38 SECTION I Pediatric Critical Care The Discipline TABLE 6 1 Synergy Model Nurse Competencies, Expanded Nurse Competency Activities Supports Clinical Judgment Skilled clinical knowledge, use of discr[.]
38 S E C T I O N I Pediatric Critical Care: The Discipline TABLE Synergy Model Nurse Competencies, Expanded 6.1 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 • • • • • 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 not actually benefit patients Quality improvement methods use multidisciplinary teams working together to help systems operate in a way that promotes the best interests of patient care Collaborative practice groups work with CPGs to initiate evidence-based and expert consensus-based interventions 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 vulnerabilities2 • 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 nursing2 • 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 helpful2 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 Families trust that nurses will be vigilant Steady attention can make an important difference by helping patients and their families better tolerate the experience of critical illness 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 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 Skilled nurses foresee differences and beliefs within the team and negotiate consensus in the best interest of the patient and family 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 CHAPTER 6 Evolution of Critical Care Nursing TABLE Synergy Model Nurse Competencies, Expanded—cont’d 6.1 Nurse Competency Activities Supports Advocacy/Moral Agency: Speaking on the patient’s behalf in an effort to preserve a patient’s lifeworld53 • 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.54 • Supports the practice of family presence during procedures and resuscitation The holistic view of the patient that nurses often possess is a reflection of moral awareness 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.55 Parents who were not able to stay described more anguish 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.56 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 nursephysician 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, hospitalacquired pressure ulcers, ventilator-associated pneumonia, and central line–associated infections.13 • Donovan and colleagues58 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 associates12 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.57 • Create a safe environment • Help patients make transitions between elements of the healthcare system using systems knowledge and intradisciplinary collaboration 3 4 5 CPGs, Clinical practice guidelines Patient-centered culture Strong leadership Continuous multidisciplinary communication Collaborative problem solving Conflict management29 39 40 S E C T I O N I Pediatric Critical Care: The Discipline 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,4 defines a dynamic patient or family caregiver state, condition, or perception that is responsive to nursing interventions Brooten and Naylor5 noted, “The current search for ‘nursesensitive patient outcomes’ should be tempered in the reality that nurses not care for patients in isolation and patients 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.6,7 Furthermore, mortality rates are reduced in units with a greater proportion of nurses with more than years of experience.6 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 years or less experience, the odds of death increased.8 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.9,10 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.11–13 Clear and effective communication between physicians and nurses is positively correlated with collaborative practice.14 Furthermore, collaborative practice within the team improves the quality of care delivered and decreases burnout.15 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.16 In the absence of collaborative practice and team communication, there is an indirect relationship to increased hospital associated infections.17 Nightingale Metrics One population-specific approach to measurement of nurse-sensitive outcomes is the Nightingale Metrics program.18 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) Leadership Excellence in a pediatric critical care unit is achieved through a combination of many factors and is highly dependent on effective leadership.19 Numerous studies have demonstrated the importance of leadership in creating an environment where both nurses and patients can flourish Specialized units such as PICUs must have staff with the expert knowledge and skill required to meet the multifaceted needs of patients and families A healthy work environment should improve CHAPTER 6 Evolution of Critical Care Nursing • BOX 6.1 • • • • • • • • • a Pediatric Intensive Care Unit: Example of Nightingale Metricsa State Behavioral Scale scores every hours In patients with a central venous line, changing the dressing every days Development of an enteral feeding guideline Mouth care every hours Venous thromboembolism: risk factors, central line removal, prophylactic medications Parental presence Pressure ulcer bundle: If patient is immobile, documentation of position change every hours and positioning of heels off the bed; if not on bed rest, documentation of patient being out of bed or held in parent’s or nurses’ arms in previous 24 hours Ventilator-associated pneumonia bundle: head of bed elevation at 30 to 45 degrees; documentation of oral hygiene twice in 24 hours; peptic ulcer prophylaxis (in patients not receiving tube feedings); discussion of extubation readiness test on rounds; daily holiday from sedation or chemical paralysis “Time to critical intervention”: response to panic laboratory value, the time intervals from sending specimen to laboratory to first intervention to correct laboratory value Metrics developed for unit-specific needs retention and recruitment An evidence-based practice working group at one facility piloted several leadership proposals to enrich the nursing work environment The criteria instituted by the AACN Standards for Establishing and Sustaining Healthy Work Environments—which include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership—were the basis for the proposals When these standards were integrated with qualities of the staff— such as clinical proficiency, personal