educational preparation and postgraduate training curriculum

Educational preparation and postgraduate training curriculum forpediatric critical care nurse practitioners*

Lauren Sorce, RN, MSN, CPNP-AC, FCCM; Shari Simone, RN, MS, CPNP-AC, FCCM;Maureen Madden, RN, MSN, CPNP-AC, FCCM

Changing healthcare demandsand constraints have led to in-creasing numbers of nursepractitioners (NPs) in pediat-

ric critical care (PCC). The addition ofNPs into PCC has been accepted by theSociety of Critical Care Medicine (SCCM).In fact, the American College of CriticalCare Medicine of SCCM published guide-lines for PICUs and included NPs as pro-viders of care (1). These guidelines state:

“At certain times of the day, the attend-ing physician in the PICU may delegate thecare of patients to a physician of at least thepostgraduate year 2 level or to an advancedpractice nurse or physician’s assistant withspecialized training in pediatric criticalcare. These nonphysician providers mustreceive credentials and privileges to providecare in the PICU only under the direction ofthe attending physician, and the credential-ing process must be made in writing andapproved by the medical director.”

However, there continues to be confu-sion within the healthcare community sur-rounding the education foundation, quali-fications, scope of practice, and specializedtraining needs of newly hired NPs, particu-larly entry-level practitioners. This article de-scribes the educational preparation of pediat-ric nurse practitioners (NPs) and providesguidelines for postgraduate training curricu-lum to successfully integrate NPs into thepediatric intensive care unit (PICU).

Clinical Foundation

The postgraduate critical care NPtraining guidelines described in this arti-

cle should serve as a resource for thesuccessful integration of entry-level pedi-atric nurse practitioners. Ideally, each NPshould have an individualized orientationplan that takes into consideration years ofexperience in pediatric critical care (staffnurse and NP), level of expertise, the ed-ucation program attended (primary oracute care), and needs of the PICU. Post-graduate education of NPs presentsunique challenges, as each NP is likely tohave variable PICU experience and clini-cal knowledge. It is important to recog-nize that many educational programs re-quire different levels of experience innursing before attendance. Thus, manyNPs come to the PICU with variable ex-perience, making their integration intothe PICU and postgraduate training dif-ferent from any other providers.

Educational Foundation

The acute care nurse practitioner(ACNP) is an advanced practice nursewho provides comprehensive care acrossthe continuum of healthcare services to

*See also p. 303.Pediatric Intensive Care Unit (LS), Children’s Me-

morial Hospital, Chicago, IL; Pediatric Intensive CareUnit (SS), University of Maryland, Baltimore, MD; andPediatric Intensive Care Unit (MM), Bristol-MyersSquibb Children’s Hospital at Robert Wood JohnsonUniversity Hospital, New Brunswick, NJ.

The authors have not disclosed any potential con-flicts of interest.

For information regarding this article, E-mail:[email protected]

Copyright © 2010 by the Society of Critical CareMedicine and the World Federation of Pediatric Inten-sive and Critical Care Societies

DOI: 10.1097/PCC.0b013e3181b80a19

Background: Nurse practitioners (NPs) in pediatric intensivecare units have increased dramatically over recent years. Al-though state regulations are changing pediatric nurse practitionercertification, licensure and credentialing requirements, availableacute care, and critical care educational programs are limited.Thus, entry-level practitioners continue to have varied clinicalexperience and educational preparation.

Objective: To describe the current educational preparation andscope of practice of pediatric NPs and provide guidelines forpostgraduate training to successfully integrate NPs into the pe-diatric intensive care unit (PICU).

Design: A group of NPs practicing in pediatric critical carerecognized the imminent need for comprehensive orientationguidelines that are readily accessible to physicians and othernurse practitioners to successfully transition entry-level NPs intothe PICU. The NPs held many discussions to identify commonal-ities and differences in the education foundation in pediatric NPprograms, expected clinical experience and knowledge of NPstudents, and anticipated needs and gaps for the entry-level

practitioner. A convenience sample of 20 pediatric critical carenurse practitioners practicing for >5 yrs were interviewed toexamine current orientation processes for entry-level NPs into thePICU. Sample orientation guidelines, job descriptions, and proce-dural competency forms were collected and reviewed from vari-ous PICUs across the United States. An orientation model wasdrafted and distributed to a secondary panel of ten experiencedpractitioners to gather expert opinions. Responses were reviewedand a revised draft of the document was distributed to a group ofAPNs involved in postgraduate education.

