Evolution of critical care nursing

Pearls

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As part of the multiprofessional team of dedicated intensive care experts, nurses are pivotal in the care of children and families during critical illness.
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Building a humanistic environment that endorses parents as unique individuals capable of providing essential elements of care to their children constitutes the foundation for family-centered care.
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Caring practices include a constellation of nursing activities responsive to the uniqueness of the patient/family and create a compassionate and therapeutic environment with the aim of promoting comfort and preventing suffering.
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Excellence in a pediatric critical care unit is achieved through a combination of many factors and is highly dependent on a healthy work environment as well as training beyond the technical requirements of the nursing role.
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Research has demonstrated that better patient outcomes are achieved when nurses are educated at the baccalaureate level and have specialty certification.
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A successful critical care professional advancement program recognizes varying levels of clinical nurse knowledge and expertise and fosters advancement through a wide range of clinical learning and professional development experiences.

Pediatric critical care nursing has evolved tremendously over the years. The nurse plays a vitally important role in the pediatric intensive care unit (PICU) by fostering an environment in which critically unstable, highly vulnerable infants and children benefit from vigilant care and the highly coordinated actions of a skilled team of patient-focused healthcare professionals. Pediatric critical care nursing practice encompasses staff nurses who provide direct patient care, nursing leaders and clinical nurse specialists who facilitate an environment of excellence, professional staff development that ensures continued nursing competence and professional growth, acute care pediatric nurse practitioners who manage patients as providers and contribute to staff nurse professional growth, and nurse scientists who generate knowledge to support the practice of pediatric critical care nursing. This chapter discusses the evolution of pediatric critical care nursing as well as the current framework for PICU nursing practice.

Early pediatric critical care nursing

The evolution of critical care dates to the days of the Crimean War when Florence Nightingale grouped the sickest patients in a cohort so that they could be more closely observed. The first PICU was opened in 1955 in Sweden with seven acute care beds and five stepdown beds (see also Chapter 1 ). While others followed in Europe and Australia, the first multiprofessional PICU in the United States was opened in 1967 by Dr. John J. Downes at the Children’s Hospital of Philadelphia. This PICU was fully equipped with monitoring and required devices for six beds. Although critically ill children had been previously studied in a cohort as a result of acute poliomyelitis outbreaks, this PICU was the first unit in the United States to care for critically ill children with a variety of diagnoses. Over the next 4 years, three additional PICUs opened on the East Coast. With the expansion of pediatric critical care medicine, the need for specialty trained nurses became vital for the care of these complex pediatric patients.

Nursing care in early PICUs focused on close observation with limited technology, primarily basic ventilators, arterial and central venous lines and simple intracranial pressure monitoring devices ( Fig. 6.1 ). As the discipline has evolved, PICU nurses have learned to manage and monitor increasingly complex technology, including multiple types of ventilators, invasive lines, cerebral monitors, renal replacement therapy, circulatory assist devices, extracorporeal circulatory membranous oxygenation, and electronic medical records ( Fig. 6.2 ). The complexity of these systems increases nurses’ mental workload and results in the need for a highly skilled PICU nursing workforce. In order to manage multiple competing priorities, safety technologies have been developed supporting the safe provision of nursing care and quality outcomes.

Describing what nurses do: The synergy model

The Synergy Model ( Table 6.1 ) describes nursing practice based on the needs and characteristics of patients and their families. The fundamental premise of this model is that patient characteristics drive required nurse competencies. When patient characteristics and nurse competencies match and synergize, optimal patient outcomes result. The major components of the Synergy Model encompass patient characteristics of concern to nurses, nurse competencies important to the patient, and patient outcomes that result when patient characteristics and nurse competencies are in synergy. A detailed description of the Synergy Model can be found at the American Association of Critical-Care Nurses (AACN) website.