values, and management experience—the results showed improvement in absenteeism, patient and staff satisfaction, and nursing quality indicators.20 The literature demonstrates that an established and proficient workforce improves patient outcomes A study conducted by Aiken and colleagues21 observed the effect of nurse staffing levels on patient outcomes and factors affecting nurse retention A total of 10,184 nurses from 168 hospitals were surveyed After adjusting for patient and hospital characteristics, each additional patient per nurse was associated with a 7% increase in the likelihood of dying within 30 days of admission and a 7% increase in the odds of failure to rescue (death subsequent to a complication that develops during the hospital stay) In addition, after adjusting for nurse and hospital characteristics, each additional patient per nurse was associated with a 23% increase in the odds of burnout and a 15% increase in the odds of job dissatisfaction Aiken and colleagues22 have continued their work by assessing the net effects of work environments on nurse and patient outcomes Using data from the same hospitals and nurses, they investigated whether better work environments were related to lower patient mortality and better nurse outcomes independent of nurse staffing and the education of the registered nurse workforce in hospitals Work environments were evaluated according to the practice environment scales of the Nursing Work Index Three of the five subscales studied were nursing foundations for quality of care; nurse manager ability, leadership, and support; and collegial registered nurse/physician relationships Outcomes studied included job satisfaction, burnout, intent to leave, quality of care, mortality, and failure to rescue They found that a greater percentage of nurses working in hospitals with unsupportive care 41 environments reported higher burnout levels and dissatisfaction with jobs They also found that work environment had a significant effect on nurses’ plans to leave their units When all patient and nurse factors were considered, the likelihood of patients dying within 30 days of admission was 14% lower in hospitals with healthier care environments These findings support the observation that nursing leaders have at least three major opportunities to boost nurse retention and patient outcomes These opportunities include increasing nurse staffing, using a more highly educated nurse workforce, and enhancing the work environment Work conducted by the same investigators validated their previous findings An observational study using discharge data for 422,730 patients aged 50 years or older who underwent common surgeries in 300 hospitals in nine European countries demonstrated that an increase in a nurse’s workload boosted the probability of inpatient mortality by 7% In addition, a greater number of nurses with bachelor’s degrees was associated with a 7% lower risk of mortality.23 Aiken and colleagues have also examined the negative effect of unfavorable work environments and increased nurse workload on pediatric patient outcomes, specifically, missed nursing care They found that missed nursing care was more common in poor work environments and more care was missed with higher nursing workloads.24 One of the best examples of a work environment that champions the nurse at the bedside is Magnet Recognition for healthcare organizations Data demonstrate that hospitals that use the structure for Magnet designation achieve significant improvements in their work environments.22 Hospitals that have even some of the Magnet characteristics exhibit improved nurse and patient outcomes Characteristics of Magnet-designated hospitals that have the most impact on nurse and patient outcomes are investments in staff development, superior management, frontline manager supervisory skill, and good nurse/physician collaboration.22 Nurses who work in Magnet-designated hospitals identify their environments as healthy A study of 12,233 nurses confirmed healthy work environments in 82% of 540 clinical units and provided evidence that applying structures supporting inter- and intradisciplinary collaboration and decision-making promote the development of healthy work environments.25 As previously noted, the AACN has championed healthy work environments, providing standards for establishing and sustaining a healthy work environment, tools to assess current state, and strategies to improve the environment in order to increase nurse satisfaction and improve patient outcomes.26 The importance of a healthy work environment cannot be stressed enough as the means to ensure a viable, competent, and caring workforce Nurses look for a culture that respects the nurse’s experience, skills, abilities, and unique contributions Beacon Award The Beacon Award for Critical Care Excellence, created by the AACN, distinguishes adult critical care, adult progressive care, and pediatric critical care units that attain high-quality outcomes This prestigious award provides the critical care community with a means of recognizing achievements in professional practice, patient outcomes, and the health of the work environment A pediatric critical care unit can achieve the Beacon Award by meeting several criteria in the areas of recruitment and retention; education, training, and mentoring; evidence-based practice and research; patient outcomes; healing environment; and leadership and organizational ethics Together, these characteristics provide a 42 S E C T I O N I Pediatric Critical Care: The Discipline comprehensive view of any given ICU To date, 31 pediatric critical care units have received the Beacon Award for Critical Care Excellence.27 Professional Development A critical aspect of development for the nurse is the ability to advance and be recognized professionally 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 Essential components of this program include an orientation program, a continuing education plan, and an array of other opportunities for clinical and professional development Unit-based advancement programs are most effective when they are linked to the nursing department’s professional advancement program A professional advancement program that recognizes and rewards evolving expertise contains elements of both clinical and professional development strategies Nurses require a broad body of knowledge to meet patient and organizational needs This