- Email: [email protected]
An innovative model of community ■ collaboration in pediatric nursing ■
An Innovative Model of Community 9 Collaboration in Pediatric Nursing 9 Shari L. Huffman, RN, BSN, Pare Pieper, ARNP-CS, MSN, Kimberly S. Jarczyk, ARNP, MSN, Dolores Jones, MS, RN, CPNP, and JoAnn Patray, PhD, ARNP Collaboration among nurses can lead to improved education and clinical practice and increased opportunities for nursing research. Although numerous descriptions of interinstitutional collaboration among nurses can be found, many projects are limited in scope or purpose. A more comprehensive approach can facilitate excellence in practice, education, and research throughout the community. By pooling professional resources, nurses across organizational lines can achieve common goals and reduce costs associated with services and programs. The purpose of this article is to describe an interinstitutional nursing model that supports collaboration while promoting standards of excellence.
J PED[ATRHEALTHCARE.(1995). 9, 263-268.
E c o n o m i c and political variables have a significant impact on the health care of children. A growing number of sick children receive most of their care outside the traditional inpatient setting. Nursing must expand its outlook to include a network of services provided in a variety of settings. Collaboration among nursing professionals is necessary to ensure quality pediatric health care in the community. The Pediatric Nursing Council of Northeast Florida (PNC) was formed to respond to the professional and patient care issues resulting from the changing health care environment. The purpose of the nursing council is to proactively build a community-based nursing services model that ensures excellence in nursing practice. The PNC represents a cost-efficient model that facilitates the sharing of professional resources (clinical, educational, and research) while promoting standards of excellence. Such collaborative approaches are vital to the future of nursing. Shari L. Huffman, RN, BSN, is a Nurse Coordinator in Pediatric Gastroenterology and Nutrition at Nemours Children's Clinic in Jacksonville, Florida. Pam Pieper, ARNP-CS, MSN, is the Pediatric Surgery Clinical Nurse Specialist/Nurse Practitioner and Pediatric Trauma Coordinator at the University of FJorida Health Science Center Jacksonville in Jacksonville, Florida. Kimberly S" Jarczyk, ARNP, MSN, is the Senior Nurse Practitioner at Nemours Children's Clinic in Jacksonville, Florida. Dolores Jones, MS, RN, CPNP, is the Director of Pediatric Education at Wolfson Children's Hospital in Jacksonville, Florida. JoAnn Patray, PhD, ARNP, is an Associate Professor in the Pediatric Nurse Practitioner Program at the University of Florida Health Science Center Jacksonville in Jacksonville, Florida. Reprint requests: Shari L. Huffman, RN, BSN, Nemours Children's Clinic, 807 Nira St., Jacksonville, FL 32207. Copyright 9 1995 by the National Association of Pediatric Nurse Associates and Practitioners. 0891-5245/95/$5.00 + 0
25/1/63674
JOURNAL OF PEDIATRIC HEALTH CARE/November-December 1995
9 REVIEW OF LITERATURE
Collaboration first appeared as a heading in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in 1989. Collaboration is described as "pooling of resources and ideas within or across disciplines for innovation, problem solving, e t c . . . " (Lockwood, 1989, p. 143) Review of nursing literature finds that collaborative projects between physicians and nurses, service institutions and educational programs, and nurses within specialty groups or organizations are well documented. Nursing has always recognized the value of partnerships between nurses and their patients/families, and collaborative nursing research is ongoing and growing. Interdisciplinary communitywide cooperation has resulted in comprehensive services across organizations for specific populations, such as medically complex or disabled children (Hochstadt & Yost, 1989), under-served inner-city groups (Katz, 1992), or the homeless (Dahl, Gustafson, & McCullagh, 1993). To our knowledge, no descriptions exist of multi-institutional models of collaboration formed by nurses to promote excellence in nursing practice for children in the community. Collaboration between service institutions and nursing education programs can improve nursing practice and education. In 1990, the American Association of Colleges of Nursing (AACN) voted to encourage all member schools to establish collaborative relationships with practice settings to advance common goals in practice, education, and research (Hegyvary, 1991). Baker, Boyd, Stasiowski, and Simons (1989)described such a partnership between a university nursing program and a local hospital. This relationship was established to "facilitate excellence in education, practice, and research" (p. 8). They emphasized that professionalism is the basis 263
Journal of Pediatric Health Care
264
Huffman et al.
9 TABLE 1
Volume 9, Number 6
Pediatric Nursing Council: Standards of practice
Standard Tracheostomy Central line Orthopedic
Enteral feedings
Implantable devices Medication administration at home
Seizures Home oxygenation Clean catheterization
Teaching material available* Home Tracheostomy Care: A Parent's Guide Your Child's Central Line: A Guide to Care Information for parents: Brace Care Cast Care Spica Cast Care External Fixator Care Checking Placement of a Nasogastric Tube Cleaning Enteral Tube Feeding Equipment Feeding Through a Gastrostomy (Jejunal, Nasogastric) Tube General Care: Children Who Require Tube Feedings How to Put in a Nasogastric Tube Medication Administration Non-nutritive Sucking Cleaning around a Gastrostomy Tube or Button Tube Feeding Your Child Implantable Devices: A Guide to Home Care Instructions for Intramuscular Injections Instructions for Subcutaneous Injections Instruction for Oral Medications Seizure Medication Handouts Seizure Disorder Information for Parents In progress In progress
*Readers interested in individual teaching materials may contact the corresponding author directly.
