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Article Evaluation - Nursing Shortage

Nursing is a career that takes dedication, time and hard work to be able to strengthen and improve medical and health needs. It allows plenty of space for growth and opportunity, as well as independence. With all of these exceptional qualities, why are we still experiencing nursing shortages?

It seemed throughout the article that it referred to working conditions as to the main reason why there's a nursing shortage. It also mentions that there seems to be a decline in interest among college students to consider nursing as a career. However, the article doesn't provide further information with reasons why. I'm curious as to why more college students "fear" or "look down upon" nursing school.

I think Certified Nursing Assistants come into great play in the healthcare field as well. With experience of being a CNA, I have learned that a lot of help comes from them and that extra hands are always appreciated. As our population continues to age, we become more in demand for CNAs, as well as nurses. Aging is inevitable. This means jobs in healthcare will always be in high demand. I think there are ways to maybe minimize nursing shortages, but I don't think it will ever be 100% fixed.

PICU – Senior Sem Project (Ideas to Add)

• The hospital team is able to provide the highest standard of care and treatment to restore and promote quality of life of children
• Staff of the PICU: critical care physicians, nurses, practitioners, nutritionists, pharmacists, social workers, care coordinators, respiratory therapists, possibly students (nursing and medical), cardiologists, etc.
• Nurses can continuously monitor heart rate, breathing, and blood pressure
• They provide therapies that might not be available in other parts of the hospital
• Intensive therapies include ventilators which allow breathing assistance, respiratory therapies with breathing treatments
• Examples of conditions that common in the PICU: severe asthma, serious infections, complications of diabetes, motor vehicle accidents
• PICU workers are highly experienced and well trained to care for some of the sickest children in the hospital. Ensuring that nurses care for fewer patients, each child receives individualized care and monitoring.
• It is important to provide family centered patient care because children will require routine care after discharge. With family participating during care, it will help them gain further knowledge and understand about their child’s disease process and the care required
• Things to prepare your child for in the PICU: IVs (pricks and pokes), medications, monitors and alarms, ventilators, frequent vitals taken, routine tests (blood work, CT scans, etc.)
• Important as a nurse to care for the patient and the family. Provide support and reassurance that child will be well cared for

• Information could be added about what nurses specifically do for patients in the PICU.
• The article touches very little on about the different levels of a PICU. We could add information about the differences between each level and what each level is capable of doing. Furthermore, what types of patients need a higher level of care that a lower level could not provide?
• The history behind the PICU is very limited in the current article. A timeline about the evolution of the PICU could be provided.
• There are a variety of procedures that are performed on pediatric patients and some of them require the patient to stay in the PICU while they recover. Including some examples of these procedures would be beneficial.
• There are special certificates that PICU nurses and staff are required to get in order to provide optimal care. These are not included in the current article, so it would be a good thing to add them.
• The staff of PICU will see many sick children and often times the children do die unfortunately. Research could be done on the side effects that death of a child causes on the staff of the PICU.

Research Articles

• Promoting Staff Resilience in PICU

Lee, K. J., Forbes, M. L., Lukasiewicz, G. J., Williams, T., Sheets, A., Fischer, K., & Niedner, M. F. (2015). PROMOTING STAFF RESILIENCE IN THE PEDIATRIC INTENSIVE CARE UNIT. American Journal Of Critical Care, 24(5), 422-430. doi:10.4037/ajcc2015720

• The Lived Experience of Parents of Children in PICU

Majdalani, M. N., Doumit, M. A., & Rahi, A. C. (2014). The lived experience of parents of children admitted to the pediatric intensive care unit in Lebanon. International Journal Of Nursing Studies, 51(2), 217-225. doi:10.1016/j.ijnurstu.2013.06.001

• Rapid Response Team and Unplanned Transfers to PICU

Humphreys, S., & Totapally, B. R. (2016). RAPID RESPONSE TEAM CALLS AND UNPLANNED TRANSFERS TO THE PEDIATRIC INTENSIVE CARE UNIT IN A PEDIATRIC HOSPITAL. American Journal Of Critical Care, 25(1), e9-e13. doi:10.4037/ajcc2016329

• Noise Level in PICU

do Carmo da Silveira Neves de Oliveira, F. M., Barbosa de Paiva, M., Aparecida de Luca Nascimento, M., Marinho Rezende, V., Sousa da Silva, A., & Lyra da Silva, C. R. (2013). Noise levels in a pediatric intensive care unit: an observational and correlational study. Online Brazilian Journal Of Nursing, 12(3), 431-441.

