02 NEW Step 2 Final

Critical Care Networks- National Nurse Leads
Step 2
National Competency Framework for
Registered Nurses
in Adult Critical Care
Step 2 Competencies
Version 2 : 2015
STEP TWO COMPETENCIES PAGE 2
Foreword
All step 2 Competencies have been designed to provide you with further core
critical care skills, building on those already attained in Step 1. As you progress
through this section of your development you will be expected to demonstrate
your enhanced theoretical knowledge and provide a rationale for your practice.
You will still require the supervision and support of your Mentor, Lead Assessor
and/or Practice Educator and you are advised to keep a record of any supportive
evidence and reflective practice to assist you during progress and assessment
reviews and to inform your NMC Revalidation.
Competence is defined throughout this document as:

‘The combination of skills, knowledge and attitudes, values and
technical abilities that underpin safe and effective critical care
nursing care and interventions’
It is anticipated that these competencies will form the next steps of your
development and will be included as part of your post registration academic
programme of education, which will be delivered by your local Higher Educational
Institute (HEI).
During this section you will build on a range of skills including:
• Assessing the complex patient • Interventional application
• Decision making • Influencing & negotiating
• Communicating • Engagement & facilitation
• Information & knowledge management • Leadership & risk assessment
• Rehabilitation & recovery planning
On completing this section you will be able to:
• Demonstrate skilled performance in the activity, whilst providing enhanced
theoretical knowledge and understanding, giving rationale for your practice
• Demonstrate application of knowledge and understanding in relation to
relevant policies, procedures and guidelines
• Participate in problem solving through critical analysis and evaluation of more
complex situations
• Develop more varied critical care experience with minimum supervision and
guidance, attaining competence in related knowledge and skills
Learner Name
PRINT SIGNATURE
Lead Assesor/Mentor Name

PRINT SIGNATURE
Contents
Page Title Page
Learning Contract 4
Authorised Signature Record 5
Step2: Tracker Sheet 6
Competencies
Respiratory System 8
Cardiovascular System 11
Renal System 12
Gastrointestinal System 15
Neurological System 16
End of Life 17
Intra & Inter Hospital Transfer 18
Rehabilitation 20
Professionalism 22
Leadership 22
Assessment, Development & Revalidation Record Summary

Initial Assessment & Development Plan 25
On-going Assessment & Development Plan 26
Additional Action Planning 27
Step 2 - Final Competency Assessment 28
Annual Competency Review (to accompany local appraisal documentation) 29
NMC Revalidation Checklist 30
Reflective Accounts to inform Revalidation

Reflective Account 32
Professional Development Discussion (PDD) 33
Abbreviations 34
Learning Resources 35
Acknowledgements 36
Created for CC3N by Giraffics Limited > mike.giraffics@googlemail.com

Learning Contract
The following Learning Contract applies to the Individual Learner, Lead Assessor/Mentor and Unit Manager/Lead
Nurse and should be completed before embarking on this competency development programme. It will provide
the foundations for:
• Individual commitment to learning
• Commitment to continuing supervision and support
• Provision of time and opportunities to learn
LEARNERS RESPONSIBILITIES
As a learner I intend to:
• Take responsibility for my own development
• Form a productive working relationship with mentors and assessors
• Deliver effective communication processes with patients and relatives, during clinical practice
• Listen to colleagues, mentors and assessors advice and utilise coaching opportunities
• Use constructive feedback positively to inform my learning
• Meet with my Lead Assessor/Mentor at least 3 monthly
• Adopt a number of learning strategies to assist in my development
• Put myself forward for learning opportunities as they arise
• Complete all Step 2 competencies in the agreed time frame
• Use this competency development programme to inform my annual appraisal, development needs and
NMC Revalidation
• Report lack of mentorship/supervision or support directly to the Lead Assessor/Mentor, and escalate to the
Clinical Educator/Unit Manager or equivalent if not resolved.
• Elements shaded grey and italicised only apply to specific centres.
Learner Name (Print) ...............................................................
Signature ................................................................................ Date: ...................................
LEAD ASSESSOR RESPONSIBILITIES

As a Lead Assessor I intend to:
• Meet the standards of regularity bodies (NMC, 2008)
• Demonstrate on-going professional development/competence within critical care
• Promote a positive learning environment
• Support the learner to expand their knowledge and understanding
• Highlight learning opportunities
• Set realistic and achievable action plans
• Complete assessments within the recommended timeframe
• Bring to the attention of the HEI, Education Lead and/or Manager concerns related to the individual nurses
learning and development
• Plan a series of learning experiences that will meet the individuals defined learning needs
• Prioritise work to accommodate support of learners within their practice roles
• Provide feedback about the effectiveness of learning and assessment in practice
Lead Assessor Name (Print) ...............................................................
Signature .......................................................................................... Date: ...................................
CRITICAL CARE LEAD NURSE/MANAGER

As a critical care service provider I intend to:
• Facilitate a minimum of 40% of learners’ clinical practice hours with their mentor/assessor and/or Practice
Educator or delegated appropriate other within the multidisciplinary team
• Provide and/or support clinical placements to facilitate the learners’ development and achievement of the
core competency requirements
• Regulate and quality assure systems for mentorship and standardisation of assessment to ensure validity and
transferability of the nurses’ competence
Lead Nurse/Manager Name (Print) ...............................................................
Signature .................................................................................................... Date: ...................................
National Competency Framework for Registered Nurses in Adult Critical Care

Authorised Signature Record

To be completed by any Lead Assessor/Mentor or Practice Educator.
Print Name Sample Signature Designation PIN Organisation

Step 2: Tracker Sheet

The following table allows the tracking of Step 2 Competencies and should be completed by, Lead Assessors/Mentors
and/or Practice Educators (or equivalent) as the individual achieves each competency statement. This provides an easy
and clear system to review and/or audit progress at a glance.
Competency Statement Date Achieved Mentor/Assessors Signature
2.1 Respiratory System
2.1.1 Anatomy & Physiology
2.1.2 Respiratory Assessment, Monitoring & Observation
2.1.3 Non-Invasive Ventilation
2.1.4 Endotracheal Intubation
2.1.5 Invasive Ventilation
2.1.6 Chest Physiotherapy
2.1.7 Tracheostomy Care
2.1.8 Chest Drain Management
2.1.9 Associated Pharmacology
2.2 Cardiovascular System
2.2.1 Assessment, Monitoring & Observation
2.2.2 Fluid Management
2.3 Renal System
2.3.2 Renal Replacement Therapy
2.4 Gastrointestinal System
2.4.1 Assessment & Management
2.4.2 Nutrition in Critical Illness
2.5 Neurological System
2.5.2 Assessment, Monitoring and Observation
Continued over page

