As part of the multiprofessional team of dedicated intensive care experts, nurses are pivotal in the care of children and families during critical illness.
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.
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.
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.
Research has demonstrated that better patient outcomes are achieved when nurses are educated at the baccalaureate level and have specialty certification.
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.
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.”
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.
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 ).