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Progressive critical care education

"In Our Unit" highlights unique practices, innovations, research, or resourceful solutions to commonly encountered problems in critical care areas and settings where critically ill patients are cared for. If you have an idea for an upcoming "In Our Unit," send it to CRITICAL CARE NURSE, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, ccn{at}aacn.org.

The PICU is a diversified and challenging place to work. Our unit is a state-of-the-art, 26-bed, multidisciplinary unit for children ages newborn to 18 years. These young patients have a wide variety of illness or injury needs, including respiratory distress, multisystem organ failure, multiple trauma, and postoperative cardiovascular care. Nurses are often overwhelmed entering this setting.

Educator Joyce McCall mentors Tige Hazleton in the PICU at Primary Children’s Medical Center in Salt Lake City, Utah.

Because of the nursing shortage, the unit must now hire new graduates. These eager but inexperienced nurses are placed into a special, progressive education program that begins in a medical-surgery area. During the 6 to 12 months when they are assigned to the medical-surgical area, these nurses can gain experience caring for children and acquire organizational skills. Also during this period, they meet once a month with a PICU educator for debriefing and an introduction to skills and critical thinking. With input from the medical-surgical team, the educator and novice nurse mutually decide when it is time to make the transition into the PICU. It is at this time that the nurse begins general orientation.

Phases 1 to 3 of the orientation are similar to programs traditionally offered in critical care units, with 6 weeks devoted to didactics and mentored clinical shifts. Because the experience is often intense, only a small amount of the information is actually fully retained by the orientee. These nurses are able to provide adequate care for stable PICU patients of all ages. If, after approximately 4 months of this independent nursing care experience, competence is demonstrated, the nurse begins phase 4 of orientation.

During this phase, the novice nurse returns to the classroom for an additional 12 hours of didactics, which focus on neurotrauma and respiratory care as it builds on the basic knowledge foundation established in the earlier orientation phases. Neurotrauma and respiratory concepts such as oxygen transport and assessment and treatment of increased intracranial pressure are reviewed. The course work is followed by 2 mentored shifts caring for unstable patients. The novice learner is given a checklist of skills to complete during these shifts. Because these nurses now have the clinical experience, applying what they have learned to actual patients is more meaningful.

After completing the clinical shifts and a checklist of information and skills, the novice nurse is given an oral evaluation in a classroom away from the bedside. To test critical thinking, the evaluator uses patient scenarios to assess skills such as blood gas interpretation and techniques for administering vasoactive drips. This experience serves as an individual teaching opportunity as well as an assessment. Identified problem areas can be given further emphasis.

Although this series of coursework, patient care, and evaluation is repeated in phase 5 of the orientation, the emphasis is on metabolic and cardiovascular patients. The full orientation usually is completed within 12 to 18 months.

However, the PICU educational program does not end with orientation. PICU nurses are required to participate in four, 4-hour, intermediate classes sometime in their first 4 years. Presented by bedside nurses, nurse practitioners, and physicians, these classes address more specific information related to cardiovascular, respiratory, neurotrauma, and metabolic patients.

After completing the intermediate classes, the nurses may choose to specialize in one of the 4 practice areas by completing an advanced module, which includes approximately 12 more hours of didactics and spending the next year caring for patients in the area they have chosen. Mentoring with a nurse expert in this specialty precedes independent experience. Advanced module education is tailored to critical care patients with frequently changing hemodynamics or who require the use of new technology.

Although these nurses remain at the bedside providing exceptional care, facilitating the program gives them an opportunity to advance their management and teaching skills, as well as their pay. The cost associated with providing this program is offset by nurse retention factors, as well as the fact that improved care capabilities presumably result in improved patient outcomes.

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