fbr a collegial relationship that supersedes institutional bias and allows for effective collaboration. Hawken and Hillestad (1990) also described a collaborative relationship between a university school of nursing and service institutions in the surrounding community. The purpose of this project is "promotion of the clinical practice of profkssional nursing" (p. 19). The authors noted that cooperation between nursing practice and education has increased over the last decade. These types of relationships help reach the goals of excellence in education and practice of individual institutions. Other successful collaborative approaches have shown the value of pooled resources for nursing continuing education. Sammut (1993) described a consortium approach to offer a critical care course open to nurses from five area hospitals. This program was organized through a planning committee with representatives from interested hospitals. The combined efforts allowed Ibr a cost-effhctive program and provided networking opportunities for all involved. Marvin and Acevedo (1991) described an interinstitutional effbrt to standardize intravenous therapy education/certification for staff nurses. Those initial efforts expanded to in-
clude intravenous therapy standards of practice for the community. A review of literature has shown that collaboration continues to flourish in a variety of settings. However, these cflbrts focus on specific projects or services. In contrast, the PNC coordinates a community-based effort by involving multiple organizations with the common, more global purpose of ensuring excellence in practice, education, and research. Bringing pediatric nurses from different settings together results in a comprehensive model that can lead to improved education and clinical practice and increased opportunities for nursing research. For the PNC, the ultimate goal is improved health care services for children. m INTERINSTITUTIONAL COLLABORATION
The practice of pediatric nursing should be considered within the context of the community. The PNC is proactively building a community-based model designed to facilitate excellence in pediatric nursing. Recognizing that effective collaboration among institutions and agencies is difficult to achieve, pediatric nursing leaders in two inpatient facilities (Wolfson Children's Hospital and University Medical Center), a large, mul-
Journal of Pediatric Health Care November-December 1995
9 TABLE 2
Huffman et al.
265
Pediatric Nursing Council: Education committee activities
Educational offering Pediatric nursing grand rounds Certification review
Pediatric nurses Christmas program
Pediatric assessment
Home care "Skills Day"
Pediatric nursing conference
tispecialty pediatric outpatient clinic (Nemours Children's Clinic), and the Jacksonville campus of the University of Florida College of Nursing initiated the efforts to collaborate. These visionaries acknowledged their collective responsibility to provide effective leadership and mentorship to empower clinicians and overcome institutional rivalry. The vision of the PNC is to fbster development of a community-wide network of pediatric health care services. Essential components of this network include education for patients, families, and professionals, nursing research, and standards of practice. The activities of the PNC are potentially cost efficient through coordination and sharing of resources, thus avoiding duplication of services and programs. For example, if each service institution develops and prints protocols for central line care or offers a pediatric nursing assessment course, each must bear the entire cost in dollars and personnel. When a single, city-wide protocol or program is developed cooperatively, costs and benefits are shared by all. In addition to pediatric nursing leaders in the community, nurses from the four institutions specializing in clinical practice, education, and research participate on the Council or on committees or task forces for special projects. The PNC oversees the activity of these groups. Three standing committees facilitate realization of these goals. The Standards of Care Committee develops research-based clinical protocols that are used across institutions and in home care. The Education Committee promotes the professional education of pediatric
Description Case presentations of medically complex children by area nurses. Review courses offered for certification examinations for pediatric nurse, neonatal nurse, and pediatric critical care nurse. Holiday evening program for area nurses focused on keeping the spiri of Christmas as a pediatric nurse. Offered through the university; provides continuing education credit and introduction to the pediatric nurse practition program. Introduction of standards to community nurses; included hands-on skills sessions. Two-day regional conference focuses on current trends of practice, updated standards, and changes in health care.
nurses. The Research Committec focuses on developing and promoting pediatric nursing research. 9 STANDARDS OF CARE COMMITTEE
Multiple agencies are often involved in discharge teaching for medically complex children. Parents may be given conflicting information, leaving them confused and uncertain about their child's care. In addition, providers are concerned and frustrated when their particular standards of care are not being met. Recognizing these difficulties, the Committee develops city-wide protocols for home care for conaplex situations. The initial efforts were directed at standardizing the teaching methods for the home care of central venous lines, so that the inpatient teaching and practice was consistent with what the home care company did and what the outpatient providers expected. Over the past 3 years, continued efforts have resulted in standards of care for orthopedics, tracheostomies, enteral feedings, medication administration (intramuscular, subcutaneous, oral), and implantable central venous access devices. Further standards under development or consideration include clean intermittent catheterization and information for parents about seizures and home oxygenation (Table 1). Task forces to develop standards are chaired by committee members and involve clinicians from home care and inpatient and outpatient services. The standards are research based and approved by the PNC and appropriate medical staff: They are printed and distributed among the institutions and may be used to revise insti-
Journal of Pediatric Health Care
266
Huff 9
9 TABLE 3
et al.
