Is there a Critical Care (Nurse) Practitioner in the House?

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Editor (Jesse): It is with very humble pleasure that injectableorange.com plays host to a great insight into the strategic, organisational and personal history of critical care nurse practitioner role in the UK. @ccpractitioner himself shares an insight into his world. I have long been a fan of Jonathan’s website. Jonathan is a living example of the ethos of critical care, tirelessly working to better himself and in the process raising the bar and sharing resources for others. Without further ado, over to Jonathan.

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The NHS Plan (2000) identified the need to undertake some experiments regarding skill mix in the National Health Service. This was followed by the Modernisation Agency establishing a New Ways of Working team in 2001. The Changing Workforce Programme subsequently developed into the National Practitioner Programme and consequently a number of new ways of working, streams were established. These covered surgery, medical care, anaesthesia, critical care, endoscopy and assistant roles in theatre.

It is widely accepted that the reduction in junior doctors’ hours (Council Directive, 2000), coupled with career development, namely Modernizing Medical Careers (SEHD, 2005), could result in a reduction in the number of hours junior doctors are available for service provision. These changes may have specific implications for the provision of medical care for critically ill patients.

A major component of this strategy was the development and introduction of the Advanced Practitioner roles. It had been recognised already that there were many healthcare professionals who wanted to use their extended skills in new ways of working. There were consequently four main ways in which roles were redesigned to offer practitioners more potential for development.

The International Council of Nursing defines an advanced nurse practitioner as;

“A registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context and/or country in which she/he is credentialed to practice”

There were several goals for the development of the new roles, which included ensuring the necessary skills and competencies required by care pathways or interventions are present in the workforce, encouraging working across professional boundaries, matching skill mix to service delivery models, reducing workforce cost and attracting a new workforce where shortages exist.

The advanced practitioner role often requires management of own caseloads with high levels of decision-making and diagnostic reasoning. The development of these roles has required substantial investment and as a consequence evidence of added value has been essential when considering developing these roles.

Both the Royal College of Nursing (RCN) and the Department of Health (DoH) have reiterated the need for advanced practitioners to be educated to Masters level and in order to achieve this I first undertook a post graduate diploma in Anaesthetic practice which I then went on to convert to a Masters degree by completing a research dissertation over another year.

The current critical care practitioners within my trust study towards their Masters degree by undertaking several modules. These include Clinical History Taking and Examination, Clinical Diagnostics, Clinical Investigations, Non-Medical Prescribing (which entitles them to prescribe anything a doctor can) and a research module teaching them how to critically analyse and formulate a research plan. These modules are also backed up by achieving a series of clinical competencies related to the intensive care unit, supervised by their consultant mentor.

They are also required to keep a logbook of the procedures they have undertaken, which initially they have to be supervised for. It is only when they are assessed as competent by their consultant mentor in that particular skill that they are able to undertake it independently. These skills include Arterial line placement, central venous catheter insertion, dialysis line placement and intubations. All the practitioners are also Advanced Life Support providers and most are also Advanced Life Support instructors.

Once considered qualified the practitioner works alongside the junior doctors on their rota on both the day and the night shift, providing valuable support to the team.

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It would not be true to say that the advance practitioner role has been taken up across the entire health service. Decisions to develop the advance practitioner role have often been taken at a local level within the health service and often depends upon the championing of extended or advance practitioner roles by one or more key individuals, commonly heads of department or chief executives. It is probably fair to say that the development of the role requires a lot of support because without it there can be resentment among staff and the feeling that the advance practice role has been introduced simply to increase volume rather than the scope of practice.

The path has not always been a smooth one during my experience as a practitioner. Initially I found it very difficult to adjust to my change in role. With my many years experience in the intensive care environment, I initially felt myself going from expert to non-expert quite quickly. Whilst I felt that I already had a lot of relevant knowledge, I very quickly became aware of the steep learning curve. Occasionally some of the junior doctors also seem to have been a little confused about the new role. I think it was hard for them to understand where nursing input stops and our practitioner role began. I do believe, however, that the practitioner now offers more teaching opportunities and learning situations for the junior doctor, rather than less. Certainly, for some of the procedures there is more likely to be support to offer them when they are trying to learn.

