The Nurse in Pediatric Critical Care

Chapter 3 The Nurse in Pediatric Critical Care



Patricia A. Moloney-Harmon, Martha A.Q. Curley



Pearls



• Nursing’s unique contribution to patients within the health care environment is that nurses create safe passage for patients and families.

• Nurses coordinate the patient’s and family’s experiences by their continuous attention to the person who exists underneath all the advanced technology that is being employed.

• Building a humanistic environment that endorses parents as unique individuals capable of providing essential elements of care to their children lays the foundation for family-centered care.

• 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.

• Excellence in a pediatric critical care unit is achieved through a combination of many factors and is highly dependent on a healthy work environment.

• Studies have demonstrated that a stable, established, and proficient nursing workforce improves patient outcomes.

• A successful critical care professional advancement program recognizes varying levels of staff nurse knowledge and expertise and fosters advancement through a wide range of clinical learning and professional development experiences.

• Technical training alone is insufficient in meeting patient and family needs in the critical care environment.

Pediatric critical care nursing has evolved tremendously over the years. The nurse is the singular person in the pediatric critical care unit who creates an environment in which critically unstable, highly vulnerable infants and children benefit from vigilant care and who coordinates the actions of a highly skilled team of patient-focused health care professionals. Pediatric critical care nursing practice encompasses staff nurses who provide direct patient care, nursing leaders who facilitate an environment of excellence, and professional staff development that ensures continued nursing competence and professional growth. This chapter discusses the essential components of pediatric critical care nursing practice.



Describing What Nurses Do: The Synergy Model


The synergy model describes nursing practice based on the needs and characteristics of patients and their families.1 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.



Patient Characteristics of Concern to Nurses


Every patient and family member brings unique characteristics to the pediatric intensive care 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, and 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/community bring to a care situation and include personal, psychological, social, technical, and fiscal resources.


These eight characteristics apply to patients in all health care settings. This classification allows nursing to have a common language to describe patients that is meaningful to all care areas. For example, a critically ill infant in multisystem organ failure might be described as an individual who is unstable, highly complex, unpredictable, highly resilient, and vulnerable, whose family is able to become involved in decision making and care but has inadequate resource availability.


Each of these eight characteristics forms a continuum, and individuals fluctuate at 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 strong 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, 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 on the basis of 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, but are not limited to, vigilance, engagement, and responsiveness. Response to diversity is the sensitivity to recognize, appreciate, and incorporate differences into the provision of care. Differences may include, but are not limited to, 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 health care team. Advocacy/moral agency is defined as working on another’s behalf and representing the concerns of the patient/family/community. The nurse serves as a moral agent when assuming a leadership role 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 (i.e., patients, families, and health care 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 health care 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 (which include 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 the 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/characteristics and nurse competencies.



Clinical Judgment


Clinical judgment, that is, 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 defines competent nursing practice. In critical care, the novice nurse focuses on individual aspects of the patient and the environment. As expertise develops, the nurse develops a global understanding of the situation. The expert nurse anticipates the needs of patients, predicts the patient’s trajectory of illness, and forecasts the patient’s level of recovery. Evolving clinical expertise creates safe passage for patients. The very best nursing care often is invisible, as it should be, because untoward effects and complications are prevented. Nursing’s unique contribution to patients within the health care environment, which encompasses all nursing’s competencies, is that nurses create safe passage for patients and families. Safe passage may include helping the patient and family move toward a greater level of self-awareness, knowledge, or health; transition through the acute care environment or stressful events; and/or a peaceful death.



Clinical Inquiry


Clinical inquiry optimizes the delivery of evidence-based care. Studying the clinical effectiveness of care and how it affects patient outcomes provides information that helps balance cost and quality. Quality improvement methods include use of multidisciplinary teams that work together to help systems operate in a way that promotes the best interests of patient care. Collaborative practice groups working with clinical practice guidelines (CPGs) provide the opportunity to initiate evidence-based interventions.


CPGs—that is, patient-centered multidisciplinary and multidimensional plans of care—help the team provide evidence-based practice and improve the process of care delivery. CPGs ensure practitioner accountability, encourage coordinated care, decrease unnecessary variation in practice patterns, improve quality and cost-effective services, and provide a means to systematically evaluate the quality and effectiveness of practice in moving patients toward desired outcomes. Effective CPGs are driven by patient needs and help provide evidence linking interventions to patient outcomes. CPGs help guide the appropriate use of resources, limiting interventions. Evidence-based guidelines can help to eliminate interventions that do not benefit patients but frequently are steeped in tradition and opinion.



Caring Practices


Caring practices bring clinical judgment to view. Caring practices are activities that are meaningful to the patient and family and enhance their feelings that the health care team cares about them. Families equate caring behaviors with competent behaviors. Families trust that nurses will be vigilant. Vigilance, which includes alert and constant watchfulness, attentiveness, and reassuring presence, is essential to limit the complications associated with a patient’s vulnerabilities.1


Nurses coordinate the patient’s and family’s experiences by their continuous attention to the person who exists underneath all the advanced technology that is employed. This steady attention can make an important difference for patients by helping patients and their families better tolerate the experience of critical illness. This aspect of practice, our presence with patients, is unique to the profession of nursing.1 For example, in working with patients with head injuries, caring nurses acknowledge the person by surrounding them with their possessions, such as family pictures and cards from friends, and their favorite music. Nurses talk with their unresponsive patients, orienting them and telling them what is going on, which preserves the patient’s “humanness.” Occasionally a patient responds as evidenced by as an increase in heart rate or blood pressure, a decrease in intracranial pressure, or the shedding of a tear. Nurses take this level of communication one step further by teaching this process to family members so they too can interact with their critically ill loved one.


