0.4% of the total number of ENs were

employed in Australian ICUs (Higlett, et al., 2005).

However, there is increasing governmental pressure to

alter the current structure of the critical care nursing

workforce to include greater numbers of non-RN staff

in response to projected nurse shortages. Dilution of

skill mix may reduce quality of care and result in

increased frequency of negative patient outcomes.

Further studies that evaluate the impact of increased

numbers of RNs in critical care, and in particular, higher

proportions of specialty educated RNs are required to

determine the impact on patient complications and

length of ICU stay.

7. Initiatives to promote and sustain the critical care

nursing workforce

The International Council of Nursing defined the goal

of workforce planning as the provision of the right

nurse, with the right qualifications with the proper

authority and appropriate recognition (AHWAC, 2002).

Further, a key aspect of improving access to ICU

services and quality of patient care is the recruitment

and retention of critical care nurses. In both Canada and

Australia, there is a shortage of critical care nurses,

though within Australia the overall RN-vacancy rate

has recently stabilised (Higlett et al. 2005). One factor

implicated in the nursing shortage is nursing education

as opportunity for career advancement and life-long

learning are seen as important retention strategies

(Yoder, 1995; Aiken et al., 2001). Therefore, it is

important to examine various education models to

determine aspects that may be adopted and lessons to

be learnt. This paper has identified the current education

systems for critical care nurses differ significantly

between the two countries. In comparison to the

Canadian model, graduate level specialty education in

Australia is relatively consistent within the tertiary

sector and sustained by the need to maintain minimum

standards for numbers of certificated staff mandated by

both nursing and medical stakeholders. There is growing

recognition for the need to standardise critical care

nursing education in Canada. In particular, the Province

of Ontario has commenced a process of significant

change as a result of discussions between key critical

care stakeholders in response to the shortage of critical

care nurses, absence of formal critical care education

programs in the tertiary sector, and inconsistency in

providing continuing education to existing critical care

nurses.

Ontario has committed to standardise critical care

nursing education and has developed new critical care

standards for practice in collaboration with the College

of Nurses of Ontario and the CACCN (MOHLTC,

2006). The goal of this initiative is to provide accessible,

quality education for new nurses in critical care as well

as provide a venue for existing nurses to engage in

simulation or e-learning to maintain or develop their

skill set through online learning modules, simulation

labs, videoconferencing and innovative approaches to

preceptored clinical placements. An effective critical care

system with appropriate health human resource man-

agement, standardised critical care education and the

capacity to accommodate surges in critical care beds will

result in improved recruitment and retention of critical

care nursing staff and better patient outcomes.

In Australia, a national taskforce has recently

completed a substantial review of nursing education

(NNNET, 2006). Current recommendations from the

review of specialisation by taskforce suggest there is a

need for the nationally coordinated development of

research-based competencies, a scope of practice and

decision-making framework (NNNET, 2005). This

strategy will further promote consistency in nursing

practice and provide critical care nurses with a standard-

ised model for practice.

Another important recommendation from the task-

force is the need for further research to explore the

relationship between postgraduate specialty education

and quality outcomes for patients and the healthcare

system. Presently, there is some evidence to support the

ARTICLE IN PRESSL. Rose et al. / International Journal of Nursing Studies 45 (2008) 1103–11091108

effect of basic nursing education level on patient

outcomes. However, little evidence exists that links

graduate level specialty education to improved patient

outcomes. This information is required to support the

widespread provision of specialty education delivered

via the tertiary sector.

8. Conclusion

Future demand for critical care services, and therefore

critical care nurses, is expected to increase with current

patterns of population growth and ageing (AHWAC,

2002). Internationally, strategies are being sought to be

able to meet this demand while maintaining quality

services that promote positive patient outcomes and

effective utilisation of resources. One such strategy is the

education and preparation of critical care nurses.

Despite similarities in health systems and ICU organisa-

tional structure, the education of critical care nurses in

Canada and Australia is strikingly different. Considera-

tion of alternative models of specialty nursing education

is necessary to improve recruitment and retention of

staff and thus prevent further nursing shortages.

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