Competency Statement Date Achieved Mentor/Assessors Signature
2.6 End of Life Care
2.6.1 Withholding and Withdrawing Treatment
2.7 Intra & Inter Hospital Transfer
2.7.1 Preparation and transfer of the critically ill
2.8 Rehabilitation
2.8.1 Contributing Factors to Rehabilitation Needs & Patient Dairies
2.9 Professionalism
2.9.1 Enhancing Professionalism
2.10 Leadership
2.10.1 Demonstrating Personal Qualities
2.10.2 Working With Others
2.10.3 Ensuring Patient Safety
2.10.4 Improving Services

2:1 Respiratory System

The following competency statements relate to the assessment and management of the respiratory status in the
general critical care environment. It is intended that the competencies in this section will build on the knowledge and
skills you gained in Step 1.
2:1.1 Anatomy & Physiology

You must be able to demonstrate your knowledge using a rationale Competency Fully Achieved
through discussion, and the application to your practice Date/Sign
• The anatomy and physiology of the upper and lower respiratory systems,
which must include:
o Internal and external respiration
o Cellular respiration
o Acid base balance
o Ventilation/perfusion (VQ) mismatch
2:1.2 Respiratory Assessment, Monitoring & Observation

• A comprehensive physical assessment of the patient’s respiratory status including:
o Overall visual assessment of patient (including, colour,
respiratory workload, respiratory pattern, use of supplementary oxygen,
demeanour, responsiveness)
o Assessment and interpretation of altered respiratory observations
(refer to Step 1.2.2 for normal parameters)
o Auscultation (including recognition of normal and added sounds)
• Arterial Blood Gas Assessment:
o Indications for ABG analysis
o Interpretation of abnormal results and formulate a plan of care
o Causes of acidosis and alkalosis
• Patient positioning:
• Discuss the benefits, risks and nursing care for patients in relation to
positioning (inclusive of prone positioning):
o Effects of positioning on the respiratory system
o How positioning is used to optimise respiratory function
2:1.3 Non-Invasive and Invasive Ventilation

• Care and management of the patient requiring Non-Invasive ventilation (NIV)

o Indications for (NIV):
o Benefits of NIV over invasive ventilation
o Correctly assemble and apply NIV circuits/equipment
o Manage the patient on NIV
o Adjust therapy in response to patients condition
o Correctly troubleshoot equipment
o Physiological effects on the patient of non-invasive ventilation
o Psychological effects on the patient of non-invasive ventilation

2:1.4 Endotracheal Intubation

• The care and management of a patient requiring endotracheal intubation:
o The role of the nurse in the intubation team
o Indications, advantages and disadvantages of endotracheal intubation
o Importance of having a plan to manage ‘Difficult Airway’
in line with current guidance
o Process of endotracheal intubation
o Correctly identify and assemble equipment required
o Correctly identify and prepare medications required
o Correct application of cricoid pressure
o Causes for emergency re-intubation and actions to minimise risk
o Plan care to meet the clinical needs of the patient
2:1.5 Invasive Ventilation

• The care and management of a patient requiring invasive ventilation:
o Indications for invasive ventilation
o Correct assembly of invasive ventilators including the setting of
appropriate parameters and alarm limits
o Use of humidification
o Use of capnography
o Manage the patient on invasive ventilation
o Physiological effects on the patient of invasive ventilation
o Psychological effects on the patient of invasive ventilation
o Significance of following a ventilator care bundle
2:1.6 Chest Physiotherapy

• Role of the nurse in identifying the need for physiotherapy,
including risks and benefits, and the nurse’s role in this treatment:
• Suctioning:
o Identify specific indicators and methods for suctioning
o Adjust therapy in response to the patient’s changing condition
o Identify potential complications associated with suctioning and
how to minimise / prevent these
o Advantages and disadvantages of sub-glottic suction
2:1.7 Tracheostomy Care

• Rationale for:
o Percutaneous tracheostomy
o Surgical tracheostomy
o Mini tracheostomy
o Laryngectomy

2:1.7 Tracheostomy Care continued

• Rationale for common types of tubes used:
o Cuffed / Un-cuffed
o Adjustable flange
o Fenestrated / Non fenestrated
o Tubes with inner tube
• Potential hazards associated with tracheostomies:
o During insertion
o Following insertion
• Psychological effects of tracheostomy
• Rationale for performing a SALT assessment
• Care and management of a patient with a tracheostomy:
o Assist with insertion of percutaneous tracheostomy
o Preparation of equipment
o Patient care and observation pre/peri/post procedure
o Monitor the patient for potential physical and psychological effects
associated with tracheostomies and respond accordingly
o Changing/cleaning of inner tubes
o Management of speaking valves
o Appropriately plan and deliver care in line with national / local guidelines
o Assist with SALT assessment
o Correctly identify when de-cannulation may be appropriate
• Appropriately monitor the patient for potential
complications post decannulation
2:1.8 Chest Drain Management

• Anatomy & physiology related to chest drain insertion:

o Physiological effect of a chest drain
• The care and management of a patient with a chest drain (refer Step 1.2.5):
o Indications for chest drain insertion
o Correct assembly of equipment required for insertion of a chest drain
according to evidence based practice
o Manage the patient with a chest drain
o Adjust therapy in response to the patient condition
o Removal of a chest drain
o Psychological care of a patient with a chest drain
2:1.9 Associated Pharmacology

• Knowledge of:
o Commonly used medications for respiratory care, indications for use,
mode of action and potential complications
• The care and management of a patient requiring pharmacology
to treat the respiratory system:
o Safely prepare and administer medications used to support
the respiratory system
o Appropriately monitor the patient during administration of medicines
o Titrate medication to achieve targets set by medical staff
(e.g. sedation score to aid compliance to mechanical ventilation)

2:2 Cardiovascular System

The following competency statements are about the assessment and management of the cardiovascular status in the
skills you gained in Step 1
2:2.1 Assessment, Monitoring & Observation
• Determinants of the Normal Cardiac Cycle