I think the greatest benefit to having the critical care practitioner is the continuity that they offer to the medical team. Many of the junior doctors rotate through the intensive care unit fairly quickly. This results in a team of doctors with reduced levels of experience in intensive care every few months. The critical care practitioner is able to bridge this gap and ensure that the care in the intensive care unit is led by current practice and research and carried out in a safe and consistent manner.

One of the issues mentioned with the advance practitioner role is that there are few further routes for career advancement. In the current climate I find this a slightly pointless argument. I was at band seven in my nursing role in critical care and without going into either education or management I was unlikely to achieve a higher grade without a major change. That major change came about when I was offered the opportunity to take up the advance practice training. Once qualified I was then able to achieve a higher band, 8a, which I otherwise was not going to get. In my trust there are now some senior advance practitioners at even higher grades, so I feel that this change in my career pathway has only raised the ceiling for me.

It is difficult to foresee where the advance practice roles will go, but I can only say that it is been a huge developmental step for me personally.

 

Reading List

 

Advanced nursing roles in critical care- a natural or forced evolution? Coombs et al. Journal of Professional Nursing Vol 23, No 2 2007: pp 83- 90.

 

Practitioner role in a hospital setting. Dalton, M. British Journal of Nursing Vol 22, No 1 2013 : pp 48- 53

 

Advanced level nursing- a position statement. Department of Health 2010

 

Exploring advanced nursing practice: past, present and future. Duke, N. British Journal of Nursing Vol 21 No 17 2012 : pp 1026-1031

 

Steering a course to advanced nursing practice. Nursing in Critical Care Vol 16 No 2 2011 : pp67-76

 

Evaluation of advanced practitioner roles. Institute for Employment studies. 2009

 

Advanced nurse practitioners. Royal College of Nursing. 2012.

Goodbye Missus Chips

 

 

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Editor’s foreword: I would like to introduce a completely unedited, unadulterated and unsolicited view from the world of a newly graduated Enrolled Nurse. I think horizontal violence within nursing is still far to common place. We can all learn something from the people that inhabit the roles that all funnel in to one key job – building patients back up again. This is a really insightful piece of self-reflection from a Nurse I am proud to call a colleague (Twitter Health Service). Over to you “Stevie”.

 

It started as an off the cuff comment. I referred to the (much analysed) chip on my shoulder. The (joking) reply was, “isn’t that the prerequisite chip on the shoulder ALL Enrolled Nurses have?” Which led me to thinking, do we really? Or is that just how others see us? What does it even mean? What do I mean when I bring it up? I decided I should ask Google this question, and depending on where you look, you get a few different answers. Urban dictionary tells me it is ‘to be touchy, to be easily provoked, or to harbour a grudge.’ Phrases.org.uk would have me believe it is ‘a perceived grievance or sense of inferiority’, and the free dictionary puts it like this, “to blame other people for something bad which has happened to you and to continue to be angry about it so that it affects the way you behave.”

What jumped out at me was ‘sense of inferiority’. Maybe that’s what’s actually feeding the chip, but to everyone else, the person with the chip comes across as thinking that they are superior, up their own arse, arrogant.

I’m not sure what I mean when I talk about the chip on my shoulder. As someone who is painfully self-aware, I’d like to think that I don’t blame other people for the things in my past & I don’t use what has happened in the past as an excuse for my current behaviours. I am not feeling particularly aggrieved right now either. I would however describe myself as sometimes touchy, somewhat easily provoked and although I am not quite in the league of my Spanish mother, I can indeed hold a grudge.

I don’t think my chip fits those definitions. Maybe mine stems from starting again in a new field at the grand old age of 32 at the bottom of the food chain, having previously been a line manager/trainer/mentor. And yes, let’s mention the food chain/hierarchy. Those who say there isn’t one in healthcare are normally fairly high up it already. I’m bright. I have ‘opinions’. I like to know the ‘why’. I ask questions. I’m confident in my abilities & keen to learn new skills. My tongue is firmly in my cheek & I do a great line in self-deprecating humour. I am cripplingly insecure. Is that my chip? Does it look like that to other people? Is it always there or does it just pop up like an air bag? Is it a defence mechanism?