Volume 9, Number 6
Pediatric Nursing Council: Research committee activities Research project
Use of normal saline solution alone versus normal saline solution and heparin sodium combined for flushing central lines Test of accuracy of two methods for predicting insertion length and distal tip placement of nasogastric tubes in children Chlorhexidine verses providone-iodine and alcohol for central venous catheter maintenance Utilization of saline instillation before suctioning of tracheostomies in children
Phase Proposal being written
Data collection
Awaiting results of similar study currently underway Literature review
i
tutional policies and procedures, teach parent/caregivers, and educate staff, school, and home care personnel. In addition, the standards are available to any interested caregivers in the community. 9 THE EDUCATION COMMITTEE
The Education Committee consists o f nurse educators, clinical nurse specialists, and staff nurses from each institution. The purpose is to meet the educational needs o f pediatric nurses in the region, including school, office, and public health nurses. A survey sent to the target population identified needs covering the spectrum o f well child care, care of the chronically ill child, disease-specific information, and nursing care o f the medically complex child. Respondents also requested review courses for various pediatric nursing certification examinations. An ongoing consideration for planning is to ensure that programs are inexpensive and available at convenient times and locations. The first educational program offered was a review course for the General Pediatric Nursing Certification Examination. Faculty members included specialty pediatric nurses from the community. Review courses for the Neonatal Certification Examinations and for the Pediatric Critical Care Examination have also been coordinated by the Education Committee. In the first year, Pediatric Nursing Grand Rounds, Which were held quarterly, once at each institution, were designed as case presentations o f medically complex children who had been cared for in at least two o f the participating facilities. Related standards o f care and research were incorporated. Speakers included hospital and clinic staff nurses, clinical specialists, nurse practitioners, and home care nurses. A moderator described how the varying institutions interacted with each other, and speakers discussed their roles in caring for the child. An evolving responsibility o f the committee has been education o f pediatric nurses regarding the newly developed standards o f practice. A 2-day symposium offered to nurses in the community presented the new standards and allowed for "hands-on" skill sessions.
Copies o f home care teaching materials were available to all participants. The Education Committee has also developed and continues to offer a pediatric assessment course through the University o f Florida Health Science Center Jacksonville. Continuing education credit is provided, and the course serves as an introduction to the Pediatric Nurse Practitioner Program available at the University. The course covers all aspects o f assessment in children, includes clinical practice and limited skills sessions, and has been particularly popular with public health nurses. Table 2 summarizes the activities o f the Education Committee. 9 THE RESEARCH COMMITTEE
Research-based clinical practice is an integral component of the PNC's philosophy. The charge o f the Standards Committee is to generate research-based standards of care. These standards are implemented on a community level through integration into the policies and procedures o f area institutions and through programs offered by the Education Committee. This process is building a substantial patient population base that can be accessed for nursing research. The Research Committee plans to establish a community-based research network, beginning with two or three clinical trials that test variables within the existing patient care standards. For example, the Research Committee is currently writing a proposal to evaluate the effectiveness o f normal saline solution versus a combination o f saline and heparin sodium flushes in maintaining patency in central venous access devices. The recognition o f the need for nursing research in this area grew out o f the Standards Committee's work on implantable venous access devices. A second study that is being coordinated through the committee is evaluation o f an equation based on height to estimate length for initial nasogastric tube placement in children. Table 3 lists the projects that the Research Committee is currently pursuing or considering. The support and commitment o f the Assistant Dean
Journal of Pediatric Health Care November-December 1995
Huffman et al.
267
Improve health care by building a P e d / a t r ~ Nursing Council network of integrated pediatric o~No,~,e~,.t~l,,~a,, nursing services that will serve as a national model of excellence. The P ~ T C foundation for a model of excellence in nursing mandates the integration of nursing practice, education, and research. MISSION: Promote excellence in nursing care to improve and preserve the health and welfare of children, their families, and the communities in which they live. 1. Collaborate with other institutions, agencies, and providers within GOALS: the community to establish and implement the highest standards of care in pediatric nursing. The standards will improve quality, be Cost effective, and research based. 2. Empower children and their families through the provision of education and resources to enable them to attain independence and wellness. 3. Empower pediatric nurses through education and resource sharing to facilitate their ability to meet the health and welfare needs of the population. 4. Assume responsibility and accountability for excellence in practice through professional self-regulation, continued personal and professional development, and support of nursing research and education. 5. Participate in nursing research activities related to the care of children.
VISION:
9 FIGURE Vision, mission, and goals of the Pediatric Nursing Council of Northeast Florida.
o f the College o f Nursing at the University of Florida Jacksonville Campus has provided the Research Committee with access to research expertise. Faculty members have acted as mentors and given much-needed support in planning these studies. In addition, nursing leaders within the various organizations encourage staff nurse participation at any point from study design through data collection and analysis. Graduate students in pediatric nursing can use the research committee as a sounding board or source for potential research topics and populations. 9 RESULTS OF THE COLLABORATION
Results from the collaborative efforts of the PNC have been both direct and indirect. Pediatric nurses in Jacksonville have a heightened awareness o f the physical, personnel, and academic resources available across agencies. Educational offerings have been opened to pediatric nurses from the four institutions, and several programs were directed at other pediatric nurses in the community. Many staff nurses who had not been involved in planning and presenting programs in the past were able to participate in these programs and share their expertise with their peers. Standards o f care have been distributed to many pediatric nurses in different settings. In addition, the annual peer review evaluation process at Nemours Children's Clinic is now open to other nurses in the community. Wolfson Children's Hospital has included participation in the committees or task forces o f the PNC as an option for nurses in their clinical ladder program.
