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Revising the Canadian Association of Critical Care Nurses Standards for Critical Care Nursing Practice: A Modified Delphi Protocol

Brandi Vanderspank-Wright, PhD, RN, CNCC(C), Sarah Crowe, MN, PMD-NP(F), NP, CNCC(C), for the Canadian Association of Critical Care Nurses, National Board of Directors

Abstract

Background: Since 1992, the Canadian Association of Critical Care Nurses (CACCN) has set the Standards of Practice for Canadian critical care nurses. The current Standards were revised in 2017, after undergoing the fifth review since inception. The Association’s practice has been to review the Standards approximately every five years.

Aim: The aim of this protocol is to provide a transparent and replicable process for Standards revision.

Methods: A two-phased design that includes a systematic review modelled on Joanna Briggs Institute (JBI) Scoping Review methodology

and second, a Modified-Delphi consensus process. The reporting of this protocol is guided by PRISMA-P reporting guidelines.

Outcomes: All items included in the final consensus will be utilized to create the revised sixth edition of the CACCN Standards for Critical Care Nursing Practice. The standards will be published in the Canadian Journal of Critical Care Nursing, posted on the CACCN website (www.caccn.ca), and shared among the CACCN network to help inform Critical Care Nursing practice in Canada.

Keywords: practice standards, systematic review, modified-Delphi, critical care nursing, protocol

Vanderspank-Wright, B., & Crowe, S. (2023). Revising the Canadian Association of Critical Care Nurses Standards for Critical Care Nursing Practice: A Modified Delphi Protocol. The Canadian Journal of Critical Care Nursing, 34(3), 18–21. DOI: 10.5737/23688653-34318

The Canadian Association of Critical Care Nurses (CACCN) is the national association representing critical care nurses (CCN) in Canada. Since 1992, the CACCN has set the standards of practice for Canadian CCNs. Standards of care provide legal guidance for what constitutes “safe and appropriate patient care” (Shapiro, 2019, p.102); nurses “are obligated to provide knowledgeable, competent, and safe care and act in the best interests of their patients” (Shapiro, 2019, p.101). Standards of practice also “delineate the scope, function, and role of the nurse in practice” (Shapiro, 2019, p.102). The Standards for Critical Care Nursing Practice (CACCN, 2017) are used to guide and to provide a resource for CCNs to ensure that best practices are utilized in Canadian critical care units. The Standards provide broad, overarching guidance that is then individualized at the unit level to ensure high quality care is provided to all patients and families accessing critical care in Canada.

The current Canadian Standards were revised in 2017, after undergoing the fifth review since inception. The Standards were initially developed utilizing literature reviews and expert nurse input in the past (Kidd et al., 1987). Although every attempt to complete a robust review has been made in the past, with the exception of the first published standards, there has not been a defined, standardized methodological process applied to the development or the review. Therefore, the aim of this protocol is to provide a transparent and replicable process for Standards revision. The reporting of this protocol is guided by PRISMA-P reporting guidelines.

Methods

Design: A two-phased design that includes a systematic review modelled on Joanna Briggs Institute (JBI) Scoping Review methodology and second, a Modified-Delphi consensus process.

Phase I: Identifying critical care nursing standards

In consultation with a medical information specialist, we will develop a rigorous search strategy to identify existing critical care nursing standards. The search will be two-fold.

First, we will conduct a systematic search of peer-reviewed publications specific to critical care nursing standards of prac- tice. Dates for the search will be limited to 2017 to present, with the rationale that the current CACCN Standards were published in 2017. Language limits will be set to English and French given that these are the two official languages used in Canada. The following databases will be searched: Medline- OVID, CINAHL, Nursing & Allied Health. The search strategy will be developed in Medline and peer reviewed. It will then be translated and executed into the remaining databases.

Second, we will conduct a robust grey literature search. Given the Canadian healthcare structure, which is under the auspices of individual provinces and territories, we will carefully collect all existing critical care nursing standards in Canada. Further, we will ensure that our grey literature search explores all major critical care nursing associations/federations. The latter will include a thorough review of websites and contact with each association via email if necessary. As a preliminary attempt to create a list of critical care nursing associations, we have drawn.

on the membership of the World Federation of Critical Care Nurses (WFCCN) membership.

Citations retrieved from the first systematic search will then be uploaded into Covidence for screening. All duplicates will be removed. We will then use a two-step screening process completed by two reviewers who will act as independent reviewers. First, the title and abstract will be screened followed by full- text screening. In instances where consensus is needed, the two principal investigators (BVW or SC) will discuss and attempt to reach consensus. If consensus cannot be reached, a third expert will be consulted. A review of reference lists of included articles will also be done to satisfy hand-searching. A PRISMA flow diagram will be used to illustrate the screening process. Inclusion and exclusion criteria have been determined a priori and are articulated in Table 1.