TABLE 6.1

Synergy Model Nurse Competencies, Expanded

Nurse Competency	Activities	Supports
Clinical Judgment: Skilled clinical knowledge, use of discretionary judgment, and the ability to integrate complex multisystem data and understand the expected trajectory of illness and human response to critical illness	• Anticipate the needs of patients • Predict patient’s trajectory of illness • Forecast patient’s level of recovery • Prevent untoward effects and complications • Facilitate safe passage for patients and families through critical illness • Help patient and family move toward a greater level of self-awareness, knowledge, or health • Transition through the acute care environment or stressful events • Peaceful death	As nurses develop their knowledge base and skill set, they move from novice to expert.
Clinical Inquiry: Studying the clinical effectiveness of care and how it influences patient outcomes	• Optimizes the delivery of evidence-based care • Provides information that helps balance cost and quality • CPGs are driven by patient needs and provide evidence linking interventions to patient outcomes • Eliminate interventions that are steeped in tradition and opinion but do not actually benefit patients	1. Quality improvement methods use multidisciplinary teams working together to help systems operate in a way that promotes the best interests of patient care. 2. Collaborative practice groups work with CPGs to initiate evidence-based and expert consensus-based interventions. 3. CPGs are patient-centered multidisciplinary, multidimensional plans of care driving evidence-based practice that improve the process of care delivery.
Caring Practices: Activities that are meaningful to the patient and family and enhance their feelings that the healthcare team cares about them	• Bring clinical judgment into view • Vigilance: alert and constant watchfulness, attentiveness, and reassuring presence • Essential to limit the complications associated with a patient’s vulnerabilities • Coordinate the patient’s and family’s experiences by continuous attention to the person who exists underneath all of the advanced technology that is employed. • Near-continuous presence with patients, unique to the profession of nursing • Preserve the patient’s humanness through activities such as surrounding patients with their possessions and favorite music, talking with and orienting unresponsive patients and teaching this process to family members, facilitating interaction with their critically ill loved one. • Integrating family-centered care into the practice of critical care • Building a humanistic environment endorsing parents as unique individuals capable of providing essential elements of care to their children. Pediatric critical care nurses have gone beyond the identification of family needs to illustrating interventions that patients and families find helpful and providing families with what they need to help their child. Parents believe the most important contribution pediatric critical care nurses make is to serve as the interpreter by translating their critically ill child’s responses to others within the PICU environment.	1. Families equate caring behaviors with competent behaviors. 2. Families trust that nurses will be vigilant. 3. Steady attention can make an important difference by helping patients and their families better tolerate the experience of critical illness. 4. Nursing research ascertains that parents a. have the need for hope, information, and proximity b. must believe that their loved one is receiving the best care possible c. seek the opportunity to be helpful, to be recognized as important, and to talk with other parents who have similar issues
Response to Diversity: Honors the differences that exist among people and individuals	• Requires that care be delivered in a nonjudgmental, nondiscriminatory manner	1. Effective communication with patients and families at their level of understanding may require customizing the healthcare culture to meet the diverse needs and strengths of families. 2. Skilled nurses foresee differences and beliefs within the team and negotiate consensus in the best interest of the patient and family.
Advocacy/Moral Agency: Speaking on the patient’s behalf in an effort to preserve a patient’s lifeworld	• Acknowledges the particular trust inherent within nurse-patient relationships • When a cure is no longer possible, nurses turn their focus to ensuring that death occurs with dignity and comfort. • Supports the practice of family presence during procedures and resuscitation	1. The holistic view of the patient that nurses often possess is a reflection of moral awareness. 2. Including family members during pediatric resuscitation is not a universal practice. A systematic review of family presence during resuscitation in the PICU supports the belief that parents who are able to be present are better able to adjust to their child’s death and better able to cope. Parents who were not able to stay described more anguish. 3. Local guidelines and education have been developed to facilitate parental presence during resuscitation. Importantly, physicians and nurses report increased comfort with parental presence when they, the professionals, are prepared to help support parent presence.
Facilitation of Learning: Ensure that patients and their families become knowledgeable about the healthcare system and make informed choices	• Employ teaching as a continuous process that involves helping the patient and family understand the critical care environment and therapies involved in critical care. • Reinforce the patient’s experience and how, most likely, the infant or child will cope with the ICU experience.	Education provides patients with the capacity to help themselves manage the experience and for parents to help their infants and children.
Collaboration	• Hospitals with good collaboration and a lower mortality rate had a comprehensive nursing educational support program that included a clinical nurse specialist and clinical protocols that staff nurses can independently initiate. • Studies examining the relationship between nurse-physician collaboration and adverse patient outcomes (falls, hospital-acquired pressure ulcers, and the development of hospital-acquired infections in critically ill adults) demonstrate that nurse-physician collaboration was inversely related to the incidence of falls, hospital-acquired pressure ulcers, ventilator-associated pneumonia, and central line–associated infections. • Donovan and colleagues reviewed the quality improvement literature specific to critical care and found a large body of evidence demonstrating that patient outcomes are improved when care is provided by a collaborative interdisciplinary team and that nurses are key team members. • Knaus and associates found an inverse relationship between actual and predicted patient mortality and the degree of interaction and coordination of multidisciplinary intensive care teams.	Collaboration requires commitment by the entire multidisciplinary team.
Systems Thinking: Ability to understand and effectively manipulate the complicated relationships involved in complex problem solving	• Design, implement, and evaluate whole programs of care. • Manage units. • Determine whether healthcare system is meeting patient needs. • Create a safe environment. • Help patients make transitions between elements of the healthcare system using systems knowledge and intradisciplinary collaboration.	1. Patient-centered culture 2. Strong leadership 3. Continuous multidisciplinary communication 4. Collaborative problem solving 5. Conflict management