• Determinants of Cardiac Output
o CO = HR (Autonomic control) x SV (Preload, afterload, contractility)
• Determinants of Blood Pressure
o BP= CO x SVR
• Determinants of Central Venous Pressure
• Normal Cardiac Conduction Pathway
• Effects of ventilation on the cardiovascular system
• Recognise when advanced cardiac support is required to correct
haemodynamic instability
• Indications for haemodynamic monitoring in relation to the critically ill adult:
o Invasive
o Non-invasive
• Comprehensive cardiovascular assessment, recording findings,
optimising treatment within prescribed limits and escalating problems
to appropriate team members:
o Pulse/ECG
o Blood pressure with specific reference to MAP
o Neurological status
o Interpretation of arterial wave forms
o Interpretation of central venous pressure values and wave forms
o Recognise the significance of a distended JVP
o Renal function & urine output
o Cardiac output measurements
o Fluid therapies
o Capillary refill
o Limb temperature
o Skin turgor
o Blood results
2:2.2 Fluid Management

• Fluid compartments within the body

• Osmosis and diffusion in relation to fluid movement
• Identify the clinical indications that necessitate fluid intervention
• Identify key differences between colloids, crystalloids and blood products
• Rationalise the choice of colloids, crystalloids and blood products in
relation to the cardiac compromised patient
• Rationalise the choice of colloids, crystalloids and blood products in
relation to the patient with pre-existing cardiac disease
• Adjust fluid management to the patient’s physiological condition

2:3 Renal system

The following competency statements are about the assessment and management of the renal status in the general
critical care environment. It is intended that the competencies in this section will build on the knowledge and skills
you gained in Step 1

• Reasons for fluid redistribution in critical illness

• Auto-regulation and the hormones that affect fluid homeostasis -
renin angiotensin, Anti Diuretic Hormone (ADH), aldosterone
• Causes of acute kidney injury (AKI) (refer to Step 1.4.1)
o Pre-renal
o Intra-Renal (intrinsic kidney failure)
o Post–renal (obstruction)
• Review a patient’s arterial blood gases and discuss their interpretation in
relation to acid base balance and electrolytes in order to optimise therapy
• Review a patient’s biochemistry and haematology results and
discuss their interpretation in relation to AKI
• Evaluate the effectiveness of fluid replacement and medications and
adjusts therapy in response to a patient’s condition
• Treatment choices available and the principles involved in:
o CCCHDF
o CVVHD
o CVVH
o SLEDD
o Haemodialysis
o Peritoneal dialysis
2:3.2 Renal Replacement Therapy

NB. The competencies below are to be achieved in centres

which deliver RRT
• The care and management of a patient being established
on renal replacement therapy:
o Correct assembly of equipment required for RRT
o Set up the appropriate equipment and consumables for
catheter insertion
o Maintain asepsis throughout the procedure in line with local policy
o Establish the patient in the correct position for catheter insertion
(depending on chosen site)
o Document catheter insertion appropriately and in line with local policy
o Outline a comprehensive monitoring and plan of care for the
maintenance of the catheter
o Ensure all relevant safety checks are performed prior to the
use of the catheter
o Maintain patency of the catheter in accordance with local policy
(e.g. hep lock)
o Secure the catheter appropriately
o Ensure all waste is disposed of in accordance with local guidelines

2:3.2 Renal Replacement Therapy continued

NB. The competencies below are to be achieved in centres

which deliver RRT
• The care and management of a patient being established
on renal replacement therapy:
o Select the prescribed treatment mode and set individualised
prescribed treatment goals
o Monitor the needs of the individual requiring this treatment therapy
o Perform all base line blood profiles prior to treatment and
offer explanations
o Perform a limb perfusion assessment, if relevant
o Record accurate fluid balance including running totals and
accumulative balance
o Establish an individualised plan of care for renal replacement therapy
• Observe, monitor and conduct the following:
o Access pressures
o Return pressures
o Trans membrane pressure
o Filter checks
o Blood chamber check, if appropriate
o Gas chamber checks, if appropriate
o Body temperature and appropriate adjustment of active
warming /cooling (through replacement fluid or blood circuit)
o Physiological parameters
o Fluid balance assessment
o Electrolyte balance
o Acid base balance
o Other, specific to own equipment used
• Anticoagulation:
o Prepare the chosen anticoagulation therapy in line with manufactures
recommendations, NMC guidance and local policy
o Safely administer anticoagulation therapy in line with NMC
guidance and local policy
o Establish monitoring plan for full blood count and coagulation blood
profiles giving rationale
o Conduct point of care testing as necessary and titrate anticoagulation
therapy in response to results according to local guidelines
• Trouble shooting:
o Position the patient appropriately (depending on catheter site)
to ensure adequate line patency and patient comfort
o Perform basic troubleshooting to ensure continuation of therapy
• Care and maintenance of Lines:
o Undertake routine dressing changes, maintaining asepsis
throughout procedure
o Observe the line site and document findings appropriately
o Heparin lock the catheter when not in use in line with
national / local guidance
o Discontinuation of RRT
o Psychological care of a patient on RRT
o Complete appropriate documentation


• Commonly used medications in AKI, indications, contraindications and the

appropriate care of the patient during therapy:
o Diuretics
o Dextrose and insulin
o Salbutamol, nebulised
o Calcium
o Calcium resonium
o Sodium bicarbonate
• Evaluate the effectiveness of fluid replacement and medications and
adjust care accordingly

2:4 Gastrointestinal System

The following competency statements are about the assessment and management of the gastrointestinal status in the
skills you gained in Step 1
2:4.1 Assessment & Management
• Surgical procedures and common reasons for intervention:
o Hartmann’s procedure
o Oesophagectomy
o Colectomy
o Toxic Mega-colon
o Paralytic ileus – causes and effects
• Acute GI conditions, signs, symptoms and common causes:
o Pancreatitis
o GI bleed
o Oesophageal varices
o Peptic/Duodenal ulcers
• Physiological changes associated with chronic and acute liver disease and
how a patient may present in critical care depending on the cause:
o Acute liver & biliary impairment, signs, symptoms and common causes
specifying how a patient may present in critical care depending on the cause
o Process of bacterial translocation
• Drain management associated with abdominal disorders
• Risks of sepsis associated with GI disorders
2:4.2 Nutrition in Critical Illness