Do ALL ENs have a chip on their shoulder? Well, a quick poll of 5 ENs (yes I know, tiny numbers, there needs to be more of us on Twitter) revealed no, we don’t think they all do, but we all independently named the same person who we think does. Awks. Not me. Phew.

Being an EN feels tricky. Our scope of practice varies from EN to EN, ward to ward, hospital to hospital, state to state. I never knew how much difference geography would make to scope of practice. In one rural ED Resus I am thinking of, with the appropriate annual training & supervision, an EN can pop in an LMA if required to do so. Down the road in the city as an EN you’d get to scribe & I doubt much else. Woo! It is of course about person not just role, however I think we are capable of more than we are consistently allowed to do.

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 I do feel I have something to prove, and I know the best way to do that is to quietly be really damn good at being an EN. But it’s hard to stop comments about ENs such as “your college needs to pull their head out of their backside and stop raising your expectations as an EN”, “you can’t do this in-service, you’re an EN, you won’t understand it”, “what’s the point of you?”, “you’re just the lackey”, “you’re not a real nurse”, feeding your chip. My personal favourite is, “you’re just an EN”. No one is just anything. I know of a ward where they like the ENs to eat their lunches next door with the students. I’d like them to try that with me. Is that my chip popping up again?

So what to do about it? If you think you’ve got a chip on your shoulder, maybe have a think about why it’s there. What makes it deploy? Are you inadvertently feeding it? When people think someone else has a chip on their shoulder, the instinct seems to be to knock it off, put them in their place, or just avoid/ignore them. None of those things seem very nice, and if insecurity is what feeds the chip, ‘taking them down a peg or two’, is probably just going to make things worse. I’ve been told (not in the healthcare facility where I’m employed), to keep students in check, to make sure they didn’t get too big for their boots. Which quite frankly, does not sit well with me at all.

Perhaps, gentle shaping as opposed to being bashed about the head with what someone else wants you to think, is the way forward. What works on my chip, (as lame as it sounds) is a little dollop of kindness. Someone taking the time to really listen to what I was trying to say, being interested, facilitating, encouraging and giving me a voice. Maybe, in a little while, the chip won’t be visible at all. I don’t think I’ll miss her.

‘Condition Haych’ – An Epidemic of Grammatical Proportions

In a recent publication in the Journal of Speaking Properly (Spurr 2014), epidemiologists suggested we are in the midst of an epidemic. Public health officials are relatively confident that the disease known as ‘Condition Haych’ is largely isolated to the Australian population at present (urgent amendment see below for update).

‘Condition Haych’ is a disease characterised by the mispronunciation of the letter ‘H’ – correctly orated as ‘Aych‘ (note the absence of preceding H).

Although the authors were unable to establish a definitive genetic link, the disease process trended toward association with environmental and lifestyle factors. Correlation with other symptoms, such as cognitive inability to distinguish between ‘their‘, ‘there‘, and ‘they’re‘; and ‘your‘ and ‘you’re‘ were statistically significant (p<0.01).

While not a terminal disease, recovery is rare and requires extensive rehabilitation with speech pathology involvement and extreme negative conditioning cognitive behaviour therapy.

I would like to thank my wife for the inspiration to write this review, she is in remission following aggressive therapy for this debilitating illness.

 

http://www.youtube.com/watch?v=c3y0CD2CoCs

Grammar: the difference between knowing your shit, and knowing you’re shit.

28th June 2014 Urgent Post-publication Update: In the past three days, confirmed cases of Condition Haych have flooded in via Injectable Orange Centre for Disease Control (aka Twitter). There have been widespread reports of Haych-like symptoms in the United Kingdom and a number of verified cases of Condition Haych in Nova-Scotia, Canada thanks to our epidemiologist on the ground @VasospasticRN. I will keep the public updated as information comes to hand.

Resuscitative Fluid Therapy – Get it in quick?

Bolus: a large dose of a substance given by injection for the purpose of rapidly achieving the needed therapeutic concentration in the bloodstream. (Merriam-Webster Dictionary Online)

Watering bike

Get those fluids in STAT

Consider a case. You are called to see a patient.

68 year old lady.

Day one post-operative phase following right total hip replacement.