For grey literature, we will search and include all documents that clearly indicate they are critical care nursing practice standards and collaborate with our medical information specialist for strategies to ensure we have adequately identified this literature.

Table 1

Inclusion and Exclusion Criteria

InclusionExclusionRationale
Practice StandardsAll other literatureWe are specifically looking for practice standards.
NursingAll other disciplinesWe are specifically looking for practice standards that guide nursing practice.
Critical Care Defined as: Intensive Care Level 2 or 3 Neonatal, Pediatric, AdultAll other practice settingsLevel 2 and 3 Critical Care Units are categories used within the Canadian context. This may include High Acuity Units and/or Progressive Care Units.

Quality appraisal

For peer-reviewed publications retrieved in the systematic search, we will use JBI quality appraisal tools. We will not exclude based on quality.

Data extraction

We will approach data extraction in two ways. First, from the peer-reviewed literature, we will extract the following data using the extraction tables.

Data Synthesis

Following extraction of the data from both the systematic search and grey literature retrieved we will then synthesize the extracted standards. We will engage in a process of mapping the standards against one another. Critical care nursing standards are generally written in the following way: an overarching standard statement and then more granular/itemized elements that reflect how the standard is actualized in clinical practice. As a result, we will group all high-level statements together and include all itemized elements with their respective statements.

The identified and mapped standards will be used to begin the Modified Delphi process. The findings from Phase 1 will constitute the literature review for this Modified Delphi.

Phase 2 – Modified Delphi

Design

A Modified Delphi modelled on Keeney et al. (2011).

Practice Standards

All other literature

We are specifically looking for practice standards.

Sample Expert Panel Composition

We will establish an expert panel to participate in the consensus

Nursing                All other disciplines

Critical Care        All other

Defined as:          practice

Intensive Care     settings

Level 2 or

3 Neonatal,

Pediatric, Adult

We are specifically looking for practice standards that guide nursing practice.

Level 2 and 3 Critical Care Units are categories used within the Canadian context. This may include High Acuity Units and/or Progressive Care Units.

building process. We will aim to have maximum variation in our expert panel. We will recruit critical care nurses in a variety of roles (see Table 2), provinces and territories, as well as representation from rural, remote, community and academic centres and adult, pediatric and neonatal clinical contexts.  We will also ensure CACCN National Board of Directors Member representation in addition to the project leads (BVW, SC). 

All participants who express interest will be invited to  participate.  All participants must be members of the CACCN; have a minimum of 5 years of experience in critical care; and be actively practicing in critical care in Canada.

Extraction Table 1.0

Study ID#    Author and     Publication,Country ofMethodologyPracticeSampleDataData
Title                 YearOriginUsed to EstablishSettingSizeCollectionAnalysis
  StandardsDescription   

Extraction Table 2.0

Setting Characteristics

Study ID#                        Author and Title            Population: Neonatal, Pediatric, Adult

Unit Classification          Hospital Setting

(Academic, Rural, Community) if described

Extraction Table 3.0

Reported Standards

Study ID#                         Author and Title                 Reported Standards               Supporting Evidence +/- GRADE2 if reported

Table 2

Nursing Roles

Clinical Nurses

Nursing Role

In Round 3, only elements ranked at 4 and 5 with a 75% consensus will move forward and constitute final consensus on the included Standards. If a fourth round is necessary because consensus was not reached during Round 3, we will require a 75% consensus on items ranked at Essential only.

In order for a participant to partake in a round they must have

Advanced Practice Nurses Nurse Educators

Nurse Managers (Assistant)

Recruiting Expert Panel Members

The CACCN head office will send an email communication to the membership advertising the recruitment. Interested participants will be asked to provide relevant demographic information through a link to an online survey using the University of Ottawa’s secure Survey Monkey to ensure that we satisfy the representation needed for the expert panel. Interested participants will be asked to provide their email address for future communication about the study including the Delphi rounds. Only the two project leads (BVW and SC) and the research assistant(s) will have access to the master list of participants’ demographics and emails.

Data Collection – Delphi Rounds

All rounds of this Modified Delphi will be completed as follows: Using the online survey platform, Survey Monkey (license held by the University of Ottawa), we will seek consensus on revisions to the Standards. The first round will focus on the overarching standards statements/themes while the second, third (and fourth if necessary) rounds will focus on the itemized elements within each overarching standard statement. Each round will consist of six weeks, using Dillman’s (1978) Total Design for Survey Research for survey distribution and reminders. An email with the electronic survey link to participate in the round will be sent with two reminders sent at weeks two and four.

