Does this nurse know my child? Continuity of nursing care in the PICU: Challenges and opportunities

nurse_shutterstock_361329365

When Jennifer Baird, PhD, MSW, RN, set out to study best practices in nursing in the pediatric intensive care unit (PICU), she didn’t know where the project would take her. “I intentionally left it open-ended,” she explains. “It was essentially an ethnographic study; I observed interactions between nurses and families over the course of a year, and also interviewed them separately.”

Baird, who is finishing up her Harvard-Wide Pediatric Health Services Research Fellowship at Boston Children’s Hospital, conducted her research in 2013 at a hospital in the Los Angeles, California area. Even though it wasn’t an explicit question, every single family brought up the subject of nursing continuity. “There was a story there,” says Baird, who published her findings this spring in Nursing Research, “And I needed to follow it.”

The story turned out to be complicated.

Continuity of nursing care: A clash of perspectives

Parents of children in the PICU overwhelmingly said they felt frustrated when they had to repeat their child’s narrative over and over again to new clinical staff. Children with complex conditions may have unique needs, preferences or reactions to certain medications, and, “Parents are the experts here,” says Baird. “Their input helps nurses and doctors do their jobs optimally, but the burden of educating new clinicians all the time is exhausting when you’re already anxious about your child’s medical condition.”

On the other hand, nursing schedules are not conducive to patient-nurse continuity.

The three days a week, 12-hour-shift model that is standard for hospital-based nurses across the U.S. makes it difficult to ensure they’re paired with the same families from one shift to the next.

Adding to the problem, notes Baird, is the fact that many young to mid-experience nurses express a desire for clinical variety. They prefer to move around from patient to patient, gain exposure to more clinical situations and learn new skills.

“I found that lots of newer nurses chose the intensive care unit (ICU) because they were drawn to the ‘excitement,’” says Baird. “But in reality, there are a whole lot of patients who aren’t what you’d call ‘exciting’ — they’re here convalescing, they’re here for longer periods of time. As medicine improves, kids are living longer with chronic illnesses and some are dependent on technology.”

Some of the older nurses, Baird says, feel the “patient-centered care” movement has gone too far. “These nurses were quite frank about what they understood to be their role: to improve the health of a patient. To them, a family’s happiness is secondary; it’s the ‘this isn’t a hotel’ mindset.”

Nurses who do prioritize continuity say they take a lot of pride in caring for one patient throughout his or her entire journey. They enjoy building personal connections with families and can be there for support during tough times. Says Baird, “Personally, I like coming into work having some sense of what to expect. A PICU can run the gamut in terms of diagnoses. I like some consistency in the midst of chaos!”

Policies in practice

At the study site, Baird learned of a form that nurses and family members can jointly sign to request care continuity. However, if the charge nurse cannot honor the request for staffing reasons, the families may be disappointed and feel mislead; furthermore, no one seemed entirely clear on the protocol.  “They didn’t know who could or should initiate that conversation, and whether or not the patient had to have been here for a certain period of time,” says Baird.

Despite the importance of the issue to parents, Baird says care continuity is not well represented in medical literature. “The broader conversation it falls into is patient experience,” she says.

This may be the best avenue for change.

Some argue patient safety is compromised when nurses work long hours. But Baird thinks radically changing the current shift model is a long-game strategy. “This can’t be a one hospital at a time thing,” she says. “Nurses will just quit and go somewhere else. Most of them have already balanced their lives around their current schedules and like it that way. And hospitals are already facing high nursing-turnover rates.” (A 10-year retrospective study, published in 2014 by the RN Work Project found that 17 percent of new nurses leave their job within one year, and 31 percent leave within two).

In the meantime, hospitals can take measures that work within the 12-hour shift schedule.

Establishing a more formal protocol for requesting the same nurse-patient pairings is a start. At Boston Children’s, the family-centered rounds initiative is integrating patient families more formally into the care team. Baird has partnered with that team — which is mostly physicians — as a nurse collaborator.

She’s also worked with Brenda Brawn, a fellow nurse who has designed an innovative way to capture parent-provided health information in the outpatient procedure setting.

Baird believes there is clearly a need across disciplines and clinical environments for better integration of parent/family provided information into the patient care process. And nurses, by nature, are uniquely positioned to address this need.

Learn more about Nursing at Boston Children’s.