"PICU Nurse Education: Is There a Difference?" by Fenella Gill, RN, PhD at ANZICS 2013

By: OPENPediatrics

It was interesting. When I was preparing this talk, I had in my mind pediatric intensive care nurse education, is there any difference? And I was thinking in terms of compared to adult intensive care. But after talking to Kimber, I was glad that I then realized that certainly in Hobart that there is the difference about, is there any difference between pediatric intensive care and neonatal intensive care. So my attempt is to address both of those in the talk today. I thought I'd start off by looking at where does pediatric intensive care fit into the big picture, and we're part of critical care nursing. And in the developed countries most of those have developed competency standards or practice standards for specialist level critical care nursing. And this was a paper published now a couple of years ago, that's already out of date.

But we did look at comparing the different countries' practice standards and found that they are all based on the beginning registered nurse standards. But when we actually looked at what was covered in the practice standards, you could see that we've got constructs that were contained in many of the standards that we've looked at. But then there was none that were common to all. So I guess we're talking about the same sort of thing.

But we might not necessarily use the same words. But you can see some of these constructs are pretty generic. And it wouldn't matter which area of critical care you worked in. I think, when you look at some of these terms, it wouldn't really matter which area of nursing you work in. They're all pretty generic. When we look at ACCCN's competency standards, in particular, I know they were last revised in 2002.

And I'm sure you'd already be aware that there are revisions underway. So the competency standards articulate specialist-level practice for critical care nursing. They were developed as a result, originally, of a big project that involved data collection from critical care areas, which included neonatal intensive care, pediatric intensive care, and adult critical care areas, as well as some other specialties. And ACCCN had developed their position statement. They recommended that these competency standards are used for the curriculum development for the courses, for postgraduate courses and, in particular, for the basis for an assessment.

But as I mentioned, they were now developed in 2002, so they are getting old now. And the other issue is that they articulate the specialist-level competency standards. So this is just a bit of background to what I'm going to talk on next then. So we don't really have an outcome for practice standards. We don't have practice standards for graduates of courses.

And we've got this mandate from our standards for workforce, that we should have a minimum of 50% nurses are qualified in their specialty. But there's no regulation about what that specialty should look like. So we're fortunate that ACCCN have a position statement, the College of Intensive Care Medicine have a standard as well as the Australian Counsel on Health Care standards. So we should be staffing our intensive care units with qualified nurses.

But we know from work originally done by Aitken and colleagues, and more recently, in some work that haven't had published yet, that there is a great variety in courses preparing nurses to be qualified, both in adult and pediatric, that the level of the qualification can vary, the curriculum can vary, the experience students have on their course varies. And their practice outcome can vary. And it may or may not actually be assessed. Internationally, there has been a move to achieve more consistency in postgraduate education. And particularly in Europe and in the UK, there are competency frameworks now for postgraduate education. So that leads me to the project that I've been working on, that's been a number of stages.

First of all, that it's sure if you're looking at what other practice standards, practice outcomes for critical care nurses and what standards and how that relates to education internationally. We undertook an analysis of 22 courses that are for critical care, with or without pediatric intensive care, and looked at, particularly, the factors that influence practice outcomes and in clinical assessment tools. And then, I think, importantly for this study, we also obtained health consumers views about what they thought was important for critical care nurses to be doing and for graduates of courses, what were the important aspects of their skills, outcome standards, what did health consumers think was important. And I'll talk a little bit more about that later on. So these, collectively then, enabled the development of some practice standards that were grouped in six domains, that we used then for a Delphi study to further develop these standards. So these are their six domains. And you can see with the first domain there, patient and family focused approach to care, many of the statements are included there that reflected what health consumers thought were important. We've got quality of care, resuscitation, assessment. And then the critical illness management incorporates a number of areas.

And that makes up pretty much half of the standards all together, and teamwork and leadership. So we undertook a three-round Delphi technique, using online SurveyMonkey. Recruited a national panel of critical care nurses.

