The assessment of clinical competency in health care has evolved over time. The reasons for this are many and include expansion of medical knowledge, development of complex subspecialties, emergence of new professional roles (eg, advanced practice registered nurses [APRNs] and physician assistants [PAs]), and a growing emphasis on quality, safety, and accountability in patient care. Educational paradigms and the increasing complexity of patient populations influence how clinicians attain, demonstrate, and maintain competency. Further, regulatory and accreditation agencies set standards around how providers demonstrate initial and ongoing competency in clinical practice.

The Interprofessional Education Collaborative (IPEC) defines competence as “the state of proficiency of a person to perform the required practice activities to the defined standard,” emphasizing its “multidimensional and dynamic” nature that evolves with time, experience, and context. However, competency assessments for providers, including physicians and advanced practice providers (APPs) within critical care, remain inconsistent and lack standardization.

In medicine, the shift toward competency-based medical education began in the early 2000s. The Accreditation Council for Graduate Medical Education (ACGME) introduced 6 core competencies ( Table 1 ) as foundational elements for graduate medical training. The development of milestones and entrustable professional activities (EPAs) has further advanced competency-based assessment, particularly in critical care medicine. Frameworks such as the ACGME Milestones for Internal Medicine-Critical Care Medicine and Anesthesiology-Critical Care Medicine fellowships provide structured tools for assessing critical care physician progress and readiness for independent practice.

The dynamic, high-acuity environment of intensive care units (ICUs) demands highly skilled, adaptable, and collaborative providers. Social, political, and economic forces, including the growing complexity of patient populations and workforce shortages, have intensified the need for flexible and team-based models of care. APPs, a collective term for APRNs and PAs, have become increasingly integral to the interprofessional teams in critical care. Currently, there are approximately 431,000 nurse practitioners (NPs) and over 178,000 PAs/Associates licensed in the United States. ^, Of those licensed as NPs, only 10% are certified as either Adult Gerontology Acute Care (6.1%) or Acute Care (3.9%). Current workforce estimates indicate that more than 30,000 NPs and over 2,000 PAs report critical care as their primary area of practice in the United States. ^, These numbers likely underrepresent the true scope of APP involvement, given persistent gaps in national workforce data collection.

More new-to-practice providers are entering the workforce. As such, the number of APP postgraduate critical care training programs has increased across the United States, with current estimates exceeding 300. Many of these programs are overseen and funded entirely by health systems in response to increasing demand for highly skilled, competent providers. Yet, no universal, standardized competency frameworks exist for APPs in critical care. This gap creates variability in preparation, expectations, and competency assessment.

Across the health professions, there are broad movements toward competency-based education and assessment that is longitudinal, developmental, and focused on real-world performance. However, in critical care, this movement has yet to fully coalesce into an interprofessional framework that includes all provider types. As the health care system continues to face challenges related to workforce instability, reduced training program enrollment, and increasing demands on the ICU, the need for shared, profession-agnostic competency structures is more urgent than ever.

Historically, health care training was rooted in discipline-specific education, with competence largely determined by apprenticeship-style evaluation. Faculty served as the gatekeepers of readiness, relying on subjective observations to assess whether a trainee was “ready” for independent practice. As medicine evolved, so too did expectations for more formal and objective systems of competency assessment.

The emergence of critical care medicine as a specialty in the late 20th century marked a significant turning point. The establishment of the Society of Critical Care Medicine in 1970 helped formalize the specialty’s identity and fostered the development of standards for practice. Initially, competency assessment remained informal and observational, continuing to emphasize knowledge acquisition over broader dimensions of clinical performance.

For much of the 20th century, written examinations were the primary tool used to assess the competence of medical trainees. This approach reinforced the notion that factual knowledge equated to clinical readiness. Over time, it became increasingly obvious that knowledge alone was not sufficient to ensure safe or effective care. This realization was catalyzed by national reports such as To Err Is Human , which highlighted widespread deficiencies in health care safety and underscored the need for competency-based systems of education and assessment.

