43CHAPTER 6 Evolution of Critical Care Nursing programs Teaching usually is under the direction of a hospital or unit based educator and generally involves less senior staff mem bers as preceptors Typ[.]
CHAPTER 6 Evolution of Critical Care Nursing programs Teaching usually is under the direction of a hospital or unit-based educator and generally involves less senior staff members as preceptors Typically, the novice nurse starts with providing care to the least complex patients The program establishes a foundation on which the novice can develop into a competent clinician.33–36 The AACN partnered with Pediatric Learning Solutions, a division of the Children’s Hospital Association, to offer the Essentials of Pediatric Critical Care Orientation program.37 This program provides a bridge for the knowledge gap between what nurses learn in their basic education program and what they need to know in order to achieve initial clinical competence with critically ill pediatric patients The program consists of seven interactive modules providing 34 courses, including case scenarios and practice activities that augment knowledge and improve job satisfaction This program provides flexibility because it is a self-paced, didactic e-learning course that can be incorporated into a blended learning environment combining traditional educational activities, such as preceptorships, discussion groups, workshops, and simulation experiences Continuing Education New medical developments, legislation, regulations, professional standards, and expectations of healthcare consumers help determine the need for continuing education and often lend themselves to in-service education programs In-services involve specific workplace learning experiences that help staff to perform assigned functions and maintain competency Continuing nursing education includes planned, organized learning experiences designed to expand knowledge and skills beyond the level of basic education.28 The focus of continuing education is information that is not specific to one institution and it builds on previously acquired knowledge and skills For continuing development, pediatric critical care nurses attend, present at and organize a wide variety of regional, national, and international conferences with pediatric-specific content sponsored by critical care nursing organizations as well as critical care societies Table 6.2 presents information on organizations providing pediatric critical care content Certification in Pediatric Nursing and Pediatric Critical Care Nursing In 1975, the AACN Certification Corporation was established to formally recognize the professional competence of critical care nurses The mission of the AACN Certification Corporation is to certify and promote critical care nursing practice that optimally contributes to desired patient outcomes The program establishes the body of knowledge necessary for critical care registered nurse (CCRN) certification, tests the common body of knowledge needed to function effectively within the critical care setting, recognizes professional competence by granting CCRN status to successful certification candidates, and assists and promotes the continual professional development of critical care nurses In 1997, the unique competencies of pediatric, neonatal, and adult critical care nurses were rearticulated using the Synergy Model2 as a conceptual framework In order to ensure that the certification reflects current practice, the AACN completes a job analysis at least every years and revises the test plan as needed The most recent test plan was revised in 2019 (Box 6.2) To date, more than 6400 pediatric critical care nurses hold CCRNPediatric certification, and nearly 300 hold the Pediatric CCRNK.38 The AACN also provided a clinical nurse specialist certification 43 TABLE Selected Critical Care Nursing Organizations 6.2 and Professional Associations Organization Website American Association of Critical Care Nurses https://www.aacn.org Australian College of Critical Care Nurses https://www.acccn.com.au/ Canadian Association of Critical Care Nurses https://www.caccn.ca/ European Federation of Critical Care Nursing Associations https://www.efccna.org/ European Society of Pediatric and Neonatal Intensive Care https://espnic-online.org/ Pediatric Cardiac Intensive Care Society https://www.pcics org/?s5nursing Southeast Asian Federation of Critical Care Nurses http://seafccn.com/ World Federation of Critical Care Nurses https://wfccn.org/ World Federation of Pediatric Intensive & Critical Care Societies https://www.wfpiccs.org/ in