All standards statements/itemized elements will be assigned a 5-Likert scale defined as follows: 1 – Not Applicable, 2 – Not at All Important, 3 Somewhat Important, 4 Important and 5 – Essential. Consensus for rounds 1-3 will be established a priori as 75% based on recommendations from Foth et al. (2016).

In Round 1, overarching statements that are ranked at 4 and 5 with a minimum of 75% consensus (Important and Essential) will move forward to Round 2. Participants will be given the opportunity to identify missing elements that should be included through an open-ended question.

In Round 2, all itemized elements associated with the overarching statements will be included as well as missing elements identified from the open-ended question. Each element will require a rating. In this round, any element with a ranking of 4–5 with a 75% consensus will move forward to Round 3.

completed the previous round (if applicable; e.g., this would apply to all but Round One). We will track participation based on the 4-digit code created by participants. For Rounds 2–4, invitations to participate will only be sent for subsequent rounds based on confirmation of participation in the previous.

Data analysis

Analysis of data collected in each Delphi round will be analyzed primarily through descriptive statistics (N, %). Open ended Responses from Round 1 will be summarized, organized thematically and transformed into a standard statement.

Ethical considerations

Ethics consultation occurred and this project was deemed quality improvement by the University of Ottawa Research Ethics Board. We will seek implied consent from all participants at the beginning of each Delphi Round as part of the electronic survey. As indicated, participants will create a 4-digit identifier that will be used as their unique participant code to track participation across the Delphi rounds. A master list of participants and codes will be kept separately from the data and will be housed on the uOttawa secure SharePoint server. Only the principal investigators (BVW and SC) will have access to the master list. All collected data will be stored on uOttawa Survey Monkey account or in a separate, secure uOttawa SharePoint file. All files, folders, and platform access will be password protected. All uOttawa software/platforms/servers require a two-factor authentication.

Data will be kept for the maximum conservation period and at minimum until the next CACCN Standards revision. Following publication of the 6th edition of the Standards, the data will then be safely destroyed.

Outcomes and Prioritization

Upon completion of the final round of the Delphi, the elements ranked at 4 and 5 with a 75% consensus will move forward and constitute final consensus. All items included in the final consensus will be utilized to create the revised sixth edition of the CACCN CCN Standards. The standards will be published in the Canadian Journal of Critical Care Nursing, posted on the CACCN website (www.caccn.ca), and shared among the CACCN network to help inform CCN practice in Canada.

Author Notes

Brandi Vanderspank-Wright, PhD, RN, CNCC(C), Canadian Association of Critical Care Nurses, National Board of Directors; School of Nursing, University of Ottawa, Ottawa, Ontario.

Sarah Crowe, MN, PMD-NP(F), NP, CNCC(C), Canadian Association of Critical Care Nurses, National Board of Directors; Fraser Health Authority, British Columbia.

Corresponding author: Brandi Vanderspank-Wright, Associate Professor, School of Nursing, University of Ottawa, Ottawa, ON. Email: bvanders@uottawa.ca

Funding and Conflict of Interest Statement: Dr. Brandi Vanderspank-Wright and Sarah Crowe are on the National Board of Directors for the Canadian Association of Critical

Care Nurses. While the authors on behalf of the CACCN have consulted with the Board specific to project design, revision and drafting of this manuscript, the substantive work is being done within the boundaries of Dr. Vanderspank-Wright and Sarah Crowe’s program of research. Aside from librarian expenses, no funds have been received by the co-author from the Canadian Association of Critical Care Nurses.

REFERENCES

Canadian Association of Critical Care Nurses (CACCN). (2017). Standards for Critical Care Nursing Practice (5th ed.). CACCN.

Dillman, D. A. (1978). Mail and tele- phone surveys: The total design method. Wiley-Interscience,

Foth, T., Efstathiou, N., Vanderspank- Wright, B., Ufholz, L., Dutthorn, N., Zimanksy, M., & Humphrey-Murto, S.

(2016). The use of Delphi and Nominal Group Technique in nursing educa- tion: A review. International Journal of Nursing Studies, 60, 112–120.

Keeney, S., Hasson, F., & McKenna, H. (2011). The Delphi Technique in Nursing and Health Research. Wiley.

Kidd, C.A., Whiteley, M., & Scherer, K. (1987). Development of Canadian

critical care nursing standards: Report of phase I. Canadian Critical Care Nursing Journal, 4(3), 8–12.

Shapiro, C., (2019). Legal implication in nursing practice. In B. J. Astle, W. Duggleby, P. Potter, A.G. Perry, P.A. Stockert, & A.M. Hall (Eds.), Canadian fundamentals of nursing (6th ed.). Elsevier.

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