• Noise Pollution Prevention Strategies

Kaur, H., Rohlik, G. M., Nemergut, M. E., & Tripathi, S. (2016). Comparison of staff and family perceptions of causes of noise pollution in the Pediatric Intensive Care Unit and suggested intervention strategies. Noise & Health, 18(81), 78-84. doi:10.4103/1463-1741.178480

• Unique Solutions in PICU

Campbell, J., Bell-Scott, W., Boehm, A., & Schlichting, D. (2001). Unique solutions in pediatric critical care. Pediatric Nursing, 27(5), 483-491

• Children's Psychological and Behavioral Responses Following PICU

Sachdev, A., Sharma, R., & Gupta, D. (2010). Cerebrovascular complications in pediatric intensive care unit. Indian Journal Of Critical Care Medicine, Vol 14, Iss 3, Pp 129-140 (2010), (3), 129.

• Children's Perceptions of PICU

Board, R. (2005). School-age children's perceptions of their PICU hospitalization. Pediatric Nursing, 31(3), 166-186.

• Family-centred care and traumatic symptoms in parents of children admitted to PICU 
  • Mortensen, J., Simonsen, B. O., Eriksen, S. B., Skovby, P., Dall, R., & Elklit, A. (2015). Family-centred care and traumatic symptoms in parents of children admitted to PICU. Scandinavian Journal Of Caring Sciences, 29(3), 495-500. doi:10.1111/scs.12179
• Adults in the PICU
  • Williams, L. (2017). Adults in the Pediatric Intensive Care Unit: A Pediatric Nurse's Perspective. AACN Advanced Critical Care, 28(2), 107-110. doi:10.4037/aacnacc2017492
• Nursing certificates and education
  • Hickey, P. A., Gauvreau, K., Tong, E., Schiffer, N. P., & Connor, J. A. (2012). PEDIATRICCARDIOVASCULAR CRITICAL CARE IN THE UNITED STATES: NURSING AND ORGANIZATIONAL CHARACTERISTICS. American Journal Of Critical Care, 21(4), 242-250. doi:10.4037/ajcc2012853
• Guidelines and Levels of Care for Pediatric Intensive Care Units
  • http://pediatrics.aappublications.org/content/92/1/166
• Preventable admissions
  • Peter, H., Andrew, A., Lee, W., Steve, R., Rafael, P., Sian, H., & ... Alison, W. (n.d). Pathways to Care for Critically Ill or Injured Children: A Cohort Study from First Presentation to Healthcare Services through to Admission to Intensive Care or Death. Plos ONE, Vol 11, Iss 1, P E0145473 (2016), (1), e0145473. doi:10.1371/journal.pone.0145473
• ICUs with most productive work environments
  • Schmalenberg, C., & Kramer, M. (2007). TYPES OF INTENSIVE CARE UNITS WITH THE HEALTHIEST, MOST PRODUCTIVE WORK ENVIRONMENTS. American Journal Of Critical Care, 16(5), 458-469.

PICU Article Improvement Ideas

Overview

A pediatric intensive care unit (also paediatric), usually abbreviated to PICU /ˈpɪkjuː/, is an area within a hospital specializing in the care of critically ill infants, children, and teenagers. A PICU is typically directed by one or more pediatric intensivists or PICU consultants and staffed by doctors, nurses, and respiratory therapists who are specially trained and experienced in pediatric intensive care. The unit may also have nurse practitioners, physician assistants, physiotherapists, social workers, child life specialists, and clerkson staff although this varies widely depending on geographic location. The ratio of professionals to patients is generally higher than in other areas of the hospital, reflecting the acuity of PICU patients and the risk of life-threatening complications. Complex technology and equipment is often in use, particularly mechanical ventilators and patient monitoring systems. Consequently, PICUs have a larger operating budget than many other departments within the hospital.