Documented Operating Room notes as ‘oozy’ operation.

Tachycardiac, hypotensive, dry mucous membranes ECG normal Sinus Tachycardia, normothermic. Moderate haemoserous loss via drain.

Decision made to give 500ml intravenous crystalloid bolus.

500ml is diligently dialled up on the infusion pump to the maximum flow rate (1000ml/hr) and ‘start’ is pressed.

Is this resuscitative fluid therapy? Is it a fluid challenge? Has the goal of therapy been defined?

Are we going to be able to assess for a significant response to these fluids?

As a critical care nurse I am amazed at how frequently in a ward context, compromised, hypotensive and clinically dry patients receive an infusion rather than the requested bolus. I am also equally as surprised that the prescribing medical officer, unless directly asked ‘how fast do you want it in?’ will not specify, yet when prescribing maintenance fluids, will diligently document a precise order of 42ml/hr.

This post is really intended to stimulate some thought about the logistics and human factors that dictate what version of an immensely common therapeutic action our patient receives.

As an in-hospital Medical Emergency Response Nurse, I am routinely employing the probing question of ‘how fast would you like that fluid administered?’ I also attach an addendum – ‘do you want it over half an hour, or would you like to pull it out of the pump so we can give it quicker, evaluate the response and you can work through some other things?’

In terms of practicalities in the delivery (lacking the presence of a medical or nursing student) – a pressure bag will free up a pair of hands from squeezing the IV fluids in by hand. In the absence of this purposefully designed solution, I have often used a manual BP cuff, wrapped firmly around the upper half of the bag and then pumped up.

BP Cuff

BP Cuff = Excellent Pressure Bag

Pressure bag

Actual Pressure Bag

Both of these options are great because you are able to observe the pressure registered by the cuff on inflation and have an estimation as to the amour of force being exerted to the forward flow against the patient’s own BP and tubing resistance. It is important to note, this does not absolve us from monitoring the patient’s response and observing the IV catheter site, but frees up a pair of trained hands to do some more meaningful (even if it is hold the patient’s hand and reassure them, explaining what is happening).

I have attached an list of my favourites for recommended reading/viewing below. These resources have all improved my understanding of the humble fluid bolus.

An elegantly simple description by Haney Mallemat @criticalcarenow

Excellent explanation of the details of a ‘Fluid Challenge’

http://lifeinthefastlane.com/education/ccc/fluid-challenge/

A great compilation of evidence and FOAM links relating to assessment of fluid responsiveness.

http://lifeinthefastlane.com/education/ccc/fluid-responsiveness/

A thought provoking and enigmatic discussion on fluids in sepsis from Paul Marik, nicely moderated by Scott Weingart @emcrit

http://emcrit.org/podcasts/paul-marik-fluids-sepsis/

 

SMACC Chicago 2015 – Don’t Make Other Plans

I know there are much more high profile websites than injectable orange publicising SMACC 2015. But this conference will be of such epic proportions that it deserves every digital footprint it gets. So… print this poster, make a point of telling your colleagues about this amazing opportunity to learn and build professional friendships. I am also absolutely thrilled that my reflection on SMACC Gold (2014) features on the save the date poster.

 

 

http://intensivecarenetwork.com/smacc-chicago/

http://lifeinthefastlane.com/save-date-smacc-chicago/

http://prehospitalmed.com/2014/05/25/smacc-chicago-2015-book-leave-now/

Plants in Simulation

The following video presentation is a brief overview of the role of the confederate in simulation. Quite simply, the confederate is one of the best tools I have found in the quest to enhance the fidelity/realism for participants in immersive simulation. I will be presenting soon at the Laerdal SUN Conference – giving a workshop on In Situ Simulation for Patient Safety – ‘Waking Sleeping Giants’ and this video is going to be given as part of a flipped workshop approach in pre-attendance. It’s my first attempt at a screen recording and I learned a great deal (mostly how not to do it next time). I would love for others to share your experiences in simulation or in production of better quality videos than mine. I am really keen to learn.

http://www.youtube.com/watch?v=tQNRKqEaLMg

References

Sanko et al. 2013 Establishing a convention for acting in healthcare simulation: merging art and science.