• Refer to patients past medical history and outline how this may
affect gastrointestinal function
• Determine the monitoring needs for the individual at risk of deterioration
related to gastrointestinal function
• Report any abnormalities to appropriate MDT member
• Correctly review a patient’s biochemistry and haematology results and
interpret the findings in relation to gastrointestinal function
• Evaluate the effectiveness of therapeutic interventions and
adjust care accordingly
• Alter nutritional regimes in line with MDT recommendations and local policy
• Recognise the patient at risk of deteriorating from sepsis

• Indications for the following medications in relation to specific GI disorders:
o Prokinetics & motility
o Laxatives
o Anti-stimulants
o Insulin/ hypoglycaemic agents
o Probiotics
o Steroids
o Anti diarrhoea drugs
o Anti secretory drugs

2:5 Neurological System

The following competency statements are about the assessment and management of the neurologically compromised
patient in the general critical care environment. It is intended that the competencies in this section will build on the
knowledge and skills you gained in Step 1

• Function of the nervous system

• Gross structures of the central and peripheral nervous system
• Functional divisions of the peripheral nervous system
• Major functional areas of the brain to include discussion of brain stem function
• Protective layers of the brain and spinal cord
• Mechanisms for normal regulation of cerebral perfusion and intracranial pressure
(ICP) with normal parameters for ICP and cerebral perfusion pressure (CPP)
• Monro-Kellie hypothesis
• Cushings triad
• Primary and secondary brain injury
2:5.2 Assessment, Monitoring and Observation

• Comprehensive neurological assessment, recording findings, optimising treatment

within prescribed limits and escalating problems to appropriate MDT members:
o Glasgow Coma Scale (GCS) assessment and accurate documentation
(refer to Step 1.6.2)
o Pupil response (size, shape and reactivity)
o Limb movements
o Indications for CT scanning according to local,
national and professional guidance
o Signs and symptoms of raised ICP
o Identifying focal deficits
• The care and management of a patient with neurological compromise:
o Maintenance of accurate fluid balance
o Administration of fluids, including oncotic therapy as prescribed
o Monitoring of haemodynamic status and managing therapy to maintain
prescribed haemodynamic parameters such as MAP
o Provide nursing care that demonstrates an awareness of the potential
impact on ICP: e.g. body alignment, tying of ET tapes
o Safe transfer to neuro-surgical/tertiary centre if required
2:5.3 Associated pharmacology

• Medications used in neurological management:

o Osmotic therapy
o Analgesia
o Sedation
o Neuromuscular paralysing agents
o Anticonvulsant therapy
o Vasoactive therapy
o Steroids
o Nimodipine
• Safely prepare and administer medications
• Monitor effects of medication

2:6 End of Life Care

The following competency statements relate to end of life (EOL) care for patients in the general critical care environment.
It is intended that the competencies in this section will build on the knowledge and skills you gained in Step 1
2:6.1 Withholding and Withdrawing Treatment

• Legal constraints, Mental Capacity Act and ethical principles of

withdrawal or withholding of treatment
• Procedures for forming and recording agreements on treatment withdrawal
• Best practice procedures for early identification of potential organ/tissue
donation according to defined triggers
• How to facilitate access to sources of support within the broader
MDT e.g. bereavement support
• Availability of care suitable for patients after withdrawal of treatment
e.g. EOL care plan
2:6.2 Assessment, Monitoring and Observation

• Establish with the MDT that further treatment for the patient is futile and that,
at some stage, active treatment should be withdrawn in the knowledge that
this will result in the patient’s death
• Consider the patients and/or families preference for where care will be delivered
after withdrawal of treatment
• Review the end of life care options suitable for patients
• Initiate a systematic timely referral to the Specialist Nurse Organ Donation
(SNOD) for all potential organ and tissue donation as part of end of life care
in line with local policy
• Involve the SNOD and participate in the planning and conduct of a MDT
approach to families for consent/ authorisation for organ and tissue donation
according to best practice guidance
• Agree with the patient, where possible and their family and
colleagues a plan of care
• Arrange resources for the delivery of the plan, including liaison with
MDT and appropriate support teams
• Evaluate the care plan according to local policy and adapt to patient need
Initiate individualised treatment plans to ease effects of illness:
o Pain
o Nausea
o Agitation
o Dyspnoea
o Respiratory Tract Secretions

2.7 Intra & Inter Hospital Transfer

The following competency statements relate to the preparation required prior to and the management of patients
during intra & inter hospital transfer. It is intended that the competencies in this section will build on the knowledge
and skills you gained in Step 1
2:7.1 Preparation and transfer of the critically ill

• Policies/procedure/guidelines related to the transport of the critically ill patient:
o ICS guidelines
o Regional standards
o Risk assessment
o Local policy
o Bed management systems
o Transfer audit documentation
• Role of team members when arranging and carrying out
an intra & inter hospital transfer
• Complete a comprehensive risk assessment in collaboration with the MDT to
ensure the patient is fit or suitable for transfer
• Identify the potential risks associated with transferring critically ill patients
• Indications for transfer from critical care including the:
o Nature: repatriation, specialist treatment, investigation, continuing care
o Sequence of expected event
o Urgency and time critical transfers
o Reasons for reviewing individuals’ priorities, needs and the time frame
with which this should be undertaken
• Transfer process including the different considerations for clinical and
non-clinical transfer decisions:
o Communication with relatives and on-going updating of
the situation as required
o Ethical issues
o Legal requirements
o Local escalation policies
o Bed management system
o Referral to receiving hospital (including critical care and specialty consultants)
o Responsibility of care during transfer
o Indemnity insurance
o Competency and skills of transferring personnel
o Risk assessment of patient’s physiological requirements and maintenance of
homeostasis during transit
o Contingency planning/back up considerations
o Drug administration during transfer
o Type of transport required, time critical issues, bariatric patients
o Communication with receiving hospital prior to transfer
o Documentation and audit
• Differing types of transport available and make recommendations for which
is the most appropriate
• Process for organising the appropriate transport:
o Ambulance service
o Vehicle specification (including on board resources and equipment)
o Ambulance equipment
o Types of transfer trolley available
o Storage of transport equipment in transit
o Time critical transfer issues