CPGs , Clinical practice guidelines.

Patient characteristics of concern to nurses

All patients and family members uniquely manifest the following characteristics during the PICU experience. These characteristics—stability, complexity, predictability, resiliency, vulnerability, participation in decision-making, participation in care, and resource availability—span the continuum of health and illness. Each characteristic is operationally defined as follows.

Stability refers to the person’s ability to maintain a steady state. Complexity is the intricate entanglement of two or more systems (e.g., physiologic, family, therapeutic). Predictability is a summative patient characteristic that allows the nurse to expect a certain trajectory of illness. Resiliency is the patient’s capacity to return to a restorative level of functioning using compensatory and coping mechanisms. Vulnerability refers to an individual’s susceptibility to actual or potential stressors that may adversely affect outcomes. Participation in decision-making and participation in care are the extents to which the patient and family engage in decision-making and in aspects of care, respectively. Resource availability refers to resources that the patient, family, and community bring to a care situation and include personal, psychosocial, technical, and fiscal resources. This classification system allows nurses to have a common language to describe patients that is meaningful to all care areas.

Each of these eight characteristics forms a continuum, and individuals fluctuate around different points along each continuum. For example, in the case of the critically ill infant in multisystem organ failure, stability can range from high to low, complexity from atypical to typical, predictability from uncertain to certain, resiliency from minimal reserves to generous reserves, vulnerability from susceptible to safe, family participation in decision-making and care from no capacity to full capacity, and resource availability from minimal to extensive. Compared with existing patient classification systems, which are primarily based on the number of therapies and procedures, these eight dimensions better describe the needs of patients that are of concern to nurses.

Nurse competencies important to patients and families

Nursing competencies, which are derived from the needs of patients, also are described in terms of essential continua: clinical judgment, clinical inquiry, caring practices, response to diversity, advocacy/moral agency, facilitation of learning, collaboration, and systems thinking.

Clinical judgment is clinical reasoning that includes clinical decision-making, critical thinking, and a global grasp of the situation coupled with nursing skills acquired through a process of integrating formal and experiential knowledge. Clinical inquiry is the ongoing process of questioning and evaluating practice, providing informed practice based on available data, and innovating through research and experiential learning. The nurse engages in clinical knowledge development to promote the best patient outcomes. Caring practices are a constellation of nursing activities that are responsive to the uniqueness of the patient/family and create a compassionate and therapeutic environment with the aim of promoting comfort and preventing suffering. Caring behaviors include vigilance, engagement, and responsiveness. Response to diversity is the sensitivity to recognize, appreciate, and incorporate patient- and family-specific differences into the provision of care. Differences may include individuality, cultural practices, spiritual beliefs, gender, race, ethnicity, disability, family configuration, lifestyle, socioeconomic status, age, values, and alternative care practices involving patients/families and members of the healthcare team. Advocacy/moral agency is defined as working on another’s behalf and representing the concerns of the patient, family, and community. For example, the nurse serves as a moral agent in identifying and helping to resolve ethical and clinical concerns within the clinical setting. Facilitation of learning is the ability to use the process of providing care as an opportunity to enhance the patient’s and family’s understanding of the disease process, its treatment, and its likely impact on the child and family. Collaboration is working with others (e.g., patients, families, and healthcare providers) in a way that promotes and encourages each person’s contributions toward achieving optimal and realistic patient goals. Collaboration involves intradisciplinary and interdisciplinary work with colleagues. Systems thinking is appreciating the care environment from a perspective that recognizes the holistic interrelationships that exist within and across healthcare systems. These competencies illustrate a dynamic integration of knowledge, skills, experience, and attitudes needed to meet patients’ needs and optimize patient outcomes.