Results: A PICU orientation model for entry-level pediatriccritical care nurse practitioners was developed.

Conclusions: The orientation curriculum presented here mayserve as a resource for NPs and collaborating physicians who aredeveloping a training program for entry-level practitioners.(Pediatr Crit Care Med 2010; 11:205–212)

KEY WORDS: pediatric intensive care; pediatric nurse practitio-ners; pediatric advanced practice nurses; orientation curriculum;training guidelines; education.

205Pediatr Crit Care Med 2010 Vol. 11, No. 2

meet the specialized physiologic and psy-chological needs of patients with complexacute, critical, and chronic health condi-tions (2). ACNPs practice in a variety ofsettings, which include acute care, andhospital-based settings such as subspe-cialty care, emergency care, and intensivecare (3–15). In response to the growingnumbers of ACNPs and need for entry-level standards of practice, the NationalOrganization of Nurse Practitioner Fac-ulties published Acute Care Nurse Prac-titioner Competencies in 2004 (12). Thisset of core competencies is applicable toall pediatric and adult ACNPs. More re-cently (2005), the Pediatric CertificationNursing Board (PCNB) established thePediatric Acute Care Nurse PractitionerExamination based on a role-delineationstudy of acute care pediatric nurse prac-titioner practices around the country(13). Before this, the American NursesCredentialing Center (ANCC) and thePCNB certified all pediatric NPs in pri-mary care only.

Education programs are now modify-ing and adding curriculum to educatepediatric NPs in pediatric acute care. Pe-diatric NPs who have completed an ACNPprogram are certified by either the PCNB,and receive the title Certified PediatricNurse Practitioner-Acute Care (CPNP-AC), or the ANCC, and receive the titlePediatric Nurse Practitioner–Board Cer-tified (PNP-BC). Pediatric NPs who havecompleted a primary care program arealso certified by the PCNB or the ANCC.Although, to date, there is no pediatriccritical care NP certification, acute carecertification is advocated to ensure astandard knowledge base that includesbasic critical care content. Educationalstandards for pediatric ACNPs are dy-namic and continually evolving as is therole. The American Association of Col-leges of Nursing, in the document, TheEssentials of Master’s Education for Ad-vanced Practice Nursing (1996), identi-fied key curriculum for all advanced prac-tice nurses (14). This curriculumincludes core graduate courses and ad-vanced practice courses (Table 1).

Recently, the PCNB developed guide-lines for pediatric ACNP educationalprogram review. These guidelines in-corporate the above outlined contentand the documents, Domains and Com-petencies of Nurse Practitioner Prac-tice (2002) (15) and The Acute CareNurse Practitioner Specialty Compe-tencies (2004) (16) (Table 2).

Regulatory changes in NP certificationand legislation are underway for adultand pediatric practitioners that supportlinking education, certification, and prac-tice. Many states have already adoptedlegislation that requires the NP to becertified in the area that most closelymatches his or her practice (17). Whilemany educational programs are currentlyintegrating acute care into their curricu-lum to meet the certification and legisla-tive changes, many nurses do not haveaccess to these programs because ofgeographical restrictions and limitedavailability. Until acute care programsare readily available to NP students, pri-mary care educated NPs will work in

acute care roles. It is imperative thatthe primary care educated NP workingin an acute care role has critical careexperience to ensure success in practiceand overall job satisfaction for both theNP and employer.

Scope of Practice

The scope of practice of the pediatricNP is defined by national and state regu-lations, collaborative practice agreement,job description, credentialing, and needsof the particular PICU. The scope of prac-tice is further defined by individual stateNurse Practice Acts. Specific componentsthat are regulated by states include pre-scriptive authority and reimbursement.The spectrum of allowances and restric-tions vary by state.