pediatric critical care, but the examination for new applicants was retired in 2015 and a new Acute Care Clinical Nurse Specialist (CNS)-Pediatric was developed that complies with the Consensus Model for Advanced Practice Registered Nurse (APRN) Regulation More information about these certifications can be found at https://www.aacn.org/certification/ get-certified.39 In addition to certification by the AACN, pediatric critical care nurses may choose to be certified by the Pediatric Nursing Certification Board (PNCB) Originally established in 1975 to develop a program to certify primary care pediatric nurse practitioners (CPNP-PC), the PNCB has expanded to certification of acute care pediatric nurse practitioners and pediatric nurses In 1989, the PNCB launched the Certified Pediatric Nurse (CPN) examination; while CPNs work in a variety of settings, many CPNs work in pediatric critical care today (www.pncb.org/about).40 In 2005, the PNCB launched the only certification examination for acute care pediatric nurse practitioners (CPNP-AC); many currently are practicing in pediatric critical care Evolution of Advanced Practice Registered Nurses into Pediatric Critical Care Clinical Nurse Specialists Clinical Nurse Specialists (CNSs), the first APRN designation, evolved from the need for a more specialized focus and increased knowledge to care for specific populations of patients, ensuring quality nursing care Initially, nurses with focused knowledge were referred to as nurse clinicians, though this terminology ultimately transitioned to CNS During the early years of the CNS, role competencies lacked clarity and although formal master’s education became a requirement for 44 S E C T I O N I Pediatric Critical Care: The Discipline • BOX 6.2 AACN Critical Care Registered Nurse-Pediatric Test Plan I Clinical Judgment (80%) A Cardiovascular (15%) Acute pulmonary edema Cardiac surgery (e.g., congenital defects) Cardiac/vascular catheterization a Diagnostic b Interventional Cardiogenic shock Cardiomyopathies (e.g., hypertrophic, dilated, restrictive, idiopathic) Dysrhythmias Heart failure Hypertensive crisis Myocardial conduction system defects 10 Structural heart defects (acquired and congenital, including valvular disease) Pulmonary (16%) B Acute pulmonary embolus Acute respiratory distress syndrome (ARDS), to include acute lung injury (ALI) and respiratory distress syndrome (RDS) Acute respiratory failure Acute respiratory infections (e.g., pneumonia) Air leak syndromes (e.g., pneumothorax, pneumopericardium) Aspiration (e.g., aspiration pneumonia, foreign body, meconium) Bronchopulmonary dysplasia, asthma, chronic bronchitis Congenital anomalies (e.g., diaphragmatic hernia, tracheoesophageal fistula, choanal atresia, pulmonary hypoplasia, tracheal malacia, tracheal stenosis) Chronic conditions (e.g., asthma, bronchitis) 10 Failure to wean from mechanical ventilation 11 Pulmonary hypertension 12 Status asthmaticus 13 Thoracic surgery 14 Thoracic trauma (e.g., fractured ribs, lung contusions, tracheal perforation) C Endocrine/Hematology/Gastrointestinal/Renal/Integumentary (19%) Endocrine a Acute hypoglycemia b Diabetes insipidus c Diabetic ketoacidosis d Hyperglycemia e Inborn errors of metabolism f Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Hematology/Immunology a Anemia b Coagulopathies (e.g., immune thrombocytopenia [ITP], disseminated intravascular coagulation [DIC], heparin-induced thrombocytopenia [HIT]) c Immune deficiencies d Leukopenia e Oncologic complications f Sickle cell crisis g Thrombocytopenia Gastrointestinal (GI) a Acute abdominal trauma b Acute GI hemorrhage c Bowel infarction/obstruction/perforation (e.g., mesenteric ischemia, adhesions) d Gastroesophageal reflux e GI abnormalities (e.g., omphalocele, gastroschisis, volvulus, imperforate anus, Hirschsprung disease, malrotation, intussusception) f GI surgeries g Hepatic failure/coma (e.g., portal hypertension, cirrhosis, esophageal varices, fulminant hepatitis, biliary atresia) h Malnutrition and malabsorption Renal/Genitourinary a Acute kidney injury (AKI), acute renal failure, acute tubular necrosis (ATN) b Chronic kidney disease c Infections d Life-threatening electrolyte imbalances Integumentary a IV infiltration b Pressure ulcer c Wounds i Infectious ii Surgical iii Trauma D Musculoskeletal/Neurology/Psychosocial (16%) Musculoskeletal a Infections Neurology a Acute spinal cord injury b Brain death c Congenital neurologic abnormalities (e.g., arteriovenous malformation, myelomeningocele, encephalocele) d Encephalopathy e Head trauma f Hemorrhage