Nurses require competence within each domain at a level that meets the needs of their patient population. Logically, more compromised patients have more severe or complex needs; this, in turn, requires the nurse to possess a higher level of knowledge and skill in an associated continuum. For example, if a patient is stable but unpredictable, minimally resilient, and vulnerable, primary competencies of the nurse center on clinical judgment and caring practices (including vigilance). If a patient is vulnerable, unable to participate in decision-making and care, and has inadequate resource availability, the primary competencies of the nurse focus on advocacy/moral agency, collaboration, and systems thinking. Although all eight competencies are essential for contemporary nursing practice, each assumes more or less importance depending on a patient’s characteristics. Optimal care is most likely when there is a match between patient needs and characteristics and nurse competencies. Table 6.1 provides further detail on each nurse competency.

Optimal patient outcomes

According to the Synergy Model, optimal patient outcomes result when patient characteristics and nurse competencies synergize. A nurse-sensitive outcome , a term first coined by Johnson and McCloskey, defines a dynamic patient or family caregiver state, condition, or perception that is responsive to nursing interventions. Brooten and Naylor noted, “The current search for ‘nurse-sensitive patient outcomes’ should be tempered in the reality that nurses do not care for patients in isolation and patients do not exist in isolation.”

Patient-level outcomes

Major patient-level outcomes of concern to pediatric critical care nurses include the presence or absence of complications and mortality. Outcomes related to limiting iatrogenic injury and complications of therapy demonstrate the potential hazards present in illness and in the critical care environment. Odds of postoperative complications in pediatric cardiac surgery patients are reduced in units with a greater percentage of nurses with Bachelor of Science degrees and in hospitals with a greater percentage of nurses with Critical Care Registered Nurse certification. ^, Furthermore, mortality rates are reduced in units with a greater proportion of nurses with more than 2 years of experience. Odds of patient death decreases in PICUs where critical care nurses have 11 or more years of experience. In contrast, in units with 20% or more of nurses having 2 years or less experience, the odds of death increased. Patient and family satisfaction ratings are subjective measures of health or the quality of health services. Patient satisfaction measures involving nursing care typically include technical and professional factors, trusting relationships, and education experiences. Patient-perceived functional status and quality of life are multidisciplinary outcome measures. ^, Linking patient satisfaction, functional status, and quality of life is important because the three factors are often related.

Provider-level and system-level outcomes

Provider-level and system-level outcomes may be intertwined and difficult to isolate. It is known that nurse-physician collaboration and positive interaction are associated with lower mortality rates, high patient satisfaction with care, and low hospital-acquired infections. Clear and effective communication between physicians and nurses is positively correlated with collaborative practice. Furthermore, collaborative practice within the team improves the quality of care delivered and decreases burnout. Hospitals that decreased burnout by 30% had a reduction in healthcare-associated infections (urinary tract and surgical site infections) with an annual savings of $68 million. In the absence of collaborative practice and team communication, there is an indirect relationship to increased hospital associated infections.

Nightingale metrics

One population-specific approach to measurement of nurse-sensitive outcomes is the Nightingale Metrics program. This program was developed so that bedside nurses could be actively involved in identifying nurse-sensitive metrics important to their unique patient and family practice. Nurses give care in an environment that should support the capacity of the patient and family to heal. In addition to supportive care, a large aspect of nursing is preventive care that often is not measured; thus care is often invisible. When measuring outcomes, it is important to account for the invisible aspects of nursing that have a tremendous impact on patients. This might include steps taken, according to the best understanding of what works, to prevent a specific complication. For example, invisible are the large numbers of pressure ulcers that never develop because of good nursing care. The Nightingale Metrics reflect unit-specific current standards of care, are based on evidence, are measurable, and reflect concerns specific to nurses working in a specific setting ( Box 6.1 ).

• BOX 6.1

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