2:7.1 Preparation and transfer of the critically ill continued

• Process for preparing to undertake an intra / inter hospital transfer of
a critically ill patient:
o Gathering of extra battery packs, alternative equipment in case of malfunction
o Clinical notes/radiology reports/recent blood profiles/investigations
o Assessment of patient’s physiological requirements during transfer
o Accuracy of portable monitoring and equipment
o Re assess safety/risk factors prior to transfer
• Process and sequence of communication required for providing oral
reports/discussions:
o Information and informed consent in the conscious patient
o Discussion with family members
o Verbal referral and handover of patients condition to receiving unit/service
o Handover of condition and physiological requirements to
the transfer team/personnel
o Sharing information with the team in relation to safety,
risk assessments and contingency planning
o Contact receiving unit/service on departure
o Formal handover to receiving unit/service on arrival
• Documentation that needs to be completed in an accurate, concise and
systematic manner during a inter hospital transfer, with appropriate duplications:
o Transfer form
o Physiological observation chart
o Nursing evaluation
o Reporting of clinical incidents
o Audit tool
• Prepare the patient for transfer by assisting the wider MDT in the
physiological optimisation/stabilisation
o Assess potentially competing needs of the patient for pre-transfer
optimisation and specialist care
o Assess clinical condition of patient before leaving the critical care unit
• Maintain the safety of the patient during transfer:
o Assessment of the extra physiological stresses experienced by the
patient during inter-hospital transfer
o Anticipation of potential problems and planning to reduce the
likelihood of their occurrence
o Maintenance of situational awareness and readiness to respond to
threatening situations if and as they occur
• Demonstrate awareness of situational factors that could impact on
the quality and safety of a critical care transfer
• Identify areas in your own transfer practice that could be improved
• Reflect on your own transfer experience

2:8 Rehabilitation
The following competency statements are about the initial rehabilitation needs of the patient in a critical care
environment, including those that have suffered a major trauma.
2:8.1 Contributing Factors to Rehabilitation Needs & Patient Dairies

• Reasons why the following specific health conditions may cause on-going
rehabilitation needs in the critically ill:
o Critical illness and patterns of recovery
o Trauma and patterns of recovery
o Cardiac disease and patterns of recovery
o Renal disease and patterns of recovery
o Acute brain injury and patterns of recovery
o Spinal injuries and patterns of recovery
o Stroke and patterns of recovery
• Understanding and awareness of the Rehabilitation prescription
• Demonstrate, understand and complete a risk assessment of a critically ill patient
in regard to rehabilitation following their illness,(i.e. short clinical assessment)
o Multi organ failure/sepsis
o Multiple trauma
o Multiple co-morbidities
o Artificial airway for more than 48 hours
o Tracheostomy
o Major surgery/amputation
o Neurological conditions
o Prolonged sedation
o Neuropathy/loss of pre admission function
o Loss of muscle mass
o Cognitive impairment
o Intrusive memories
o Sleep deprivation
o Post -traumatic stress disorder
o Delirium
o Anxiety
o Depression
• Diversity issues and how they may impact on the patients rehabilitation needs:
o Age
o Culture
o Religion
o Language
o Sexuality
o Identity

2:8.1 Contributing Factors to Rehabilitation Needs & Patient Dairies continued

• Initiate (where used) and understand the benefits of patient diaries in

the recovery from critical illness:
o Explanation for loss of time
o Providing information for a period of their life for which they may not
have any memory of
o Accepting and understanding their own emotions
o Accepting and understanding the emotions of their family
• Understand and comply with the legal and ethical considerations
for patient diaries:
o Use of photographs
o Confidentiality
o Consent issues
o Relatives versus Staff diary entries
o Level of information written
• Resources available for recovering critical care patient’s:
o Rehabilitation teams (where available)
o Step down follow up visits
o On-going rehabilitation goals
o Make swift referrals to appropriate multidisciplinary team members
o Intensive rehabilitation clinics
o Follow up clinics
o Local patient and relative information
o ICU Steps
o Other support groups

2:9 Professionalism
The following competency statement is about maintaining professionalism in critical care nursing practice.
It is intended that the competencies in this section will build on the knowledge and skills you gained in Step 1.
2:9.1 Enhancing professionalism

• NMC Code (2015) Professional standards of practice and behaviour for
nurses and midwives
• Demonstrate self-awareness of own strengths and limitations
• Demonstrate effective inter-professional relationships that facilitate
meeting the needs of patients and families
• Demonstrate an ability to be a motivated self-directed learner
• Demonstrate an ability to be an effective mentor and role model as appropriate
• Demonstrate safe and effective written, verbal, telephone and
electronic communication strategies
• Demonstrate safe effective work/life balance strategies
2:10 Leadership
The following competency statement is about increasing leadership skills to support your professional
development in critical care. It is intended that the competencies in this section will build on the knowledge
and skills you gained in Step 1.
2:10.1 Demonstrating Personal Qualities

• Develop self-awareness and acknowledge limitations
• Be able to manage own time effectively
• Actively seek opportunities and challenges for personal learning
and development
• Acknowledge mistakes and treat them as learning opportunities
• Change behaviour in the light of feedback and reflection

2:10.2 Working With Others

• Identify opportunities where working in collaboration with others can
bring added benefits
• Promote the sharing of information and resources
• Actively seek the views of others
• Have a clear sense of your role, responsibilities and purpose within the team
• Adopt a team approach, acknowledging and appreciating efforts,
contributions and compromises
• Recognise the common purpose of the team and respect team decisions
• Support others to provide good patient care and better services
2:10.3 Ensuring Patient Safety

• Understand your role in influencing the quality of safe and
effective critical care services
• Identify actual or potential risks or incidents and take required actions
• Promote a safe culture that learns from and responds to risk
• Instigate immediate response to safe guard patients
• Report adverse or potential risks through internal clinical
incident reporting system
2:10.4 Improving Services

• Obtain and act on patient, carer and service user feedback and experiences
• Question existing practices and challenge present performance/culture
• Contribute to change management initiatives being led
by more experienced staff
• Contribute to quality improvement projects being undertaken in your unit

Assessment, Development &

Revalidation Record Summary
Date Assessment Completed Lead Assessor/Mentor Signature

Initial Assessment & Development Plan
Date | | | (Please add date to the Assessment Record Summary)