requirement necessitates a lifelong process of professional development targeted to specific levels of clinical practice Nurses can choose from many learning options, such as academic education, continuing education programs, participation in research, collaborative learning, case studies, and simulations Nurses view the availability of continuing education as very important.28 Staff Development The goal of nursing staff development programs is safe, competent practice Comprehensive programs provide the critical resources to support and promote practice In addition, professional nursing standards of practice, healthcare laws, regulations, and accreditation requirements focus on the components of competent patient care to protect the healthcare consumer The establishment of a staff development program that is linked to clinical practice is key to the success of professional nurse development Technical training alone is no longer sufficient to meet the care delivery needs of the nurse in the critical care environment In addition to knowledge about disease processes and physiologic instability associated with them, critical care nurses require broad knowledge and expertise in areas such as communication, critical thinking, and collaboration.29 They need to attain the diverse skills necessary to meet the complex needs of their patients and families Theory and science are required to meet the Synergy competencies and include topics such as specific disease processes, nursing procedures, cultural awareness, moral and ethical principles and reasoning, research principles, and learning theories This information can be presented using a variety of methods attending to the specific needs of the learners and adult learning principles Realistic clinical scenarios, case studies, and simulations that represent the dynamic and ambiguous clinical situations nurses encounter daily are most effective.28 Bedside teaching is particularly helpful in the development of clinical judgment and caring practice skills Expert nurses are role models of many of the competencies delineated by the Synergy Model; novice nurses learn by watching these expert nurses and emulating their behaviors Communicating and demonstrating clinical knowledge focuses learning, positively affects patient outcomes, and adds to the total body of nursing knowledge.30 Simulation-based learning is now routine in pediatric critical care nursing practice and advanced practice nursing as a state-ofthe-art educational approach Simulation serves several purposes, such as enhancing patient safety, increasing clinical competence, and promoting effective teamwork Simulation provides a nonthreatening environment where participants can integrate cognitive, psychomotor, and affective skill attainment without fear of hurting patients.31 All pediatric critical care nursing practice should ideally be evidence based Although most nursing programs introduce the concepts of evidence-based practice, practicing nurses require continued support to ensure that they can access and evaluate the literature, make appropriate decisions regarding implementing needed practice changes, and evaluate the effectiveness of new practices in improving patient outcomes Information about research and research use builds clinical inquiry and system thinking skills Demystifying research, outcome, and quality processes contributes to the development of these key skills The use of journal club formats and supporting staff involvement in research helps develop clinical inquiry skills Building knowledge in the areas of healthcare trends and political action expands system thinking skills The development of critical thinking skills and problemsolving skills also assists with the development of system thinking Developing excellent communication skills is an essential part of nurses’ professional development plans In addition to their value in enhancing relationships with patients, families, and colleagues, good communication skills are critical for teaching less experienced staff Presenting clinical teaching strategies and helping staff to determine learner readiness and to assess understanding will facilitate learning The importance of developing patience, flexibility, and a nonconfrontational style is reinforced Negotiation, conflict resolution, time management, communication, and team building are components of collaboration skills Role-playing, role modeling, and clinical narratives are methodologies that have been used to develop collaboration skills Nurses learn technical skills and scientific principles in many ways, but caring practices and advocacy are developed only through relationships that evolve over time.32 Nurturing, professional relationships with experienced staff allow novices to integrate their evolving perspectives into practice Expert nurses who share their clinical knowledge and coach other nurses have a tremendous impact on novice nurses Nurses who coach so because they are able to clinically persuade and guide less experienced staff in challenging situations They demonstrate expert skills and expedite the ongoing clinical development of others A variety of staff development programs exist, but most fall into either orientation or continuing education programs Orientation Orientation programs help acclimate new staff to unit-based policies, procedures, services, physical facilities, and role expectations in a work setting A specific type of orientation that has developed in response to the nursing shortage is the critical care internship or nurse residency program These programs have been developed as a mechanism to recruit, train, and retain entry-level nurses They are designed to transition nurses with little or no nursing experience into the complex critical care environment They provide extended clinical support for novice nurses and introduce new knowledge more deliberately than traditional orientation programs Basic information, skill acquisition, and socialization are the core features of these programs This foundation builds on the knowledge and skills acquired in nursing school ... political action expands system thinking skills The development of critical thinking skills and problemsolving skills also assists with the development of system thinking Developing excellent communication... 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... 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