Indirectly, the collaborative efforts o f the PNC have led to a more comprehensive community-based view of the child, increased interinstitutional collegiality, and improved communication across agencies. The expectation in the community now is that practice and standards will be based on research. Many nurses have had the opportunity to learn the skills and benefits o f networking with other nursing professionals. Pediatric nurses in the community have been exposed to the graduate program at the university, and practicing masters-prepared clinicians serve as preceptors and mentors for individual students. 9 FUTURE DIRECTION
The founding members o f the PNC have renewed their commitment to supporting pediatric nursing in northeast Florida. The council has agreed to continue meeting quarterly and is exploring options for developing a charter and bylaws. Recently, a philosophy statement was adopted (Figure). The Standards Committee will continue to work on various projects, such as standards for home care o f the child on oxygen and for the child with seizures. Recognizing a professional responsibility to the community, the committee is exploring ways to share the standards with all pediatric nurses in northeast Florida. The Education Committee plans to offer further programs, including pediatric physical assessment, presentation o f nursing research studies, and review courses for pediatric certification examinations. The University plans to offer college credit for the physical
268
Journal of Pediatric Health Care Volume 9, Number 6
Huffman et al.
assessment course. A r e g i o n a l 2 - d a y e d u c a t i o n a l conference is b e i n g p l a n n e d , focusing o n c u r r e n t concepts in pediatric care. T h e c o n f e r e n c e will i n c o r p o r a t e the activities o f the P N C , c u r r e n t t r e n d s in practice, u p d a t e d standards, a n d changes in h e a l t h care. T h e Research C o m m i t t e e is m e e t i n g regularly a n d is i n t e r e s t e d in s t u d y i n g the use o f c h l o r h e x i d i n e for central venous line care a n d the effectiveness o f using saline solution before the s u c t i o n i n g t r a c h e o s t o m i e s .
resources. T h e s e collaborative efforts can facilitate excellence in professional n u r s i n g practice and help prepare for n u r s i n g ' s role in the future o f health care. []
REFERENCES Baker, C. M., Boyd, N.J., Stasiowski, S. A., & Simons, B. J. (1989). Interinstitutional collaboration for nursing excellence: Part 1, creating the partnership. Journal of Nursind Administration 19, 8-12. Dahl, S., Gustafson, C., & McCullagh, M. (1993). Collaborating to develop a community-based health service for rural homeless persons. Journal of Nursing Administration, 23, 41-45. Hawken, P. L., & Hillestad, A. (1990). Promoting nursing's health care agenda through collaboration. Nursing and Health Care, 11, 17-19. Hegyvary, S. T. (1991 ). Collaborative relationships for education and practice. Journal of Professional Nursing, 7, 148. Hochstadt, N.J., & Yost, D. M. (1989). The health care-child welfare partnership: Transitioning medically complex children to the community. Children's Health Care, 18, 4-11. Katz, T. (1992). Partnerships help children in need. Healthcare Forum Journal, 35, 22-27. Lockwood, D. (Ed.). (1989). Cumulative index to nursing and allied health literature (Vol 34). Glendale, CA: CINAHL Marvin, P., & Acevedo, M. (199l). Regional excellence in intravenous therapy: It all began with community intravenous therapy education. Journal of Intravenous Nursing, 14, 123-125. Sammut, N. A. (1993). Critical care education: A consortium approach. Journal of Nursing Staff Development, 10, 219-222.
T hcollaborative e seffortsecan facilitate
excellence in professional nursing practice and help prepare for nursing's role in the future of health care. T h e d e b a t e , discussion, and rhetoric a b o u t h e a l t h care r e f o r m is o n g o i n g . E c o n o m i c and political variables will c o n t i n u e to affect h e a l t h care a n d the future o f nursing. N u r s i n g can p r e p a r e for the challenges o f health care r e f o r m by i n t e g r a t i n g nursing e d u c a t i o n , research, a n d practice in the c o m m u n i t y . T h e P N C demonstrates t h a t interinstitutional c o l l a b o r a t i o n a m o n g nurses p r o m o t e s efficient use o f professional
SPECIAL TESTING OPPORTUNITY sponsored by NAPNAP and THE NATIONAL CERTIFICATION BOARD OF PEDIATRIC NURSE PRACTITIONERS AND NURSES
The National CertificationBoard of Pediatric Nurse Practitioners and Nurses is pleased to announce that The National Qualifying Examination for Pediatric Nurse Practitionerswill be offered in conjunction with the National N A P N A P Conference on March 6, 1996 in San Diego, CA. Certification is important to Pediatric Nurse Practitioners, both as a means of maintaining high standards of practice within the profession and as a mechanism for establishing the role of the Pediatric Nurse Practitionerin the health care system. The NCBPNP/N provides this opportunity for Pediatric Nurse Practitioners(PNPs) through its certification program. Certification provides:
o o o
Recognition for professional competency to employers, consumers and others in the health care system. Appropriate credentialsto state licensing boards. Enhancement of professional mobility and financial gain.