This meeting between Learner and Lead Assessor/Mentor should take place within 3 months of starting this section
of your development. It is to identify the learning needs of the nurse during their Step 2 development and to identify
those areas on which to concentrate.
CURRENT CRITICAL CARE KNOWLEDGE, UNDERSTANDING AND SKILLS
c o py
o to
Ph
COMPETENCIES TO BE ACHIEVED
if
u ire d
e q
SPECIFIC SUPPORTIVE STRATEGIES REQUIRED
R
Learners Signature: ……………………………………………
Lead Assessors / Practice Educators Signature: ……………………………
NEXT AGREED MEETING DATE: | | |

Ongoing Assessment & Development Plan

This meeting between Learner and Lead Assessor/Mentor is to identify the progress made by the nurse in achieving
the competencies identified in the initial and/or previous meetings. It is here further objectives will be set. Ongoing
assessments should take place at least every 3 months. If the learner requires additional support a further action plan
can be completed.
REVIEW OF COMPETENCIES ACHIEVED
y
ON TARGET: YES NO
c o p
IF NOT WHICH COMPETENCIES HAVE YET TO BE MET
o to
Ph
if
REASONS FOR NOT ACHIEVING
u ire d
SPECIFIC OBJECTIVES TO ACHIEVE COMPETENCE
Re q
KEY AREAS & ADDITIONAL COMPETENCIES TO BE ACHIEVED BEFORE NEXT MEETING

Additional Action Planning
Date | | |
This document is to be completed as required to set SMART objectives for the learner who requires additional support
to achieve certain competencies (these will have been identified during the 3 monthly Ongoing Assessment
& Development plan).
AREAS FOR FURTHER ACTION PLANNING
c o py
o to
Ph
if
u ire d
Re q

Step 2 - Final Competency Assessment
This meeting is to identify that all the competencies within Step 2 have been achieved and that the nurse is
considered a safe competent practitioner.
COMPETENCY STATEMENT:
The nurse has been assessed against the competencies within this document and measured against the definition of
competence below by critical care colleagues, mentors and assessors and is considered a competent safe practitioner
y
within the critical care environment:
o p
“The combination of skills, knowledge and attitudes, values and technical abilities that underpin safe and
c
effective critical care nursing care and interventions”
to
As part of quality assurance the nurse is expected to maintain a portfolio of practice as part of NMC regulations and
revalidation to support ongoing competence and declare any training and/or development needs to their line manager
o
or appropriated other.
Ph
Competency will be reviewed annually as part of staff personal development plans and evidence of this will be
required for NMC revalidation. Where necessary objectives will be set to further develop any emerging competency
required to work safely within the critical care environment.
if
LEAD ASSESSORS COMMENTS
u ire d
Re q
LEARNERS COMMENTS

Annual Competency Review (to accompany local appraisal documentation)

This record is a statement between the nurse who has completed Step 2 competencies successfully and their
Appraiser. It should be used alongside local appraisal systems annually to ensure that the nurse continues to
demonstrate themselves as a safe competent critical care practitioner
OVERALL COMPETENCY MAINTAINED YES NO
py
If not which competencies require further development
to c o
Pho
if
Specific objectives to achieve competence
u ire d
Re q
Further Comments
Signature: ……………………………………………

NMC Revalidation Checklist (every 3 years)

Revalidation is a continuous process that nurses need to engage with throughout their career. It is not a point in
time activity or assessment; however, you will need to be able to provide evidence of achievement against the NMC
requirements. This document should be completed as part of your local appraisal.
EVIDENCE OF COMPLETING 450 PRACTICE HOURS IN CRITICAL CARE YES NO
y
LIST EVIDENCE PRODUCED BELOW
o c o p
Pho t
EVIDENCE OF COMPLETING 40 HOURS CONTINOUS PROFESSIONAL DEVELOPMENT (CPD) YES NO
if
(20 Hours need to be participatory learning, list evidence produced below)
u ire d
e q
EVIDENCE OF 5 REFELECTIONS YES NO
R
EVIDENCE OF APPROPRIATE PROFESSIONAL INDEMNITY ARRANGEMENTS YES NO


NMC Revalidation Checklist continued
3rd PARTY CONFIRMATION
LEARNER CONFIRMER
LEARNERS NAME CONFIRMERS NAME
o py
LEARNERS SIGNATURE CONFIRMERS SIGNATURE
o to c
Ph
LEARNERS JOB TITLE CONFIRMERS JOB TITLE
LEARNERS PIN CONFIRMERS PIN
if
LEARNERS E MAIL ADDRESS CONFIRMERS E MAIL ADDRESS
u ire d
Re q

Reflective Accounts to inform NMC Revalidation

You are required to record a minimum of five written reflections on the NMC Code (2015) and your
Continuous Professional Development as well as gaining practice-related feedback, as outlined in
‘How to revalidate with the NMC’.
You are advised to complete the following documents during your critical care development to
inform your NMC Revalidation, you are required to discuss these reflections with your Mentor/Lead
Assessor and/or Practice Educator at your on-going assessment reviews, your final assessment and/or your
annual progress review as part of your local appraisal process. Once you have discussed these reflections
your Mentor/Lead Assessor and/or Practice Educator will need to complete the relevant ‘Professional
y
Development Discussions’ (PDD) documentation to provide evidence of this.
p
Reflective Account Date
o
| |
c
Please fill in a page for each of your reflections, ensuring you do not include any information that might identify a
o
specific patient or service user. You must discuss these reflections as part of a professional development discussion (PDD)
t
with another NMC registrant who will need to complete the PDD document to provide evidence of this taking place.
Pho
What was the nature of the CPD activity/ practice-related feedback?
if
What did you learn from the CPD activity and/or feedback?
u ire d
Re q
How did you change or improve your work as a result?
How is this relevant to the Code?