We had 105 agree to participate. Recruited that panel purposefully using a structured approach, having a combination of adult intensive care adult critical care, more broadly, coronary care, high dependency, and also pediatric intensive care. And groups, in particular, those advisory group, we called them. So people that had expertise in standards in education. Course stakeholders were course coordinators of the many critical care courses that are run across Australia.

Practice stakeholders, so there were people working in clinical practice, in clinical education and management, and then course graduates. So critical care nurses who had finished a critical course within 12 months. And we asked them to rate their level of agreement, as in how important they thought these statements were, on a 1 to 7 scale.

And then we also asked them to rate the level of practice that they would expect a graduate to achieve. And you can see there, on the bottom corner here, the level of practice categories. And they were developed based on Miller's work of assessment framework and also the CoBaTrICE Collaboration's recent work for core competencies for medical training in intensive care. And so we've got five categories of what you'd expect for a graduate. So what did we find? We found we were able to develop some practice standards, that there's actually 98 standards. So we actually ended up with a few more than we started with. We had some deletions, some additions, some editing, et cetera.

And we were able to identify three levels of practice that are expected of a graduate. So there were some core competencies that graduates were expected to be able to demonstrate independently, to manage patients. Some where it recognized it was beyond the scope of their course, that they wouldn't be able to be independent.

But they should have had some exposure, some experience, and have some knowledge, to be able to demonstrate under supervision. And then a third level, where it wouldn't have had exposure, experience, but were expected to have some knowledge of and describe. And I think, importantly, this study has shown that graduates-- or what's expected of graduates, of course-- is that they can independently care for the majority of critically ill patients in most contexts, but not all contexts. Because you could think about how specialized we can be in intensive care. It was agreed that it should be using a patient and family-focused approach, but I think, also importantly, that graduates are not expected to be a team leader.

And I think that was an important finding because there's been a big variety in what has been expected of graduates. So that clearly then provides a definition for workforce standards. So we thought it would be important to see whether we were a consensus, were there a difference of views, particularly between the stakeholder groups? So we had the advisory group course coordinators and graduates and those who worked in practice.

And we found that there was no difference across any of those domains, the six domains. There was no difference. What do you think we found when we compared adults in pediatrics? Do you think they would have the same or different views? They were the same in five out of six of the domains. The one domain that was different was in the resuscitation domain, which did surprise me slightly. I thought there may have been a difference in the family-focused approach to care. But in the resuscitation domain, when we drilled down to look at which statement in particular, it was the family-focused approach. It was that facilitation of family presence at resuscitation. And I guess, when I'm going on to the next few slides, that's something that comes out from the literature.

This important clinical practice guidelines now, developed in the mid 2000s, published in 2007, was a review of care of the family and the patients in intensive care and covering adult, pediatric, and neonatal intensive care. And the group reviewed over 300 studies to develop 43 recommendations. And you can see some of the key principles there, of how family should be cared for in an intensive care unit. And the recommendations-- so we say now, that's like nearly 10 years ago, but how are we doing? As a student of intensive care, I think this is quite a good model to show what are the factors that influence family satisfaction. And other than the patient and family-related factors, the other three key items are that-- it depends on the family's expectations-- the hospital infrastructure and processes of care can really impact on family satisfaction. And then that whole area about information and communication. So even in just this paper, published by Al-Mutair and colleagues in 2007, was a review of family needs and involvement intensive care.

And you think by now we would be getting it right. But no, there are still big gaps in what families say they need and want and what perceptions are of what they need. And there's a gap. Although everyone's positive about family-centered care, in particular the health providers being positive, in terms of families being present in routine care. What's not so consistent is the area about the family presence at resuscitation. So this is this infrastructure about can families be present or not. And in the adult environment, that's still something that's evolving. In Europe there's been moves to develop visiting policies. And in the UK, the BACC and the British Association of Critical Care Nurse have developed a position statement for families visiting in intensive care.