Registration begins November 15, 1995 and ends January 15, 1996. Contact the National CertificationBoard today for further information. The National Certification Board of Pediatric Nurse Practitioners and Nurses 416 Hungerford Drive, Suite 222 Rockville, Maryland 20850-4127 301-340-8213 II
I
J PED[ATRHEALTHCARE.(1995). 9, 263-268.
E c o n o m i c and political variables have a significant impact on the health care of children. A growing number of sick children receive most of their care outside the traditional inpatient setting. Nursing must expand its outlook to include a network of services provided in a variety of settings. Collaboration among nursing professionals is necessary to ensure quality pediatric health care in the community. The Pediatric Nursing Council of Northeast Florida (PNC) was formed to respond to the professional and patient care issues resulting from the changing health care environment. The purpose of the nursing council is to proactively build a community-based nursing services model that ensures excellence in nursing practice. The PNC represents a cost-efficient model that facilitates the sharing of professional resources (clinical, educational, and research) while promoting standards of excellence. Such collaborative approaches are vital to the future of nursing. Shari L. Huffman, RN, BSN, is a Nurse Coordinator in Pediatric Gastroenterology and Nutrition at Nemours Children's Clinic in Jacksonville, Florida. Pam Pieper, ARNP-CS, MSN, is the Pediatric Surgery Clinical Nurse Specialist/Nurse Practitioner and Pediatric Trauma Coordinator at the University of FJorida Health Science Center Jacksonville in Jacksonville, Florida. Kimberly S" Jarczyk, ARNP, MSN, is the Senior Nurse Practitioner at Nemours Children's Clinic in Jacksonville, Florida. Dolores Jones, MS, RN, CPNP, is the Director of Pediatric Education at Wolfson Children's Hospital in Jacksonville, Florida. JoAnn Patray, PhD, ARNP, is an Associate Professor in the Pediatric Nurse Practitioner Program at the University of Florida Health Science Center Jacksonville in Jacksonville, Florida. Reprint requests: Shari L. Huffman, RN, BSN, Nemours Children's Clinic, 807 Nira St., Jacksonville, FL 32207. Copyright 9 1995 by the National Association of Pediatric Nurse Associates and Practitioners. 0891-5245/95/$5.00 + 0
25/1/63674
JOURNAL OF PEDIATRIC HEALTH CARE/November-December 1995
9 REVIEW OF LITERATURE
Collaboration first appeared as a heading in the Cumulative Index to Nursing and Allied Health Literature (CINAHL) in 1989. Collaboration is described as "pooling of resources and ideas within or across disciplines for innovation, problem solving, e t c . . . " (Lockwood, 1989, p. 143) Review of nursing literature finds that collaborative projects between physicians and nurses, service institutions and educational programs, and nurses within specialty groups or organizations are well documented. Nursing has always recognized the value of partnerships between nurses and their patients/families, and collaborative nursing research is ongoing and growing. Interdisciplinary communitywide cooperation has resulted in comprehensive services across organizations for specific populations, such as medically complex or disabled children (Hochstadt & Yost, 1989), under-served inner-city groups (Katz, 1992), or the homeless (Dahl, Gustafson, & McCullagh, 1993). To our knowledge, no descriptions exist of multi-institutional models of collaboration formed by nurses to promote excellence in nursing practice for children in the community. Collaboration between service institutions and nursing education programs can improve nursing practice and education. In 1990, the American Association of Colleges of Nursing (AACN) voted to encourage all member schools to establish collaborative relationships with practice settings to advance common goals in practice, education, and research (Hegyvary, 1991). Baker, Boyd, Stasiowski, and Simons (1989)described such a partnership between a university nursing program and a local hospital. This relationship was established to "facilitate excellence in education, practice, and research" (p. 8). They emphasized that professionalism is the basis 263
Journal of Pediatric Health Care
264
Huffman et al.
9 TABLE 1
Volume 9, Number 6
Pediatric Nursing Council: Standards of practice
Standard Tracheostomy Central line Orthopedic
Enteral feedings
Implantable devices Medication administration at home
Seizures Home oxygenation Clean catheterization
Teaching material available* Home Tracheostomy Care: A Parent's Guide Your Child's Central Line: A Guide to Care Information for parents: Brace Care Cast Care Spica Cast Care External Fixator Care Checking Placement of a Nasogastric Tube Cleaning Enteral Tube Feeding Equipment Feeding Through a Gastrostomy (Jejunal, Nasogastric) Tube General Care: Children Who Require Tube Feedings How to Put in a Nasogastric Tube Medication Administration Non-nutritive Sucking Cleaning around a Gastrostomy Tube or Button Tube Feeding Your Child Implantable Devices: A Guide to Home Care Instructions for Intramuscular Injections Instructions for Subcutaneous Injections Instruction for Oral Medications Seizure Medication Handouts Seizure Disorder Information for Parents In progress In progress
*Readers interested in individual teaching materials may contact the corresponding author directly.