As a result, the health care system began a paradigm shift toward a more holistic view of competence that included not only knowledge and technical skills but also clinical judgment, communication, professionalism, and teamwork. Accrediting bodies such as the ACGME, the American Association of Colleges of Nursing (AACN), and organizations such as the National Organization of Nurse Practitioner Faculties (NONPF) and Quality & Safety Education for Nurses began developing competency-based educational frameworks that emphasized measurable outcomes across a range of domains (see Table 1 ). This shift brought new attention to the importance of behavioral attributes, interpersonal effectiveness, and systems-based practice. However, while many of these frameworks advanced competency thinking for learners in training, relatively little literature has addressed how competencies should be defined, assessed, or maintained among practicing providers.

Most competency models remain role-specific, reflecting the traditional silos of health care education. Yet in modern ICUs, care is delivered by interprofessional teams operating together and under intense pressure and complexity. Despite this, team-based education and competency development are still not standard practice. Health care professionals are trained in parallel rather than together, and systems for assessing team function are poorly developed or absent altogether. Competency in critical care should not be just about assembling the right mix of disciplines; it should also be about how well those disciplines work together to deliver care.

Health care often uses comparisons from other industries in considerations of safety and high reliability. Competency is another domain in which health care can learn from industry. In aviation, pilot training incorporates structured assessment of technical and nontechnical skills, including decision-making, situational awareness, and crew resource management (CRM). CRM emphasizes the importance of communication, leadership, and teamwork, particularly during high-stress scenarios. These same principles are directly applicable to critical care, where interdisciplinary teams must make rapid, coordinated decisions under pressure.

Similarly, the military has a long history of clearly defined, role-specific competencies integrated into a team-based operational structure. Military personnel are trained not only to master their individual roles but also to function within complex, adaptive teams. Competency is continuously assessed, reinforced, and updated through simulation, drills, and after-action reviews. The expectation is not only proficiency at the individual level but also seamless integration within a larger operational unit. This systems-level approach to readiness is increasingly relevant in health care, particularly in ICUs, where high acuity and complexity demand both individual skill and team cohesion.

Despite these lessons from other fields, health care has been slow to adopt standardized, interprofessional competency frameworks, particularly for practicing providers. This gap is concerning in critical care, where interdisciplinary teams are the norm and effective team function is vital to patient safety and outcomes. Although clinicians work together in practice, they are rarely trained or assessed as teams. In contrast to aviation and military models, where team-based simulation and performance evaluation are standard, health care still lacks the infrastructure or culture to support similar practices.

The current landscape of competency in critical care is fragmented. There is growing recognition of the importance of team-based practice, yet most assessment frameworks remain focused on individual, discipline-specific performance. Additionally, while interprofessional care delivery is expected, there are few shared standards or benchmarks for what effective team performance looks like or how it should be taught, evaluated, or maintained.

Competency frameworks play a critical role in the education, assessment, and ongoing development of health care professionals. They serve to define knowledge, skills, attitudes, and other characteristics essential for effective practice and to facilitate professional mobility, performance evaluation, and consistency in clinical care.

A 2019 scoping review by Batt and colleagues examined the multifaceted roles of competency frameworks across health professions. They highlight the frameworks’ importance in analyzing expertise, promoting professional standards, and facilitating workforce development, and caution that the nature of health care practice makes capturing and operationalizing competencies inherently difficult. They found that existing frameworks lack organizing conceptual models or robust empirical underpinnings, potentially limiting their utility in real-world applications.

Goldman and colleagues emphasize that interprofessional competency frameworks, while essential for improving communication, quality, and safety, often take a reductionist approach that focuses on discrete, observable behaviors. The authors identify core interprofessional competencies such as communication, roles and responsibilities, and teamwork, and underscore the need for frameworks to be context-sensitive and organizationally supported.

The European Society of Intensive Care Medicine established an international collaboration of organizations and clinicians to align training in critical care medicine worldwide. The Competency-Based Training in Intensive Care Medicine in Europe (CoBaTrICE) initiative defines a core syllabus of competencies for intensive care physicians and sets common standards for training and assessment across Europe. It encompasses the full set of knowledge, skills, and behaviors and attitudes required across all 102 defined competencies.