Pediatric critical care nurses, more than any other intensive care unit (ICU) nursing subspecialty, have made significant progress in integrating family-centered care into the practice of critical care. Building a humanistic environment that endorses parents as unique individuals capable of providing essential elements of care to their children lays the foundation for family-centered care. Family-centered care is more than just providing parents with unlimited access to their children.1


Nursing research provides the foundation for this change in practice. Based on nursing research, we know that parents have the need for hope, information, and proximity; to believe that their loved one is receiving the best care possible; to be helpful; to be recognized as important; and to talk with other parents with similar issues. Pediatric critical care nurses have gone beyond the identification of family needs to illustrating interventions that patients and families find helpful.1 We provide 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” of their critically ill child’s responses and of the pediatric ICU environment.



Response to Diversity


Response to diversity honors the differences that exist in the people we are and in the individuals we care for. At a minimum, it requires that care be delivered in a nonjudgmental, nondiscriminatory manner. Effective communication with patients and families at their level of understanding may require customizing the health care culture to meet the diverse needs and strengths of families. Skilled nurses foresee differences and beliefs within the team and negotiate consensus in the best interest of the patient and family.



Advocacy/Moral Agency


Moral agency acknowledges the particular trust inherent within nurse-patient relationships, a trust gained from nursing’s long history of speaking on the patient’s behalf in an effort to preserve a patient’s “lifeworld” (Hooper, personal communication, 1996). The holistic view of the patient that nurses often possess is a reflection of moral awareness.


When a cure is no longer possible, nurses turn their focus to ensuring that death occurs with dignity and comfort. Nurses “orchestrate” death, supporting parents and family members through the death of their loved one. Nurses often coordinate the experience for patients and families when death is imminent. This most intimate aspect of nursing care is a profound contribution to humankind.2


Pediatric critical care nurses provide critical support of the practice of family presence during procedures and resuscitation. Including family members during pediatric resuscitation is not a universal practice. However, one study established that the parents who were able to be present during their child’s resuscitation collectively believed that their presence provided comfort to their child and themselves.3 Parents who were not able to stay regretted not being able to comfort their child in the final moments of his or her life. The study authors advocated that policies be developed to facilitate parental presence during resuscitation. A study of physicians ascertained that most respondents encouraged family members to be present during their child’s resuscitation.4 The majority of physicians believed that being there was helpful to parents and that physicians should be prepared for this practice. Nurses take on the essential accountability of preparing families to stay with their child.5



Facilitator of Learning


Nurses facilitate learning so that patients and their families become knowledgeable about the health care system and can make informed choices. Teaching is an almost continuous process that involves helping the patient and the family understand the critical care environment and therapies involved in critical care. Also essential is reinforcement of the patient’s experience and how, most likely, the infant or child will cope with the ICU experience. This education provides patients with the capacity to help themselves and for parents to help their infants and children.



Collaboration


Collaboration requires commitment by the entire multidisciplinary team. A classic study done by Knaus et al.6 found an inverse relationship between actual and predicted patient mortality and the degree of interaction and coordination of multidisciplinary intensive care teams. 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. The American Association of Critical-Care Nurses Demonstration Project also documented a low mortality ratio, low complication rate, and high patient satisfaction in a unit that had a high perceived level of nurse/physician collaboration, highly rated objective nursing performance, a positive organizational climate, and job satisfaction and morale.7



Systems Thinking


Nurses are constantly challenged to design, implement, and evaluate whole programs of care, manage units where programs of care are provided, and determine whether the health care system is meeting patient needs.8 These vital components require a patient-centered culture that stresses strong leadership, coordination of activities, continuous multidisciplinary communication, open collaborative problem solving, and conflict management.9 For many years nurses have learned to manipulate the system on behalf of their patients; however, systems thinking10—that is, the ability to understand and effectively manipulate the complicated relationships involved in complex problem solving—is a new but necessary skill in taking overall responsibility for the caregiving environment.


Managing complex systems is essential to creating a safe environment. Nurse-patient relationships commonly occur around transitional periods of instability brought about by the demands of the health care situation. Helping patients make transitions between elements of the health care system—for example, into and out of the community—requires systems knowledge and intradisciplinary collaboration.11

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue

Related posts:

Critical Care in Public Health Emergencies Noninvasive Ventilation: Concepts and Practice Pediatric Transport: Shifting the Paradigm to Improve Patient Outcome Life-Threatening Viral Diseases and Their Treatment Gastrointestinal Structure and Function Research in Pediatric Critical Care

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 7, 2016 | Posted by in CRITICAL CARE | Comments Off on The Nurse in Pediatric Critical Care

Full access? Get Clinical Tree
Get Clinical Tree app for offline access