• Provide a few examples of children who may be admitted to the PICU
• Instead of saying "specially trained" change it to "certified"
• Include the specific ratio of providers to patients to show a comparison
• Define acuity or provide a link
• Include roles and responsibilities of each of the staff mentioned
• Elaborate on different technology and equipment used and how it may affect children

History[edit | edit source]

Goran Haglund established the first pediatric intensive care unit, which he called a "pediatric emergency ward", in 1955.

Infants were first kept intubated for long periods in the early 1960s. Breathing tubes made out of polyvinyl chloride (PVC) allowed clinicians to avoid performing tracheostomy (surgically inserting a tube into the windpipe) in more children who required prolonged mechanical ventilation.

• Elaborate more on the early history of the pediatric emergency ward
• Include more information about the progression of the PICU over the years
• Include other procedures that can be performed in the PICU other than just tracheostomies and breathing tubes (instead of saying breathing tubes, say endotracheal tubes [ET tubes])
• Provide information on what the PICU is like in today's world

Levels of care[edit | edit source]

United States[edit | edit source]

Level 1[edit | edit source]

Level I PICUs are variable in size, personnel, physical characteristics, and equipment, and that they differ in the types of specialized care (i.e., care following transplantation or cardiac surgery) that they provide. Nurse-to-patient ratios range from 2 nurses to 1 patient to 1 nurse to 3 patients. Registered respiratory therapists are required to be assigned primarily to the Level I PICU in-house 24 hours per day.

Level 2[edit | edit source]

Level II PICUs are smaller than level I PICUs and are able to care for less critical patients.

• What are some examples of children that require a level 1 PICU?
• What differentiates a level 1 PICU from a level 2 PICU?
• Provide information of the certificates required by each PICU level
• Provide information on the other staff members that are in the PICU other than nurses and respiratory therapists

PICU Draft

The Pediatrics Intensive Care Unit is a unit in the hospital that provides the highest level of medical care to children.

History of the PICU

Goran Haglund is credited with establishing the first pediatric ICU in 1955. The PICU was located at Children’s Hospital of Goteburg in Sweden. The first PICU in the United States was not developed until 12 years later. In 1967, John Downes established the first PICU in North America at the Children’s Hospital of Philadelphia. The establishment of these two units would eventually lead to hundreds of PICUs being developed across North American and Europe. This number is still increasing in present day.

There were a variety of factors that lead to the development of PICUs. John Downes identified five specialties of medicine that aided in the development. These specialties included adult respiratory ICUs, neonatal intensive care, pediatric general surgery, pediatric cardiac surgery, and pediatric anesthesiology.

Between 1930 and 1950 the poliomyelitis epidemic had created a greater need for adult respiratory intensive care, including the iron lung. There were times when children would contract polio and would have to be treated in these ICUs as well. This contributed to the need for a unit where critically ill children could be treated. Respiratory issues were also increasing in children because neonatal intensive care units were increasing the survival rates of infants. This was due to advances in mechanical ventilation. However, this resulted in children developing chronic lung diseases, but there was not a specific unit to treat these diseases.

Advancements in pediatric general surgery, cardiac surgery, and anesthesiology were also a driving factor in the development of the PICU. The surgeries that were being performed were becoming more complicated and required more extensive postoperative monitoring. This monitoring could not be performed on the regular pediatric unit, which led to Children’s Hospital of Philadelphia’s development of the first PICU. Advancements in pediatric anesthesiology resulted in anesthesiologist treating pediatric patients outside of the operating room. This caused pediatricians to obtain skills in anesthesiology in order to make them more capable of treating critically ill pediatric patients. These pediatric anesthesiologist eventually went on to develop and subsequently run PICUs.

PICU Characteristics

There are a variety of PICU characteristics that allow the healthcare providers to deliver the most optimal care possible.  The first of these characteristics is the physical environment of the PICU. The layout of the unit should allow the staff to constantly observe the patients they are caring for. The staff should also be able to rapidly respond to the patients if there is any change in the patient’s clinical status.

Correct staffing is the next vital component to a successful PICU. The nursing staff is highly experienced in providing care to the most critical patients. The nurse to patient ratio should remain low, meaning that the nurses should only be caring for 1-2 patients depending on the clinical status of the patients. If the patient's clinical status is critical, then they will require more monitoring and interventions that a patient that is stable.

