LR20 / Effectiveness of nurse practitioners in pediatric critical care (CRM)

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Human factors
Patient safety theme the SCP/clinical risk management practice is aimed at
CRM practice aimed at describing the distinctive role characteristics, management skills, and technical procedures of the nurse practitioner (NP) caring for critically ill children
Objective of the CRM practice
The need for expertly trained NPs has intensified in conjunction with increased acuity of the pediatric critical care patient population. Considering the unique and valuable contributions that NPs make to patient care the practice documents the distinct role characteristics, management skills, technical, procedures, and perceived level of supervision required by NPs practicing in the pediatric critical care setting [p406, 1].
Short description of the CRM practice, including any references for further information
American Association of Critical Care Nurses developed documents for regulating the scope and standards of the critical care nursing practices. To understand better the role of the NP in pediatric critical care, a survey was created and distributed to NPs working in pediatric critical care. The 2-part questionnaire which was the research tool used in the survey was elaborated based on other validated tools (see implementation tool section) and was trialed during a pilot project. Prior to distribution, the final version of the survey tool was revised following review and feedback from several experts in pediatric advanced practice (including a Synergy Model expert) for content validity [p398, 1], [2]. Potential respondents were sought from subscribers to the Pediatric Intensive Care Advanced Practice Nursing (PICUAPN) and the Advanced Nursing Practice in Acute and Critical Care (ANPACC) electronic list servers during 1999 and 2000 and additional participants were identified by contacting graduates of master’s degree programs specializing in pediatric critical care, networking with professional colleagues, and attendance at national conferences [p398, 399, 1]. The inclusion criteria were: master’s degree in nursing, direct patient management responsibilities, and working in a critical care environment (defined as a PICU (pediatric intensive care units) including cardiac and neurological units and step-down units that cared for children with hemodynamic instability and respiratory insufficiency requiring mechanical ventilation. The survey was distributed and returned electronically via the Internet and in written form through postal mailings, with a response rate of 93%. If the survey was returned incomplete, the respondents were contacted again by phone or electronic mail to complete the survey. The respondent’s participation was voluntary and without compensation [p400, 1].
Innovator of the SCP, country of origin
USA, survey al national level, USA, American Association of Critical Care Nurses
Involved health care staff
NPs working with critically ill children and adults with direct patient management responsibilities.
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
USA/pediatric intensive care units [p405, 1] USA / intensive care units [2]
Summary of evidence for effectiveness, including references
American Association of Critical-Care Nurses established a set of models, standards, education modules and certifications for NP working in critical care focused on achieving the best level of care by continuous education, developing networks of excellences and best practices [2 and 4]. The importance and effectiveness of NPs in pediatric critical care from one study: – all NPs surveyed participated in direct patient care and this activity accounted for, on average, 71.5% (range = 30% to 100%) of their work time and the remained time for nursing education (range =0% to 20%), medical education (range = 0% to 10%), coordination of care (range = 0% to 30%), support of systems (range = 0% to 23%), consultation (range = 0% to 20%), research (range = 0% to 20%) and bedside nursing care (range = 0% to 20%) = 82% of respondents participated in a coordination of services including referrals, identifying resources, discharge planning, and team meeting – 65% of NP respondents contributed to support of systems including unit planning and leadership activities [p401, 1] – NPs with more experience identified a higher skill level and more relative time commitment to education, research, and support of systems – multidisciplinary education and support of services are integral components of the NP role in pediatric critical care [p406,407, 1].
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
There is clear description of the context [2]. The focus is on assesing the role and skils of NP in critical pediatric and adult care [2]. There is a resemblance with results obtained from surveys for adults critical care There are models of scope and standards for NP in acute care[2].
Summary of available information on feasibility, including references
Limits of sthe survey aiming to asses the NP’s effectiveness in pediatric critical care: 1.) bias introduced from self-assessment (for completing the open-ended questions is use self-assessment, thereby rendering a subjective rather than objective measure.) 2.) -the amount of time required to complete the survey – further research is necessary to continue to: validate the effectiveness of NPs in pediatric critical care (especially the specialized functions of the NP in pediatric critical care and linking those functions with quality outcome measures and cost-effectiveness) and -asses the contribution of the NP to the care delivered by the healthcare team (these types of investigations will help to define populations that are best served by the NP and which NP role functions demonstrate best practice outcomes with specific populations) 3.) bias represented by the underrepresented in the sample of the NPs or professional organizations with limited professional connections via Internet 4.) all regional differences may not have been captured (results may have been influenced by the allowances or limitations of certain states regarding its own individual Nurse Practice Act [p406, 1]
Existing implementation tools, including references
Implementation tool of the intensive care NP : AACCN –scope and standards for acute and critical care nurse practice [2] Implementation tool of the intensive care pediatric survey was a 2-part questionnaire developed using the survey tools of De Nicola and associates [22:p1856–1864, 3] and Kleinpell [8:p156–162, 4]. First part included 54 items (NPs’ background, work environment, reporting structure, salary, and overall role components), while the second part used the 8 components of American Association of Critical-Care Nurses’ s (AACN) Synergy Model for Patient Care as a framework to solicit management skills and tasks frequently performed by NPs in pediatric critical care [p398, 1].
Potential for/description of patient involvement in the CRM practice, including references
The patient is not directly involved, but the model is focused in finding the best practice in critical care children or adults patients [1, 2, 3, 4].
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1]Judy T. Verger, RN, MSN, CRNP, CCRN; Kelly Keefe Marcoux, MSN, CPNP-AC; Maureen A. Madden, MSN, CPNP-AC, FCCM; Tom Bojko, MD, MS, FAAP, FCCM; Jane H. Barnsteiner, RN, PhD, FAAN (2005): Nurse Practitioners in Pediatric Critical Care, Results of a National Survey, AACN Clinical Issues Volume 16, Number 3, pp. 396–408, 2005, AACN [2] American Association of Critical-Care Nurses (AACN). AACN’s Synergy Model for Patient Care Available at: Accessed March 2005 [3] DeNicola L, Kleid D, Brink L, et al. Use of pediatric physician extenders in pediatric and neonatal intensive care units. Crit Care Med. 1994; 22:1856–1864 [4] Kleinpell R. Acute-care nurse practitioners: roles and practice profiles. AACN Clin Issues. 1997; 8:156–162.
Dr. Carmen Sasu, National School of Public Health and Management, Romania
National School of Public Health and Management, Romania
Any additional information on the CRM (e.g. implementation barriers and drivers)
This survey was design to develop at national level that includes all NP in pediatric critical care.