And that's also something we're doing with ACCCN, and are thinking of terming it more about families' involvement in intensive care. So that's something that is not done consistently. But there are some initiatives that, I think, are exciting. And I've got a couple of examples there, to address the information and communication needs for families, involving families in providing patient care with Marian Mitchell and colleagues.

And there's been some work done in a number of countries about using patient diaries, both for communication mode, but also its benefit in reducing patient's post-traumatic stress disorder. But I think the key point is that there's lots of good things being done, but it's not being done consistently. In the NICU setting, family-centered care is something that's been a part of the philosophy for many, many years. But this recent study, conducted in Sydney, really identified that what nurses struggle with is shifting their role from being the doer, the carer, to being more the support of parents. And that's something they don't necessarily find easy.

And the workforce mix is a lot of inexperienced nurses. And those are the nurses that find it more difficult to be able to support families, at the same time as being able to provide their family care, their patient care. So they're finding it hard to do that multitasking. So I think that's something else that I'll come back to, as we go through.

And there is a still a lack of guidelines. So there is an inconsistency, that some people are better at doing it than others. But not everybody's doing the same thing. And then in the PICU setting, this is a framework that Jos Latour used from some of his work around patient satisfaction and similar sort of themes there you can see. What affects parent satisfaction is physical and emotional support, coordination of care, parents being involved, having respect and information and education. So parental expectations, again, this is Latour and colleagues' work, looking at there are differences about perceptions of parents and health professionals.

So we don't always know we've got it right. The parental involvement-- there's still a lack of consistency. This is work in Europe, with Fulbrook and colleagues, that they found that although pediatric and critical nurses are much more positive about parents presence then adult colleagues, there's still an inconsistency. And many units don't have policies about parents' presence, either in the unit at all or for resuscitational procedures.

So looking at, how does that work in Australia? For part of our study in developing the practice standards, we sought health consumers' views. And they identified what they thought were important components of their critical care nurse role. You can see some of the similar themes that I've been talking about already, about making the patient feel safe, providing physical care, but importantly that it's supporting socioemotional needs. There was an inconsistency reported by the health consumer groups, that some people are better at it than others. And in some places it's done better than others. And for practice standards for critical care course graduates, they really believe it's those important communication, listening skills, all of those attributes that you heard Elaine speak about in the first session are so important to the consumer. And I think this even more important now. We're focusing much more on the quality of work with health consumers. So I think the principles are in the family-centered care setting in intensive care. Then for nurse education, it's facilitating that patient and family-centered approach.

So there needs to be that philosophy underpinning all programs. From the beginning it's not learning how to look after the patient first and the family second, having a standardized approach to having policies and guidelines, and influencing nurse's attitudes, so that they value and really do embrace looking after families, that it's not something that some people are good at and others are not, but we all do it well. So applying that to the PICU setting then for education, in particular, I'm going to be a bit more specific then. Learners in PICU come from all sorts of backgrounds. And I realize when Kimber was speaking then, I didn't have midwives, but sorry. [LAUGHING] But there are many backgrounds the nurses come from.

And so they bring in their different skills. They may come from an adult intensive care or critical background. They may come from a neonatal, from a pediatric background. They may come from a PICU background, but it's another PICU. Or they may have none. So we haven't got a homogeneous group when we're providing an education program. So we really need to have a structured approach, that has clear competency and outcome-based approach, so that we can fit everybody in, meet their needs, and achieve the outcome. So that's that the steps in planning the competency-based education. So really, identifying-- and I'm going to talk about what is your core business-- identifying what are the abilities you need for the nurses working in your unit, defining what's required, and whether that's looking after infants with oxygen delivery systems or is that looking after children with a non-invasive ventilation, or is that looking after children who are mechanically ventilated? And so there are components and milestones along that in developmental stages. So you can design the curriculum accordingly and choose the appropriate assessment tools-- which I haven't got time to talk about-- and of course, evaluate your program.