A collaborative agreement between thepediatric critical care NP and the attendingphysician(s) is required by most states. Thiscollaborative agreement delineates how theNP and physician will work together toachieve an effective clinical practice ar-rangement. It is important for the NP andphysician to be clear about the practice sitedefinition and delineation of collaboration.The individual practice site dictates howdetailed or specific the collaborative agree-ment needs to be. This agreement delin-eates activities that can be performed au-tonomously and those that requirephysician collaboration. In addition, the NPjob description and institutional require-ments, such as credentialing, will furtherdefine the individual ACNP role, particu-larly in states where collaborative practiceagreements are not required.

Various models of pediatric criticalcare NP practice have been developedacross the country (9,18–20). In 2000,Verger and colleagues (9) published a de-scriptive study of the role of NPs in pedi-atric critical care. The responsibilities re-ported by practicing NPs included directpatient care management, consultation,education, research, quality improve-ment, program development, and leader-ship activities. More recently (2005),Verger and colleagues presented the re-sults of a national survey which describesthe current scope of practice and the con-tributions that NPs make in the pediatriccritical care setting (10).

The entry-level practitioner and theexperienced practitioner will obviouslyhave different levels of responsibilities.However, as the entry-level NP gains clin-ical expertise, responsibilities will furtherdevelop and expand. Furthermore, a sam-

Table 1. Curriculum model

Graduate nursing core: foundation curriculumfor all students pursuing a master’sdegree in nursing

ResearchPolicy, organization, and financing of health careEthicsProfessional role developmentTheoretical foundations of nursing practiceHuman diversity and social issuesHealth promotion and disease prevention

Advanced practice nursing core: essentialcontent for nurses who will engage in directpatient/client services at an advanced level(includes nurse practitioners, clinical nursespecialists, nurse midwives and nursesanesthetists)

Advanced health/physical assessmentAdvanced physiology and pathophysiologyAdvanced pharmacology

Table 2. Acute care nurse practitioner specialtycompetencies

Acute care specialty curriculumHealth promotion/health protection, disease

prevention, and treatmentDiagnosis of health statusPlan of care, implementation, and evaluationAcute care pediatric nurse practitioner-

patient relationship: communication andcrisis management

Teaching/coaching functionProfessional roleManaging and negotiating healthcare servicesMonitoring and ensuring quality careCultural competencies

Clinical experiences (inclusive)Minimum of 600 supervised clinical hours

related to acute care nurse practitionerpractice

Minimum of 500 supervised clinical hours inclinical settings associated with themanagement of complex acute, critical,and chronically ill children

Minimum of 50 supervised clinical hoursfocused on well child care

206 Pediatr Crit Care Med 2010 Vol. 11, No. 2

ple job description developed from a varietyof pediatric critical care NP job descriptionsis provided which describes the breadth ofresponsibilities that can be incorporatedinto the NP role (see Appendix A).

Postgraduate Training andOrientation Curriculum

Informal interviews were conductedwith 20 pediatric critical care nurse prac-titioners practicing for �5 yrs to examinethe current orientation processes for en-try-level NPs into the PICU. Additionally,individual hospital orientation guide-lines, job descriptions, procedure compe-tency forms from various PICUs acrossthe United States, and published paperson role delineation, integration of the NProle, and adult and pediatric resident andfellow critical care training guidelineswere reviewed (21–26).

The results of these interviews andreviews demonstrated that each individ-ual center employing NPs was strugglingto create a comprehensive orientationprogram. In addition, when the need foran orientation program was identified,the centers networked with other centersto identify a process that fit the orienta-tion of the site’s new NPs. The burdencreated was a retrofitting of one hospital’sprogram into another hospital. This wasconsistent with each interview. As a re-sult, the need for a unified recommenda-tion was evident to allow for a compre-hensive approach that could be modifiedbased on the needs of the pediatric NPsand the hospital. An orientation modelwas drafted and distributed to a second-ary panel of ten experienced practitionersfor expert opinions. Responses were re-viewed and a revised draft of the orienta-tion model was distributed to a group ofAPNs involved in postgraduate educationfor consensus.