In most cases, the nurses and physicians are caring for the same patients for a long period of time. This allows the providers to build rapport with the patients, so that all of the patient’s needs are fulfilled. The nurses and physicians must work together as a collaborative team to provide optimal care. The successful collaboration between nurses and physician has resulted in lower mortality rates not just in PICUs, but all intensive care units.

Levels of Care

As medicine has matured over time, the development of the pediatrics intensive care unit has expanded to maintain a level one and a level two PICU. Among these two different levels, they are able to provide critical care and stabilization for each child before transferring to a different acuity.

In the level one PICU, health care team members must be capable of providing a wide variety of care that typically involves intensive, rapidly changing, and progressive approach. In the level two PICU, patients will present with less complex acuity and will be more stable.

Conditions Requiring PICU

Respiratory issues including (acute) respiratory distress syndrome (ARDS), asthma and apnea, sepsis, traumas (may include abuse), congenital or acquired heart defects, mechanical ventilation, and complications of diabetes (ketoacidosis). Gastrointestinal conditions include bowel perforations and bleeds, cancer / chemotherapy, organ transplants (kidney, heart), seizures, and poisoning.

PICU Nurse Skills and Certifications

As a PICU nurse, extended knowledge and certifications may be required. Recognition and interpretation are two of the many required skills for a PICU nurse. This allows nurses to be able to detect any changes in the patient's condition and to respond accordingly. Other skills may include route of administration, resuscitation, respiratory and cardiac interventions, preparation and maintenance of patient monitors, and psycho-social skills to ensure comfort of patient and family.

There are a variety of certificates that are required for registered nurses to acquire in order to work in the PICU. One of these certifications is the Critical Care Registered Nurse (pediatric) certificate. This certificate allows nurses to care for critically ill pediatric patients in any setting, not just the PICU. Other certificates include cardiopulmonary resuscitation, pediatric basic life support, and pediatric advance life support.

Hospital Team

In the PICU, it is important that all team members hold a wide variability of training and experience in order to provide high quality care. Due to different priorities among inter-professionals, the PICU care team includes many different roles. (physicians, nurses, pharmacists, respiratory therapists, child life, intensivists, cardiologists, physical / occupational therapists, social workers) Each member of the inter-professional team are highly skilled and trained to deliver the best care for each and every child. It is important for each one to introduce themselves to the family and to explain their role to hopefully expand understanding to family members.

Factors Leading to Poor Outcomes in PICU Patients

The patients in the PICU are the most critically ill children in the hospital setting. There are times where these children do not have the best outcomes, which may result in permanent deficits or even death. There are times where nothing more could have been done to improve the outcome for these patients. However, there are times where care could have differed and the end result may have been better.

There are a variety of factors that have lead to poor outcomes in PICU patients. The main factor that leads to inadequate care for PICU patients is improper health assessment by the healthcare providers. This may include not observing a change in the patient’s clinical status, delayed resuscitation efforts, delayed decision making, or a combination of any of these factors. If any of these factors due occur, it may result in permanent deficits in the most critical patients.

Measures may be taken to prevent improper assessments from occurring. Proper education on how to conduct a proper assessment and how to recognize a critically ill pediatric patient can improve patient outcomes. This includes being able to recognize signs of deteriorating clinical status and perform proper triage of patients. This education is not only for the PICU staff, but also for emergency medical services, the emergency department staff, and staff of the pediatric unit.

Challenges of Working in the PICU

Death of patients admitted to the PICU is inevitable, which subsequently results in emotional stress and occupational burnout of the staff. For patients that do get discharged from the unit, often times they are not free of chronic conditions or disabilities. There are other factors that lead to stressful work conditions for the staff of the PICU. The staff often work for long periods at a time in order to stabilize the most critically ill pediatric patients. They must collaborate with other members the healthcare team in order to develop the best plan of care. Once a plan of care is developed, then the staff must communicate the plan with the patient's family in order to see if it matches their beliefs. All of this causes the staff a great deal of stress and each member of the unit must develop their own coping mechanisms in order to prevent burnout.