So what is your core business? And I think-- I was glad to see, that on Kimber's slide-- that looking after the sick respiratory patient is core business in PICU. And how many times do your hear that, particularly when you're getting relieving stuff? Are they vent comp? Well, what we mean by that, I think-- and I hate that word myself-- but what we mean by that is that nurses working in pediatric intensive care are able to provide the nursing care or manage the nursing care for critically ill patients requiring mechanical ventilation. And if we can achieve that, then we've got core skills. And this is at the interest of all professional activities that have been described by Frank and colleagues, in some work in medical competency-based education. So it's knowing what's called business. So then, applying that to what the learner needs are, so depending on what the learners' backgrounds are, are they aware that newborns' response to hypoxia is going to revert to fetal circulation? Or if they're from an adult background, are they going to be able to assess respiratory failure? Or if they're from a neonatal background, are they going to think beyond thinking about circulating volume of the preterm or newborn, to a more adult physiology? So thinking about managing the fluid status of the patient who's ventilated. So keeping in mind, is it this sort of patient, with respiratory failure, that you're going to be expecting nurses to care for effectively? Or is it more like a complex patient, who's had cardiac surgery, who's got different issues to consider in their respiratory management? And again, another example of a patient, I guess, more specialized, a patient with burns and inhalation injuries who's got additional challenges for their respiratory management. So it's putting it together, thinking about four-year learner. Are you expecting them to have knowledge of and describe? Are you expecting them to be able to demonstrate under supervision? So they're very much just beginning their pathway of PICU practice.

Would you be able to expect them to manage the patient independently? So perhaps the outcome of a critical care course. Or were you expecting this nurse to be able to teach their supervisor this? So this is more leadership level of competency. But we're talking about the same thing, the patient requiring ventilator support. But we don't expect the same thing from every one of our nurses. But behind that competency of courses all of the curriculum that goes into that, so the knowledge, the skills, attitudes and values that underpin competency. So just putting it all together then, to finish then. It's for the development of PICU education, in particular, for developing our learners. It's keeping in mind, we understand the level that we're expecting of our learners.

We, I think, working in the area, don't expect beginning practice graduates from last semester, who are now working in our PICU, to be able to look after a ventilated patient. Our managers do or our admin staff, to expect that to happen within a matter of weeks. But we know that takes time, and it's a developing process. We need to know who our patient group are. And Kimber provided a profile there of the patient case mix in Hobart and then NICU/PICU. So bearing in mind, what do we need to know? Understanding the nurse's learning needs. So understanding their background. So it's not one package that fits all. It needs to be individualized.

And realize then that nurse's experience will be varied. And it does develop over time. So that's something that we need to be realistic, with their milestones and the time frames we put on learning. The knowledge and curriculum will then build on nurse's previous knowledge and experience, and structure it based on what do we need to achieve in the end? Because it can be completely overwhelming. And I know, when I first started teaching in postgraduate education, I really felt like everybody needed to know everything. But I think over time-- and I guess with more experience and knowledge myself-- I now realize that we really need to be clear about what do we want the nurse to be able to do and know about. And make sure it's focused, less is definitely more, what's really important? And then the skills, I think what's really important is that ability to multitask. It's not about looking after the patient first and then I should become more proficient and be able to look after the family as well. It needs to be in tandem, because that's what we do. That's our business, is looking after families.

And so much about standardizing approaches and to assessment. And Tina prompted me to think also about early warning systems, so that there is a commonality. There's a sameness. So that people are thinking smartly, critical thinking about doing things the same way. And it doesn't give people opportunity to make mistakes. So standardizing the way we do things, standardizing equipment, and the role of simulation is so important, both for practicing technical skills, physical skills, but also those communication skills and supporting family skills.

And attitudes and values, I think, we've got a big role in really instilling, in all nurses, and not only PICU nurses, how important it is to look after families and make that easy, to be able to do it the right way, by having policy and guidelines to standardize that approach as well. So thank you.

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