i Intracranial (ICH) ii Intraventricular (IVH) iii Subarachnoid (traumatic or aneurysmal) a Hydrocephalus b Ischemic stroke c Neurologic infectious disease (e.g., viral, bacterial, fungal) d Neuromuscular disorders e Neurosurgery f Seizure disorders g Space-occupying lesions (e.g., brain tumors) h Spinal fusion i Traumatic brain injury (e.g., epidural, subdural, concussion, nonaccidental trauma) Behavioral/Psychosocial a Abuse, maltreatment, neglect b Agitation c Developmental delays d Failure to thrive e Medical nonadherence f Suicidal ideation and/or behaviors E Multisystem (14%) Asphyxia Comorbidity in patients with transplant history End of life Healthcare-associated infections (HAI) a Central line–associated bloodstream infections (CLABSI) b Catheter-associated urinary tract infection (CAUTI) c Ventilator-associated pneumonia (i.e., ventilator-associated event [VAE]) Hemolytic uremic syndrome (HUS) Hypotension Infectious diseases a Multidrug-resistant organisms (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus [VRE], carbapenem-resistant Enterobacteriaceae [CRE]) b Influenza (e.g., pandemic or epidemic) Multiorgan dysfunction syndrome (MODS) Multisystem trauma 10 Pain CHAPTER 6 Evolution of Critical Care Nursing • BOX 6.2 45 AACN Critical Care Registered Nurse-Pediatric Test Plan—cont’d 11 Palliative care 12 Sepsis continuum (systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, septic shock) 13 Shock states a Distributive (e.g., anaphylactic, neurogenic) b Hypovolemic 14 Sleep disruption (including sensory overload) 15 Submersion injuries 16 Thermoregulation 17 Toxic ingestions/inhalations (e.g., drug/alcohol overdose) 18 Toxin/drug exposure (including allergies) the role, the curriculum varied from school to school As a result, there was confusion about the role and unique skill set of the CNS By the mid-1990s, standards and competencies for CNSs were developed, resulting in improved role definition.41 The components of the CNS role, similar to other APRN roles, became expert clinician, educator, researcher, and administrator However, a contemporary view of CNSs identifies change agent, strategist, bridge builder, and communicator in addition to expert clinician as key components of the role.42 CNSs work within three spheres of influence: (1) patients (clinical experts supporting direct care at the bedside), (2) nurses (advancing and improving nursing practice) and (3) systems (working with interdisciplinary teams and fostering system innovations).43–45 CNSs in the PICU date back to the 1980s As technology continued to expand in the PICU environment and patient acuity increased, nursing care became more complex CNSs were uniquely prepared to guide and support expanding nursing practice CNSs in the PICU worked to improve quality of care, provide education through a variety of mechanisms, structure and organize orientation for new nurses, and promote best practice With the changes seen in healthcare finance in the 1990s, particularly the emergence of managed care, many hospitals restructured their organizations to the detriment of the CNS role Although critically important to the functioning of the PICU, financing the work of the CNS was no longer supported As a result, the CNS role was eliminated or phased out in many institutions Because the CNS did important work, the responsibilities were transitioned to other professionals Yet, in some institutions, the role was maintained Today, it is being reimplemented with the changing financial landscape, which rewards quality and value-based healthcare.42 Pediatric Nurse Practitioners Another APRN role, the Pediatric Nurse Practitioner (PNP), came into healthcare in the 1960s when the need to care for more children arose.46 PNPs were educated in specialty training programs focusing on delivery of preventive and primary care Graduate-level degrees were mandated for this role in many states by the early 1980s and today is the minimum expected degree for entry into practice across the United States Although currently not fully adopted nationally, in 2004, the American Association of Colleges of Nursing recommended the practice doctorate (Doctor of Nursing Practice [DNP]) for the nurse practitioner as the entry into practice degree.47 In the 1990s, PNP practice extended to pediatric critical care with the rise in number of PICUs and number of PICU beds48 and the need for additional personnel The addition of PNPs in the II Professional Caring and Ethical Practice (20%) A B C D E F G Advocacy/Moral Agency Caring Practices Response to Diversity Facilitation of