35CHAPTER 5 Leading and Managing Change in the Pediatric Intensive Care Unit accompanying editorial identified the importance of postimple mentation monitoring of protocol adherence and ongoing review[.]
CHAPTER 5 Leading and Managing Change in the Pediatric Intensive Care Unit accompanying editorial identified the importance of postimplementation monitoring of protocol adherence and ongoing review of protocol impact on identified metrics The editorial concluded with a call to develop “structural methods for evaluation of sustainability.”39 One such tool is currently under development: the Clinical Sustainability Assessment Tool (CSAT), which followed the success of the Program Sustainability Assessment Tool (PSAT), freely available at https://sustaintool.org The PSAT tool was designed for, validated in, and successfully used by public health programs and has had wide use since introduction.40–42 In contrast, the CSAT is specifically designed for use in clinical medicine Designed to be completed by all involved medical care team members either as part of the change planning phase or as an assessment of an existing practice, the CSAT asks respondents to identify and rank resources, attitudes, and personnel across seven domains encompassing team, system infrastructure, and administrative characteristics that would be most important to ensuring sustainability of the specific clinical initiative being implemented With input from clinical care specialists from multiple professions—including adult- and pediatric-based practices, inpatient-based and outpatient-based locations, medical and surgical specialties, and implementation scientists—the CSAT tool has undergone pilot testing and is now awaiting validation.43 Conclusion Change leaders face a daunting task A diverse group of individuals comprise the PICU team This team functions as part of a larger hospital or academic system that is navigating the everchanging landscape of pediatric healthcare Change leaders and managers can easily be overwhelmed with a feeling of dread and futility As Machiavelli wrote centuries ago, human nature resists change To be successful, the change process must start with an intentional strategy that combines inspirational leadership to provide the guiding vision that triggers a positive visceral response 35 with concerted management that adheres to a structured yet adaptive tactical approach All of this must include a strategy for sustaining desired change over time Change in systems as complex as the PICU and healthcare must create a sense of belonging and group identity, must foster and support distributed leadership, and must demonstrate ongoing patient value by balancing the ideals of providing the highest quality care and the pragmatic reality of rising healthcare costs and limited resources Key References Balas MC, Burke WJ, Gannon D, et al Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines Crit Care Med 2013;41(9 Suppl 1): S116-127 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science Implement Sci 2009;4:50 Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L A systematic review of the use of the Consolidated framework for implementation research Implement Sci 2016;11:72 Kotter JP Leading Change Boston: Harvard Business Press; 2012 NHS Leaders Everywhere: The Story of NHS Change Day A learning report 2013 https://www.slideshare.net/NHSIQ/the-story-of-change-day?from_ action5save Porter ME, Lee TH The strategy that will fix health care Harv Bus Rev 2013;91(10):50-70 Yaghmai BF, Di Gennaro JL, Irby GA, Deeter KH, Zimmerman JJ A pediatric sedation protocol for mechanically ventilated patients requires sustenance beyond implementation Pediatr Crit Care Med 2016;17(8):721-726 The full reference list for this chapter is available at ExpertConsult.com e1 References National Health Service 2013 Change Day Video https://www youtube.com/watch?v5h7A9rohysZw Accessed April 17, 2019 Francis R Press Statement Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry: Chairman’s Statement London, United Kingdom: Stationery Office; 2013 NHS Leaders Everywhere: The Story of NHS Change Day A learning report 2013 https://www.slideshare.net/NHSIQ/the-story-of-changeday?from_action5save Bevan H Biggest Ever Day of Collective Action to Improve Healthcare that Started with a Tweet https://www.mixprize.org/story/biggestever-day-collective-action-improve-healthcare-started-tweet-0 Kubler-Ross E On Death and Dying New York, NY: Macmillan Publishing Company; 1969 Scheck CL, Kinikci AJ Identifying the antecedents of coping with an organizational acquisition: a structural assessment J Organiz Behav 2000;21:627-648 Phillips JR Enhancing the effectiveness of organizational change management Human Resource