fbr a collegial relationship that supersedes institutional bias and allows for effective collaboration. Hawken and Hillestad (1990) also described a collaborative relationship between a university school of nursing and service institutions in the surrounding community. The purpose of this project is "promotion of the clinical practice of profkssional nursing" (p. 19). The authors noted that cooperation between nursing practice and education has increased over the last decade. These types of relationships help reach the goals of excellence in education and practice of individual institutions. Other successful collaborative approaches have shown the value of pooled resources for nursing continuing education. Sammut (1993) described a consortium approach to offer a critical care course open to nurses from five area hospitals. This program was organized through a planning committee with representatives from interested hospitals. The combined efforts allowed Ibr a cost-effhctive program and provided networking opportunities for all involved. Marvin and Acevedo (1991) described an interinstitutional effbrt to standardize intravenous therapy education/certification for staff nurses. Those initial efforts expanded to in-
clude intravenous therapy standards of practice for the community. A review of literature has shown that collaboration continues to flourish in a variety of settings. However, these cflbrts focus on specific projects or services. In contrast, the PNC coordinates a community-based effort by involving multiple organizations with the common, more global purpose of ensuring excellence in practice, education, and research. Bringing pediatric nurses from different settings together results in a comprehensive model that can lead to improved education and clinical practice and increased opportunities for nursing research. For the PNC, the ultimate goal is improved health care services for children. m INTERINSTITUTIONAL COLLABORATION
The practice of pediatric nursing should be considered within the context of the community. The PNC is proactively building a community-based model designed to facilitate excellence in pediatric nursing. Recognizing that effective collaboration among institutions and agencies is difficult to achieve, pediatric nursing leaders in two inpatient facilities (Wolfson Children's Hospital and University Medical Center), a large, mul-
Journal of Pediatric Health Care November-December 1995
9 TABLE 2
Huffman et al.
265
Pediatric Nursing Council: Education committee activities
Educational offering Pediatric nursing grand rounds Certification review
Pediatric nurses Christmas program
Pediatric assessment
Home care "Skills Day"
Pediatric nursing conference
tispecialty pediatric outpatient clinic (Nemours Children's Clinic), and the Jacksonville campus of the University of Florida College of Nursing initiated the efforts to collaborate. These visionaries acknowledged their collective responsibility to provide effective leadership and mentorship to empower clinicians and overcome institutional rivalry. The vision of the PNC is to fbster development of a community-wide network of pediatric health care services. Essential components of this network include education for patients, families, and professionals, nursing research, and standards of practice. The activities of the PNC are potentially cost efficient through coordination and sharing of resources, thus avoiding duplication of services and programs. For example, if each service institution develops and prints protocols for central line care or offers a pediatric nursing assessment course, each must bear the entire cost in dollars and personnel. When a single, city-wide protocol or program is developed cooperatively, costs and benefits are shared by all. In addition to pediatric nursing leaders in the community, nurses from the four institutions specializing in clinical practice, education, and research participate on the Council or on committees or task forces for special projects. The PNC oversees the activity of these groups. Three standing committees facilitate realization of these goals. The Standards of Care Committee develops research-based clinical protocols that are used across institutions and in home care. The Education Committee promotes the professional education of pediatric
Description Case presentations of medically complex children by area nurses. Review courses offered for certification examinations for pediatric nurse, neonatal nurse, and pediatric critical care nurse. Holiday evening program for area nurses focused on keeping the spiri of Christmas as a pediatric nurse. Offered through the university; provides continuing education credit and introduction to the pediatric nurse practition program. Introduction of standards to community nurses; included hands-on skills sessions. Two-day regional conference focuses on current trends of practice, updated standards, and changes in health care.
nurses. The Research Committec focuses on developing and promoting pediatric nursing research. 9 STANDARDS OF CARE COMMITTEE
Multiple agencies are often involved in discharge teaching for medically complex children. Parents may be given conflicting information, leaving them confused and uncertain about their child's care. In addition, providers are concerned and frustrated when their particular standards of care are not being met. Recognizing these difficulties, the Committee develops city-wide protocols for home care for conaplex situations. The initial efforts were directed at standardizing the teaching methods for the home care of central venous lines, so that the inpatient teaching and practice was consistent with what the home care company did and what the outpatient providers expected. Over the past 3 years, continued efforts have resulted in standards of care for orthopedics, tracheostomies, enteral feedings, medication administration (intramuscular, subcutaneous, oral), and implantable central venous access devices. Further standards under development or consideration include clean intermittent catheterization and information for parents about seizures and home oxygenation (Table 1). Task forces to develop standards are chaired by committee members and involve clinicians from home care and inpatient and outpatient services. The standards are research based and approved by the PNC and appropriate medical staff: They are printed and distributed among the institutions and may be used to revise insti-
Journal of Pediatric Health Care
266
Huff 9
9 TABLE 3
et al.