The IPEC, representing 22 US health professions associations, has attempted to standardize interprofessional competencies. Their 2023 framework identifies 4 core domains: Values and Ethics, Roles and Responsibilities, Communication, and Teamwork. IPEC defines collaborative practice as occurring “when multiple healthcare workers from different professional backgrounds work together with patients, families, caregivers, and communities to deliver the highest quality of care across settings.” Interprofessional education (IPE) is presented as a necessary step in preparing a “practice-ready workforce” capable of responding to diverse and evolving local health needs.

Fessler and colleagues developed a consensus list of EPAs and Curricular Milestones (CMs) for fellowship training in pulmonary, critical care, and combined pulmonary/critical care medicine, aligned with the ACGME Next Accreditation System. The EPAs define the key tasks that graduates should be able to perform unsupervised (eg, manage acute critically ill patients, lead a multidisciplinary team, perform common procedures). The CMs provide a detailed roadmap of knowledge, skills, and behaviors across the 6 ACGME core competencies, designed to track fellow progress and guide program curricula.

Efforts to define competencies specific to critical care, and more specifically to APPs, have gained momentum in recent years. A scoping review by Egerod and colleagues on advanced practice nursing in critical care across Europe highlights persistent inconsistencies in role definitions, education, and scope of practice. The authors reference a foundational set of core competencies, including advocacy, ethics, clinical judgment, collaboration, and research, often organized into pillars of generic and specialty-specific clinical practice, leadership, and scholarly activities. Similarly, Kaldan and colleagues note considerable variability in critical care training and competency expectations for both physicians and advanced practice nurses across Europe, suggesting a lack of harmonization that impacts workforce readiness. Most recently, The American College of Chest Physicians is launching a new certification program for NPs and PAs in critical care that is designed to formally recognize and validate the specialized expertise of APPs in intensive care settings.

In the United States, Harrison and colleagues used a Delphi methodology to define EPAs for neurocritical care (NCC) APPs. Their findings illustrate that while APPs frequently learn critical care skills on the job, formal training often lacks depth and specificity. They identified 6 core and 47 nested EPAs to structure and assess the scope of practice in NCC. This work builds on earlier studies, such as Luckianow and colleagues, which identified significant gaps in ICU-specific knowledge and procedural competency among newly graduated NPs and PAs. These findings have supported the growth of postgraduate fellowship programs, aiming to bridge the gap between generalist training and the demands of critical care.

Kopf and colleagues developed a competency-based curriculum for novice NPs transitioning into ICU roles. Using a modified Delphi technique, they identified 9 domains, including diagnostic reasoning, mechanical ventilation, procedural skills, patient safety, and end-of-life care. This structured curriculum aimed to reduce the variability in new provider preparedness and to standardize expectations during the early stages of ICU practice.

Despite growing efforts to define role-specific competencies, relatively few frameworks address the team-level competencies required for safe and effective ICU care. Literature tends to focus on individual professional development, often overlooking the collective capabilities necessary in team-based settings.

In nursing, the AACN offers the Synergy Model for Patient Care, a conceptual framework that matches nurse competencies to patient needs. The model includes domains such as clinical judgment, caring practices, collaboration, and systems thinking, emphasizing that optimal outcomes occur when patient characteristics and provider competencies are aligned. Although widely adopted in clinical nursing practice, its application to team-based care and interdisciplinary collaboration is less clearly defined. In fact, most of the literature found surrounding competencies and critical care exist in nursing literature, perhaps limiting uptake by other disciplines.

Overall, the literature reflects a growing recognition of the need for structured, evidence-based competency frameworks in critical care that move beyond individual roles to support team performance. However, challenges persist in achieving consensus, particularly across professional boundaries, and in developing frameworks that are both comprehensive and adaptable to complex, real-world clinical environments. As the demands of critical care continue to grow, so too does the urgency of establishing shared competencies that can guide not only education and assessment, but also interprofessional collaboration and organizational accountability.