Management 1983;22(1/2):183-199 Conner DR Managing at the Speed of Change: How Resilient Managers Succeed and Prosper Where Others Fail New York, NY: Random House; 1992 Kotter JP Leading Change Boston, MA: Harvard Business Press; 2012 10 Porter ME, Teisberg EO Redefining Health Care: Creating Value-Based Competition on Results Boston, MA: Harvard Business Press; 2006 11 Porter ME, Lee TH The strategy that will fix health care Harv Bus Rev 2013;91(10):50-70 12 Moskovitz L, Garcia-Lorenzo L Changing the NHS a day at a time: the role of enactment in the mobilisation and prefiguration of change J Soc Polit Psychol 2016;4(1):196-219 13 Lewin K Frontiers in group dynamics In: Cartwright D, ed Field Theory in Social Science London: Social Science Paperbacks; 1947 14 Burnes B Kurt Lewin and the planned approach to change: a reappraisal J Manage Stud 2004;41(6):977-1002 15 MindTools Lewin’s Change Management Model: Understanding the Three Stages of Change https://www.mindtools.com/pages/article/ newPPM_94.htm 16 Lippitt R, Watson J, Westley B The Dynamics of Planned Change: a comparative study of principles and techniques New York: Harcourt, Brace, & World, Inc.; 1958 17 Rogers EM, Shoemaker FF Commuincation of Innovations: A CrossCultural Approach New York: Free Press; 1971 18 Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science Implement Sci 2009;4:50 19 Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L A systematic review of the use of the consolidated framework for implementation research Implement Sci 2016;11:72 20 Balas MC, Burke WJ, Gannon D, et al Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines Crit Care Med 2013;41(9 Suppl 1): S116-127 21 Orchard CA, King GA, Khalili H, Bezzina MB Assessment of Interprofessional Team Collaboration Scale (AITCS): development and testing of the instrument J Contin Educ Health Prof 2012;32(1):58-67 22 Pun BT, Balas MC, Barnes-Daly MA, et al Caring for critically Ill patients with the ABCDEF bundle: results of the ICU liberation collaborative in over 15,000 adults Crit Care Med 2019;47(1): 3-14 23 Arteaga G, Kawai Y, Rowekamp D, et al Bundling the bundles: can we change culture with a holistic approach to patient care in the ICU? Crit Care Med 2018;46(suppl1):629 24 Helfrich CD, Li YF, Sharp ND, Sales AE Organizational readiness to change assessment (ORCA): development of an instrument based on the Promoting Action on Research in Health Services (PARIHS) framework Implement Sci 2009;4:38 25 QI Essentials Toolkit http://www.ihi.org/resources/Pages/Tools/ Quality-Improvement-Essentials-Toolkit.aspx 26 Guest G, Namey E, McKenna K How many focus groups are enough? Building an evidence base for nonprobability sample sizes Field Methods 2017;29(1):3-22 27 Wolfe H, Zebuhr C, Topjian AA, et al Interdisciplinary ICU cardiac arrest debriefing improves survival outcomes Crit Care Med 2014;42(7):1688-1695 28 Zebuhr C, Sutton RM, Morrison W, et al Evaluation of quantitative debriefing after pediatric cardiac arrest Resuscitation 2012;83(9):11241128 29 Reeder RW, Girling A, Wolfe H, et al Improving outcomes after pediatric cardiac arrest: the ICU-Resuscitation Project: study protocol for a randomized controlled trial Trials 2018;19(1):213 30 Taveira-Gomes T, Ferreira P, Taveira-Gomes I, Severo M, Ferreira MA What are we looking for in computer-based learning interventions in medical education? A systematic review J Med Internet Res 2016;18(8):e204 31 Schneiderman J, Corbridge S, Zerwic JJ Demonstrating the effectiveness of an online, computer-based learning module for arterial blood gas analysis Clin Nurse Spec 2009;23(3):151-155 32 Patel R Evaluation and assessment of the online postgraduate critical care nursing course Stud Health Technol Inform 2007;129(Pt 2):1377-1381 33 Mangum R, Lazar J, Rose MJ, Mahan JD, Reed S Exploring the value of just-in-time teaching as a supplemental tool to traditional resident education on a busy inpatient pediatrics rotation Acad Pediatr 2017;17(6):589-592 34 Waddell DL, Dunn N Peer coaching: the next step in staff development J Contin Educ Nurs 2005;36(2):84-89; quiz 90-81 35 Alamgir H, Drebit S, Li HG, Kidd C, Tam H, Fast C Peer coaching and mentoring: a new model of educational intervention for safe patient handling in health care Am J Ind Med 2011;54(8):609-617 36 Gordon SJ, Melillo KD, Nannini A, Lakatos BE Bedside coaching to improve nurses’ recognition of delirium J Neurosci Nurs 2013; 45(5):288-293 37 Deeter KH, King MA, Ridling D, Irby GL, Lynn AM, Zimmerman JJ Successful implementation of a pediatric sedation protocol for mechanically ventilated patients Crit Care Med 2011;39 (4):683-688 38 Yaghmai BF, Di Gennaro JL, Irby GA, Deeter KH, Zimmerman JJ A pediatric sedation protocol for