Volume 9, Number 6
Pediatric Nursing Council: Research committee activities Research project
Use of normal saline solution alone versus normal saline solution and heparin sodium combined for flushing central lines Test of accuracy of two methods for predicting insertion length and distal tip placement of nasogastric tubes in children Chlorhexidine verses providone-iodine and alcohol for central venous catheter maintenance Utilization of saline instillation before suctioning of tracheostomies in children
Phase Proposal being written
Data collection
Awaiting results of similar study currently underway Literature review
i
tutional policies and procedures, teach parent/caregivers, and educate staff, school, and home care personnel. In addition, the standards are available to any interested caregivers in the community. 9 THE EDUCATION COMMITTEE
The Education Committee consists o f nurse educators, clinical nurse specialists, and staff nurses from each institution. The purpose is to meet the educational needs o f pediatric nurses in the region, including school, office, and public health nurses. A survey sent to the target population identified needs covering the spectrum o f well child care, care of the chronically ill child, disease-specific information, and nursing care o f the medically complex child. Respondents also requested review courses for various pediatric nursing certification examinations. An ongoing consideration for planning is to ensure that programs are inexpensive and available at convenient times and locations. The first educational program offered was a review course for the General Pediatric Nursing Certification Examination. Faculty members included specialty pediatric nurses from the community. Review courses for the Neonatal Certification Examinations and for the Pediatric Critical Care Examination have also been coordinated by the Education Committee. In the first year, Pediatric Nursing Grand Rounds, Which were held quarterly, once at each institution, were designed as case presentations o f medically complex children who had been cared for in at least two o f the participating facilities. Related standards o f care and research were incorporated. Speakers included hospital and clinic staff nurses, clinical specialists, nurse practitioners, and home care nurses. A moderator described how the varying institutions interacted with each other, and speakers discussed their roles in caring for the child. An evolving responsibility o f the committee has been education o f pediatric nurses regarding the newly developed standards o f practice. A 2-day symposium offered to nurses in the community presented the new standards and allowed for "hands-on" skill sessions.
Copies o f home care teaching materials were available to all participants. The Education Committee has also developed and continues to offer a pediatric assessment course through the University o f Florida Health Science Center Jacksonville. Continuing education credit is provided, and the course serves as an introduction to the Pediatric Nurse Practitioner Program available at the University. The course covers all aspects o f assessment in children, includes clinical practice and limited skills sessions, and has been particularly popular with public health nurses. Table 2 summarizes the activities o f the Education Committee. 9 THE RESEARCH COMMITTEE
Research-based clinical practice is an integral component of the PNC's philosophy. The charge o f the Standards Committee is to generate research-based standards of care. These standards are implemented on a community level through integration into the policies and procedures o f area institutions and through programs offered by the Education Committee. This process is building a substantial patient population base that can be accessed for nursing research. The Research Committee plans to establish a community-based research network, beginning with two or three clinical trials that test variables within the existing patient care standards. For example, the Research Committee is currently writing a proposal to evaluate the effectiveness o f normal saline solution versus a combination o f saline and heparin sodium flushes in maintaining patency in central venous access devices. The recognition o f the need for nursing research in this area grew out o f the Standards Committee's work on implantable venous access devices. A second study that is being coordinated through the committee is evaluation o f an equation based on height to estimate length for initial nasogastric tube placement in children. Table 3 lists the projects that the Research Committee is currently pursuing or considering. The support and commitment o f the Assistant Dean
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Improve health care by building a P e d / a t r ~ Nursing Council network of integrated pediatric o~No,~,e~,.t~l,,~a,, nursing services that will serve as a national model of excellence. The P ~ T C foundation for a model of excellence in nursing mandates the integration of nursing practice, education, and research. MISSION: Promote excellence in nursing care to improve and preserve the health and welfare of children, their families, and the communities in which they live. 1. Collaborate with other institutions, agencies, and providers within GOALS: the community to establish and implement the highest standards of care in pediatric nursing. The standards will improve quality, be Cost effective, and research based. 2. Empower children and their families through the provision of education and resources to enable them to attain independence and wellness. 3. Empower pediatric nurses through education and resource sharing to facilitate their ability to meet the health and welfare needs of the population. 4. Assume responsibility and accountability for excellence in practice through professional self-regulation, continued personal and professional development, and support of nursing research and education. 5. Participate in nursing research activities related to the care of children.
VISION:
9 FIGURE Vision, mission, and goals of the Pediatric Nursing Council of Northeast Florida.
o f the College o f Nursing at the University of Florida Jacksonville Campus has provided the Research Committee with access to research expertise. Faculty members have acted as mentors and given much-needed support in planning these studies. In addition, nursing leaders within the various organizations encourage staff nurse participation at any point from study design through data collection and analysis. Graduate students in pediatric nursing can use the research committee as a sounding board or source for potential research topics and populations. 9 RESULTS OF THE COLLABORATION
Results from the collaborative efforts of the PNC have been both direct and indirect. Pediatric nurses in Jacksonville have a heightened awareness o f the physical, personnel, and academic resources available across agencies. Educational offerings have been opened to pediatric nurses from the four institutions, and several programs were directed at other pediatric nurses in the community. Many staff nurses who had not been involved in planning and presenting programs in the past were able to participate in these programs and share their expertise with their peers. Standards o f care have been distributed to many pediatric nurses in different settings. In addition, the annual peer review evaluation process at Nemours Children's Clinic is now open to other nurses in the community. Wolfson Children's Hospital has included participation in the committees or task forces o f the PNC as an option for nurses in their clinical ladder program.