(Select a theme, Prioritise people - Practice effectively - Preserve safety - Promote professionalism and trust)
Signature:

Professional Development Discussion (PDD)
Date | | |
You are required to have a PDD with another NMC registrant covering your written reflections on the Code, your CPD
and practice-related feedback. This form should be completed by the registrant (Mentor/Lead Assessor and/or Practice
Educator) with whom you have had the discussion.
NAME NMC PIN
py
EMAIL ADDRESS
c o
PROFESSIONAL ADDRESS (INCLUDING POSTCODE)
o to
Ph
NAME OF REGISTRANT WITH WHOM YOU HAD A PDD DISCUSSION
if
NMC Pin of registrant with whom you had a PDD discussion
NUMBER OF REFLECTIONS DISCUSSED:
u ire d
Re q
Declaration: I confirm that I have discussed the number of reflective accounts listed
above, with the above named registrant, as part of a PDD
Signature:

Abbreviations
A,B,C,D,E Airway, Breathing, Circulation, Disability, Exposure ICNARC Intensive Care National Audit & Research Centre
ABG Arterial Blood Gas ICP Intracranial Pressure
ADH Anti-Diuretic Hormone ICS Intensive Care Society
AHP Allied Health Care Professional ICU Intensive Care Unit
AKI Acute Kidney Injury I:E Ratio Inspiratory : Expiratory Ratio
ALI Acute Lung Injury IHD Intermittent Haemo Dialysis
ALS Advanced Life Support ILS Intermediate Life Support
ANTT Aseptic Non Touch Technique IPC Infection Prevention & Control
ARDS Acute Respiratory Distress Syndrome IRV Inverse Ration Ventilation
AVPU Alert, Voice, Pain, Unresponsive IV Intravenous
BACCN British Association of critical Care Nurses JVP Jugular Venous Pressure
BLS Basic Life Support KSF Knowledge & Skills Framework
BNF British National Formulary MAP Mean Arterial Pressure
BP Blood Pressure MDT Multidisciplinary Team
BTS British Thoracic Society MEDUSA Injectable Drug Administration Guide
CAM-ICU Confusion Assessment Method MRI Magnetic Resonance Imaging
CC3N Critical Care Networks National Nurse Lead Group MRSA Methicillin-resistant Staphylococcus Aureus
CCMDS Critical Care Minimum Data Set MUST Malnutrition Universal Screen Tool
C-Diff Clostridium difficile NEWS National Early Warning Score
CMS Capacity Management System NG Nasogastric
CO Cardiac Output NHS National Health Service
CO2 Carbon Dioxide NICE National Institute of Clinical Excellence
COPD Chronic Obstructive Pulmonary Disease NICE CG National Institute of Clinical Excellence-
COSHH Control of Substances Hazardous to Health Clinical Guideline
CPAP Continuous Positive Airway Pressure NIV Non Invasive Ventilation
CPD Continuing Professional Development NJ Naso-jejunal
CPE Carbapenemase Producing Enterobacteriaceae NMC Nursing & Midwifery Council
CPP Cerebral Perfusion Pressure NPSA National Patient Safety Agency
CRBSI Catheter Related Blood Stream Infection PCA Patient Controlled Analgesia
CSF Cerebrospinal Fluid PDD Professional Development Discussion
CT Computerised Tomography PEA Pulseless Electrical Activity
CV Cardiovascular PEG Percutaneous Endoscopic Gastroscopy
CVP Central Venous Pressure PIN Personal Identification Number
CVVH Continuous Veno Venous Haemofiltration PPE Personal Protective Equipment
CVVDH Continuous Veno Venous Dialysis RCN Royal College of Nursing
CVVHDF Continuous Veno Venous Haemodiafiltration RIG Radiologically Inserted Gastrostomy
CXR Chest X-Ray RR Respiratory Rate
DBD Donation following Brain Death RRT Renal Replacement Therapy
DCD Donation following Circulatory Death SAH Subarachnoid Haemorrhage
DOH Department of Health SALT Speech and Language Therapy
DOS Directory of Service SIRS Systemic Inflammatory Response Syndrome
ECG Electrocardiograph SLEDD Sustained Low-Efficiency Dialysis
EPUAP European Pressure Ulcer Advisory Panel SMART Specific, Measurable, Achievable, Realistic, Timely
ET Endotracheal SNOD Specialist Organ Donation Nurse
EtCO2 End Tidal Carbon Dioxide SPO2 Saturated Oxygen
ETT Endotracheal Tube SR Sinus Rhythm
GCS Glasgow Coma Scale SVO2 Mixed Venous Oxygen Saturation
GI Gastrointestinal SV Stroke Volume
H2 Antagonist Histamine H2-receptor antagonists SVR Systemic Vascular Resistance
HEI Higher Educational Institute SVT Sinus Ventricular Tachycardia
HII High Impact Intervention TMP Trans Membrane Pressure
HME Heat Moisture Exchange VAP Ventilator Associated Pneumonia
HR Heart Rate V/Q Ventilation / Perfusion
VRE Vancomycin Resistant Enterococci
VTE Venous thromboembolism

Learning Resources
BACCN website: www.baccn.org.uk
Brain Trauma Foundation (2007) Guidelines for the management of traumatic brain injury. Journal of Neuro Trauma.
24 (1) pp S- 59 S - 64. p 17-23. p 47-74
Borthwick, M, Bourne, R, Craig, M, Egan, A and Oxley, J (2006) Detection, prevention and treatment of delirium in
critically ill patient. United kingdom Clinical Pharmacy association.
CC3N website: www.cc3n.org.uk
Department of Health (1996) Guidelines on admission to and discharge from intensive care and
high dependency units. DoH, London
Department of Health (2009) Reference guide to consent for examination or treatment (2nd edition) London: DH
Department of Health (2008).Clean, safe care: Reducing infections and saving lives. Gateway ref: 9278
Department of Health (2010) High Impact Intervention: Renal haemodialysis. DOH guideline.
Department of Health (2012) Health and Social Care Act. March 2012, TSO
EPUAP (2009) European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.
Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel
Faculty of Intensive Care Medicine website: www.ficm.ac.uk
ICU Steps website: www.icusteps.org
ICNARC website: www.icnarc.org
Intensive Care Society website: www.ics.ac.uk
Intensive Care Society (2004) Guidelines for Adult Organ and Tissue Donation Prepared on behalf of the Intensive
Care Society by the Society’s Working Group on Organ and Tissue Donation
Intensive Care Society (2009) Standards and recommendations for the provision of renal replacement therapy
on the intensive care unit in the United Kingdom. ICS guideline
Intensive Care Society (2011) Guidelines for the transport of critically ill adults. Standards and Guidelines
National Institute for Clinical Excellence (2007) Head Injury: Triage, Assessment and Early Management of
Head Injury in Children, Infants and Adults. www.nice.org.uk/CG056
NCEPOD (2009) Adding Insult to injury: a review of the care of patients who dies in hospital with a
primary diagnosis of acute kidney injury (acute renal failure. NICE publication
NHS England website: www.england.nhs.uk
NHS Confederation (2012): The NHS handbook: The essential guide to the new NHS.
Available at www.nhsconfed.org
NOrF website: www.norf.org.uk
NMC website: www.nmc.org.uk
RCN website: www.rcn.org.uk
Tortora G. J. and Derrickson B., H. (2011) Principles of Anatomy and Physiology, International Student Version
(13th Edition). John Wiley & sons, inc. New York.
UK Code of Practice for the diagnosis of brain stem death; including guidelines for the identification and
management of potential organs and tissue donors. Working Party established through the Royal College of
Physicians on behalf of the Academy of Medical Royal Colleges (1998)