mechanically ventilated patients requires sustenance beyond implementation Pediatr Crit Care Med 2016;17(8):721-726 39 Ista E, van Dijk M How to sustain quality improvements in sedation practice? Pediatr Crit Care Med 2016;17(8):792-794 40 Schell SF, Luke DA, Schooley MW, et al Public health program capacity for sustainability: a new framework Implement Sci 2013;8:15 41 Luke DA, Calhoun A, Robichaux CB, Elliott MB, Moreland-Russell S The Program Sustainability Assessment Tool: a new instrument for public health programs Prev Chronic Dis 2014;11:130184 42 Calhoun A, Mainor A, Moreland-Russell S, Maier RC, Brossart L, Luke DA Using the Program Sustainability Assessment Tool to assess and plan for sustainability Prev Chronic Dis 2014;11:130185 43 Luke DA, Malone S, Prewitt K, Hackett R, Lin JC The clinical sustainability assessment tool (CSAT): Assessing sustainability in clinical medicine settings 11th Annual Conference on the Science of Dissemination and Implementation in Health Washington D.C December 2018 e2 Abstract: A modern pediatric intensive care unit (PICU) faces constant pressures to implement new clinical care practices, introduce new equipment, or assimilate new systems in response to rapidly evolving healthcare regulatory, economic, and patientcentered demands while maximizing healthcare value To meet new challenges and advance PICU care optimally, the process of change requires a combination of leadership and management in order to develop an intentional strategy and carry out a structured yet adaptable implementation approach The PICU team can increase the likelihood of successful and sustainable change in care practices by understanding the strengths and weaknesses of existing interprofessional team function and empowering distributed leadership, personal agency, and group identity among the diverse people who comprise the PICU team The fields of business administration and management, dissemination and implementation science, and quality improvement offer models and tools that can guide a PICU team embarking on new initiatives Key words: change leadership, change management, interprofessional team, consolidated framework for implementation research, quality and process improvement, sustainability 10 Chapter Title Evolution of Critical Care Nursing CHAPTERR.AUTHOR LAUREN SORCE AND RUTH LEBET PEARLS • • • • To gain basic of the development of theintensive eye As part of theknowledge multiprofessional team of dedicated To develop understanding at famicare experts,essential nurses are pivotal in thehow careabnormalities of children and various stages of development can arrest or hamper normal lies during critical illness formationa of the ocularenvironment structures and visual pathways Building humanistic that endorses parents as unique individuals capable of providing essential elements of care to their children constitutes the foundation for familycentered 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 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.1 This PICU was fully equipped with monitoring and required devices for six beds Although critically ill children had been previously studied in a 36 • • • To acquire adequate information about anatomy of a Excellence in a pediatric critical care unitnormal is achieved through the eye and related structures andisdevelop a strong foundation combination of many factors and highly dependent on a for the understanding of common ocular problems and healthy work environment as well as training beyond thetheir techconsequences nical 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 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 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.2 The fundamental premise of this model is that patient characteristics CHAPTER 6 Evolution of Critical Care Nursing 37 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.3 Patient Characteristics of Concern to Nurses • Fig 6.1 Nursing care in early pediatric intensive care units focused on close observation and limited technology, primarily basic ventilators, arterial and central venous lines, and simple intracranial pressure monitoring devices (From The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.) 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 • Fig 6.2 Pediatric intensive care unit 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 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 ... 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... 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... United States was opened in 1967 by Dr John J Downes at the Children’s Hospital of Philadelphia.1 This PICU was fully equipped with monitoring and required devices for six beds Although critically