Indirectly, the collaborative efforts o f the PNC have led to a more comprehensive community-based view of the child, increased interinstitutional collegiality, and improved communication across agencies. The expectation in the community now is that practice and standards will be based on research. Many nurses have had the opportunity to learn the skills and benefits o f networking with other nursing professionals. Pediatric nurses in the community have been exposed to the graduate program at the university, and practicing masters-prepared clinicians serve as preceptors and mentors for individual students. 9 FUTURE DIRECTION
The founding members o f the PNC have renewed their commitment to supporting pediatric nursing in northeast Florida. The council has agreed to continue meeting quarterly and is exploring options for developing a charter and bylaws. Recently, a philosophy statement was adopted (Figure). The Standards Committee will continue to work on various projects, such as standards for home care o f the child on oxygen and for the child with seizures. Recognizing a professional responsibility to the community, the committee is exploring ways to share the standards with all pediatric nurses in northeast Florida. The Education Committee plans to offer further programs, including pediatric physical assessment, presentation o f nursing research studies, and review courses for pediatric certification examinations. The University plans to offer college credit for the physical
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assessment course. A r e g i o n a l 2 - d a y e d u c a t i o n a l conference is b e i n g p l a n n e d , focusing o n c u r r e n t concepts in pediatric care. T h e c o n f e r e n c e will i n c o r p o r a t e the activities o f the P N C , c u r r e n t t r e n d s in practice, u p d a t e d standards, a n d changes in h e a l t h care. T h e Research C o m m i t t e e is m e e t i n g regularly a n d is i n t e r e s t e d in s t u d y i n g the use o f c h l o r h e x i d i n e for central venous line care a n d the effectiveness o f using saline solution before the s u c t i o n i n g t r a c h e o s t o m i e s .
resources. T h e s e collaborative efforts can facilitate excellence in professional n u r s i n g practice and help prepare for n u r s i n g ' s role in the future o f health care. []
REFERENCES Baker, C. M., Boyd, N.J., Stasiowski, S. A., & Simons, B. J. (1989). Interinstitutional collaboration for nursing excellence: Part 1, creating the partnership. Journal of Nursind Administration 19, 8-12. Dahl, S., Gustafson, C., & McCullagh, M. (1993). Collaborating to develop a community-based health service for rural homeless persons. Journal of Nursing Administration, 23, 41-45. Hawken, P. L., & Hillestad, A. (1990). Promoting nursing's health care agenda through collaboration. Nursing and Health Care, 11, 17-19. Hegyvary, S. T. (1991 ). Collaborative relationships for education and practice. Journal of Professional Nursing, 7, 148. Hochstadt, N.J., & Yost, D. M. (1989). The health care-child welfare partnership: Transitioning medically complex children to the community. Children's Health Care, 18, 4-11. Katz, T. (1992). Partnerships help children in need. Healthcare Forum Journal, 35, 22-27. Lockwood, D. (Ed.). (1989). Cumulative index to nursing and allied health literature (Vol 34). Glendale, CA: CINAHL Marvin, P., & Acevedo, M. (199l). Regional excellence in intravenous therapy: It all began with community intravenous therapy education. Journal of Intravenous Nursing, 14, 123-125. Sammut, N. A. (1993). Critical care education: A consortium approach. Journal of Nursing Staff Development, 10, 219-222.
T hcollaborative e seffortsecan facilitate
excellence in professional nursing practice and help prepare for nursing's role in the future of health care. T h e d e b a t e , discussion, and rhetoric a b o u t h e a l t h care r e f o r m is o n g o i n g . E c o n o m i c and political variables will c o n t i n u e to affect h e a l t h care a n d the future o f nursing. N u r s i n g can p r e p a r e for the challenges o f health care r e f o r m by i n t e g r a t i n g nursing e d u c a t i o n , research, a n d practice in the c o m m u n i t y . T h e P N C demonstrates t h a t interinstitutional c o l l a b o r a t i o n a m o n g nurses p r o m o t e s efficient use o f professional
SPECIAL TESTING OPPORTUNITY sponsored by NAPNAP and THE NATIONAL CERTIFICATION BOARD OF PEDIATRIC NURSE PRACTITIONERS AND NURSES
The National CertificationBoard of Pediatric Nurse Practitioners and Nurses is pleased to announce that The National Qualifying Examination for Pediatric Nurse Practitionerswill be offered in conjunction with the National N A P N A P Conference on March 6, 1996 in San Diego, CA. Certification is important to Pediatric Nurse Practitioners, both as a means of maintaining high standards of practice within the profession and as a mechanism for establishing the role of the Pediatric Nurse Practitionerin the health care system. The NCBPNP/N provides this opportunity for Pediatric Nurse Practitioners(PNPs) through its certification program. Certification provides:
o o o
Recognition for professional competency to employers, consumers and others in the health care system. Appropriate credentialsto state licensing boards. Enhancement of professional mobility and financial gain.
Registration begins November 15, 1995 and ends January 15, 1996. Contact the National CertificationBoard today for further information. The National Certification Board of Pediatric Nurse Practitioners and Nurses 416 Hungerford Drive, Suite 222 Rockville, Maryland 20850-4127 301-340-8213 II
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