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[.]
Trang 1CHAPTER 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
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
suc-cess 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
mul-tiple professions—including adult- and pediatric-based practices,
inpatient-based and outpatient-based locations, medical and
sur-gical 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
individu-als comprise the PICU team This team functions as part of a
larger hospital or academic system that is navigating the
ever-changing 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
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 com-plex as the PICU and healthcare must create a sense of belonging and group identity, must foster and support distributed leader-ship, 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, chal-lenges, 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.
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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):1124-1128.
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 effec-tiveness 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 Pe-diatr 2017;17(6):589-592.
34 Waddell DL, Dunn N Peer coaching: the next step in staff
develop-ment 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
as-sess 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.
References
1 National Health Service 2013 Change Day Video https://www.
youtube.com/watch?v5h7A9rohysZw Accessed April 17, 2019.
2 Francis R Press Statement Report of the Mid Staffordshire NHS
Foundation Trust Public Inquiry: Chairman’s Statement London,
United Kingdom: Stationery Office; 2013.
3 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
4 Bevan H Biggest Ever Day of Collective Action to Improve Healthcare
that Started with a Tweet
https://www.mixprize.org/story/biggest-ever-day-collective-action-improve-healthcare-started-tweet-0
5 Kubler-Ross E On Death and Dying New York, NY: Macmillan
Publishing Company; 1969.
6 Scheck CL, Kinikci AJ Identifying the antecedents of coping with
an organizational acquisition: a structural assessment J Organiz
Behav 2000;21:627-648.
7 Phillips JR Enhancing the effectiveness of organizational change
management Human Resource Management 1983;22(1/2):183-199.
8 Conner DR Managing at the Speed of Change: How Resilient
Manag-ers Succeed and Prosper Where OthManag-ers Fail New York, NY: Random
House; 1992.
9 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
re-appraisal 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
Cross-Cultural 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
awaken-ing and breathawaken-ing coordination, delirium monitorawaken-ing/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.
Trang 3Abstract: A modern pediatric intensive care unit (PICU) faces
constant pressures to implement new clinical care practices,
intro-duce new equipment, or assimilate new systems in response to
rapidly evolving healthcare regulatory, economic, and
patient-centered 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 distrib-uted 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,
interprofes-sional team, consolidated framework for implementation research, quality and process improvement, sustainability
Trang 410
Chapter Title
CHAPTER AUTHOR
PEARLS
• To acquire adequate information about normal anatomy of the eye and related structures and develop a strong foundation for the understanding of common ocular problems and their consequences.
• To gain basic knowledge of the development of the eye.
• To develop essential understanding how abnormalities at
various stages of development can arrest or hamper normal
formation of the ocular structures and visual pathways.
6
Evolution of Critical Care Nursing
LAUREN R SORCE AND RUTH LEBET
• As part of the multiprofessional team of dedicated intensive
care experts, nurses are pivotal in the care of children and
fami-lies during critical illness.
• Building a humanistic environment that endorses parents as
unique individuals capable of providing essential elements of
care to their children constitutes the foundation for
family-centered care.
• Caring practices include a constellation of nursing activities
re-sponsive to the uniqueness of the patient/family and create a
compassionate and therapeutic environment with the aim of
promoting comfort and preventing suffering.
PEARLS
• Excellence in a pediatric critical care unit is achieved through a combination of many factors and is highly dependent on a healthy work environment as well as training beyond the tech-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 rec-ognizes varying levels of clinical nurse knowledge and expertise and fosters advancement through a wide range of clinical learn-ing and professional development experiences.
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
fa-cilitate an environment of excellence, professional staff
develop-ment that ensures continued nursing competence and
profes-sional 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
dis-cusses 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
fol-lowed 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
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 4 years, three additional PICUs opened on the East Coast With the expan-sion of pediatric critical care medicine, the need for specialty trained nurses became vital for the care of these complex pedi-atric 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 membra-nous oxygenation, and electronic medical records (Fig 6.2) The complexity of these systems increases nurses’ mental work-load 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
Trang 5CHAPTER 6 Evolution of Critical Care Nursing
drive required nurse competencies When patient characteristics and nurse competencies match and synergize, optimal patient out-comes result The major components of the Synergy Model encom-pass patient characteristics of concern to nurses, nurse competen-cies 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
All patients and family members uniquely manifest the following characteristics during the PICU experience These characteristics— stability, complexity, predictability, resiliency, vulnerability, par-ticipation in decision-making, parpar-ticipation in care, and resource availability—span the continuum of health and illness Each char-acteristic 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
summa-tive 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 com-mon language to describe patients that is meaningful to all care areas
Each of these eight characteristics forms a continuum, and in-dividuals 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 clas-sification 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
Nursing competencies, which are derived from the needs of pa-tients, 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 situa-tion coupled with nursing skills acquired through a process of
inte-grating 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
• Fig. 6.1 Nursingcareinearlypediatricintensivecareunitsfocusedon
closeobservationandlimitedtechnology,primarilybasicventilators,arte-rialandcentralvenouslines,andsimpleintracranialpressuremonitoring
devices.(FromTheAlanMasonChesneyMedicalArchivesofTheJohns
HopkinsMedicalInstitutions.)
• Fig. 6.2 Pediatricintensivecareunitnurseshavelearnedtomanageand
monitorincreasinglycomplextechnology,includingmultipletypesofven-
tilators,invasivelines,cerebralmonitors,renalreplacementtherapy,circu-latoryassistdevices,extracorporealcirculatorymembranousoxygenation,
andelectronicmedicalrecords.