Learning Collaboration Systems Thinking Clinical Inquiry Data from AACN Certification Corporation CCRN Exam Handbook 2019 https://www.aacn.org/,/ media/aacn-website/certification/get-certified/handbooks/ccrnexamhandbook.pdf PICU was also endorsed by the American Academy of Pediatrics.49 By the early 2000s, the numbers of PNPs in critical care grew even more as a result of restricted resident duty hours set forth by the Accreditation Council for Graduate Medical Education.50 Owing to the need for specialized education for these areas, master’s programs were created that focused on acute care and critical care To standardize APRN practice across the country, a consensus model was developed for regulation of licensure, accreditation, certification, and education.51 Concisely, this model serves as a guide to inform organizations about selection of the best fitting candidate for an open APRN position, aligning education, licensure, certification, and practice (e.g., hiring a CPNP-AC for the PICU and CPNP-PC for the primary care office) Because this model is yet to be adopted by all states and the availability of CPNP-ACs is limited, some PICUs continue to hire either CPNP-PCs or family nurse practitioners for the provision of patient care Given this issue, postgraduate training of PNPs not educated in acute care is critical to ensure competency and delivery of high-quality care Nursing Research Pediatric critical care nursing is a science as well as an art It is vital that nursing interventions supporting the care of the critically ill child and family be grounded in high-quality evidence generated through pediatric-specific research Whereas knowledge generated in the larger neonatal and adult populations can inform pediatric practice, the developmental and maturational differences in our unique patient population require independent study In 2015, a group of international pediatric nurse scientists convened to summarize the state of the science in pediatric critical care nursing and to prioritize a list of nursing research topics for future focus The group identified four top research priorities, including end-of-life care and decision-making, interventions impacting the child and family experiencing withdrawal of lifesustaining therapies, long-term psychosocial outcomes of pediatric critical illness, communicating clinical assessments and improving teamwork, and articulating core nursing competencies that prevent unstable situations from deteriorating into crises.52 Today, there are increasing numbers of pediatric critical care nurse scientists internationally who collaborate and address these and many other research priorities Summary Pediatric critical care nursing has evolved into a specialty in its own right Pediatric critical care nurses make significant and unique contributions to the healthcare of children A pediatric 46 S E C T I O N I Pediatric Critical Care: The Discipline critical care nurse requires knowledge and skills in both the art and science of nursing A supportive, empowered environment and support for professional advancement are essential to the development of knowledge and skills Ongoing research for the advancement of pediatric critical care nursing is important Key References Aiken LH, Clarke SP, Sloane 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Available at: https://nacns.org/about-us/what-is-a-cns/ 46 Ford LC, Silver HC The expanded role of the nurse in child care Nurs Outlook 1967;15:43-45 47 American Association of Colleges of Nursing AACN Position Statement on the Practice Doctorate In Nursing Available at: www.aacn.nche edu/DNP/DNPPositionStatement.htm 48 Randolph AG, Gonzales CA, Cortellini L, Yeh TS Growth of pediatric intensive care units in the United States from 1995 to 2001 J Pediatr 2004;144:792-798 49 Schaeffer HA, Hardy DR, Jewett PH, et al The role of the nurse practitioner and physician assistant in the care of hospitalized children Pediatrics 1999;103:1050-1051 ... catheterization a Diagnostic b Interventional Cardiogenic shock Cardiomyopathies (e.g., hypertrophic, dilated, restrictive, idiopathic) Dysrhythmias Heart failure Hypertensive crisis Myocardial conduction... Professional Caring and Ethical Practice (20%) A B C D E F G Advocacy/Moral Agency Caring Practices Response to Diversity Facilitation of Learning Collaboration Systems Thinking Clinical Inquiry... uremic syndrome (HUS) Hypotension Infectious diseases a Multidrug-resistant organisms (e.g., methicillin-resistant Staphylococcus aureus [MRSA], vancomycin-resistant Enterococcus [VRE], carbapenem-resistant