Acknowledgements
This framework has been developed in partnership with a wide range of stakeholders from practice and academia
within the critical care community across England, Wales and Northern Ireland. Thanks are extended to all
contributors specifically the following:
CHAIR:
Melanie Kynaston, Cheshire & Mersey Critical Care Network & Deputy Chair: CC3N
WORKING PARTY 2015:

Andrea Baldwin, Lancs & South Cumbria Critical Care Network & CO Chair: National Network Directors
Andrea Berry, Greater Manchester Critical Care Network & Chair: UKCCNA
Angela Himsworth, Central England, Birmingham & the Black Country and North West Midlands Critical Care
Network & Chair: CC3N
Ann Price, BACCN Representative & Canterbury Christ Church University
Anne Miles, Wye Valley NHS Trust, Hereford
Alison East, East Of England Critical Care Network
Alison Eddleston, University of Central Lancashire University
Amelda Blignaut, IHAS Representative
Caroline Wood, Mid Trent Critical Care Network
Diane Eady, Mid Trent Critical Care Network
Helen Jones, Cheshire & Mersey Critical Care Network & The Walton Centre NHS Foundation Trust
Julie Platten, North of England Critical Care Network
Kate Deacon, University of Wolverhampton
Karen Donnelly, South Tees NHS Foundation Trust
Neville Rumsby, Liverpool Heart & Chest Hospital NHS Foundation Trust
Nicola Witton, Keele University
Lesley Durham, North of England Critical Care Network
Lorna Johnson, West Yorkshire Critical Care Network
Lorraine Marsons, Birmingham City University
Pauline Freeman, University of Hertfordshire
Robin Duncan, North of England Critical Care Network, City Hospitals Sunderland NHS Trust
Samantha Cook, Greater Manchester Skills Institute
Sheila Kinoulty, Critical Care Network of Northern Ireland, CCaNNI
Thanks is also extended to the original 2012 working party

Notes

Critical Care Networks-National Nurse Leads (CC3N) 2015
All rights reserved. No reproduction, copy or transmission of this publication may be made without written
permission. No paragraph of this publication may be reproduced, copied or transmitted save with written permission
or in accordance with the provisions of the Copyright, Designs and patents Act 1988.
Neither the Critical Care Networks-National Nurse Leads (CC3N) nor the authors accept any responsibility for any
loss or damage arising from actions or decisions based on the information contained in this publication. Ultimate
responsibility for the treatment of patients and interpretation of the published materials lies with the Registered Nurse.
This document has been produced with support from these organisations and is available through the CC3N website:
www.cc3n.org.uk. It has received interest internationally and may be available in the future in alternative languages, it
has also be used to inform registered nurse competency development in specialities outside of critical care.
Critical Care Networks- National Nurse Leads
www.cc3n.org.uk www.baccn.org.uk www.ics.ac.uk
www.rcn.org.uk www.icusteps.org.uk www.norf.org.uk
www.aiho.org.uk

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Critical Care Networks- National Nurse Leads

Competence is defined throughout this document as:

Lead Assesor/Mentor Name

Page Title Page

Assessment, Development & Revalidation Record Summary

Reflective Accounts to inform Revalidation

Created for CC3N by Giraffics Limited > mike.giraffics@googlemail.com

Learner Name (Print) ...............................................................

Signature ................................................................................ Date: ...................................

LEAD ASSESSOR RESPONSIBILITIES

Lead Assessor Name (Print) ...............................................................

Signature .......................................................................................... Date: ...................................

CRITICAL CARE LEAD NURSE/MANAGER

Lead Nurse/Manager Name (Print) ...............................................................

Signature .................................................................................................... Date: ...................................

National Competency Framework for Registered Nurses in Adult Critical Care

Authorised Signature Record

Print Name Sample Signature Designation PIN Organisation

National Competency Framework for Registered Nurses in Adult Critical Care

Step 2: Tracker Sheet

Competency Statement Date Achieved Mentor/Assessors Signature

2.1 Respiratory System

2.1.1 Anatomy & Physiology

2.1.2 Respiratory Assessment, Monitoring & Observation

2.1.3 Non-Invasive Ventilation

2.1.4 Endotracheal Intubation

2.1.5 Invasive Ventilation

2.1.6 Chest Physiotherapy

2.1.7 Tracheostomy Care

2.1.8 Chest Drain Management

2.1.9 Associated Pharmacology

2.2 Cardiovascular System

2.2.1 Assessment, Monitoring & Observation

2.2.2 Fluid Management

2.3 Renal System

2.3.1 Anatomy & Physiology

2.3.2 Renal Replacement Therapy

2.3.3 Associated Pharmacology

2.4 Gastrointestinal System

2.4.1 Assessment & Management

2.4.2 Nutrition in Critical Illness

2.5 Neurological System

2.5.1 Anatomy & Physiology

2.5.2 Assessment, Monitoring and Observation

2.5.3 Associated Pharmacology

Continued over page

National Competency Framework for Registered Nurses in Adult Critical Care

Competency Statement Date Achieved Mentor/Assessors Signature

2.6 End of Life Care

2.6.1 Withholding and Withdrawing Treatment

2.7 Intra & Inter Hospital Transfer

2.7.1 Preparation and transfer of the critically ill

2.8.1 Contributing Factors to Rehabilitation Needs & Patient Dairies

2.9.1 Enhancing Professionalism

2.10.1 Demonstrating Personal Qualities

2.10.2 Working With Others

2.10.3 Ensuring Patient Safety

2.10.4 Improving Services

National Competency Framework for Registered Nurses in Adult Critical Care

2:1 Respiratory System