The postgraduate training and orien-tation should be an individualized pro-cess based on the NPs previous clinicalexperiences and graduate education cur-riculum. In addition, one should alsoconsider the Institute of Medicine’s sup-port of interprofessional education (IPE).It is stated that IPE facilitates an im-proved understanding and communica-tion between healthcare professionalsleading to improved safety and qualityof care for patients (27). TranslatingIPE into multiprofessional care is alsoconsistent with the mission of SCCMwhich promotes this for all critically illpatients (28). Integrating the concepts

of multiprofessional care and IPE arecritical to development of the orienta-tion model and involves sharing theresponsibilities of clinical mentoringamong all the providers in the PICU.The following curriculum can serve as aresource for NPs and collaborating phy-sicians who are developing a trainingprogram for newly hired NPs.

The curriculum outlined in this arti-cle might resemble that of fellowshiptraining. It is imperative to recognizethat not all units are fortunate enough tohave the ideal model of intensive caredelivery which includes all members ofthe healthcare team. As such, PICU NPsare increasingly working in units thathave no fellows or residents, and mayfunction as the first line for most acuteissues with or without in-house attendingphysician collaboration. Thus, a curricu-lum that is modifiable for all practicesettings is appropriate.

The curriculum is organized into gen-eral components, including administra-tive and professional requirements andcore clinical content. The clinical contentis intended to establish a beginning com-mon knowledge base for all entry-levelpractitioners, rather than to promote anexpected expertise at the end of the ori-entation process. Furthermore, to deliversafe, evidenced-based, quality care, thecore concepts and knowledge should bethe same for all providers in the PICU assupported by the Institute of Medicine’sinterprofessional education (27). How-ever, the time any one individual spendssecuring knowledge in these areas willvary.

General Components

1. Pre-EmploymentRequirements

● Licensure/certification–refer to StateBoard of Nursing as practice require-ments will vary

● Drug Enforcement Administration—www.deadiversion.usdoj.Gov

● Credentialing and privileging● Refer to hospital medical staff services● Certifications–pediatric advanced life

support (PALS) and cardiopulmonaryresuscitation (CPR)

2. Scope of Practice

● Position responsibilities● Job description/role delineation● National and state regulations

● Standards of care–American Associa-tion of Critical Care Nurses (AACN),National Association of Neonatal andPediatric Nurse Practitioners (NAPNAP)

● Collaborative practice● Procedures

3. System Orientation

● Unit operations● Standards of care● Policies and procedures (unit and/or

specialty and hospital-wide)● Documentation guidelines

4. Clinical Training

● Suggestions for acquisition of knowl-edge and skills: (see Appendix B)

● Didactic lectures (core clinical con-tent lectures may be provided by allproviders participating in the multi-disciplinary team)

● Pediatric fundamental critical caresupport course

● Introduction to core knowledge andprocedural skills

● Procedural competencies/operatingroom experience/technology simula-tion

● Self-learning modules● Clinical experiences● Timeframe individualized to meet the

needs of the individual NP

Core Clinical Curriculum

The core clinical curriculum is orga-nized into general clinical goals and spe-cific cognitive and technical competen-cies that are common to most PICUs. Thecontent is not intended to serve as a com-plete list of all topics that should be cov-ered during orientation. Rather, the con-tent is intended to serve as a guide forphysicians and NPs who are mentoringentry-level nurse practitioners. NPs whoundergo the orientation process set forthcan be expected to provide safe care forcritically ill children in collaborationwith attending physicians and should notbe expected to function independently. Itis only through vast clinical experiencesand continued education that the NP willbecome increasingly proficient in themanagement of these children.

1. Clinical Goals

The following are suggested minimumexperiences for entry-level practitioners tocomplete during orientation in collabora-tion with the IPE team:


● Diagnoses and stabilizes patients withimpending organ failure (respiratory,cardiac, neurologic, hepatic, gastroin-testinal, hematologic, renal, etc.)

● Identifies the need for and initiatescardiopulmonary resuscitation

● Diagnoses and prevents hemody-namic instability and initiates treat-ment for shock (that is, cardiogenic,traumatic, hypovolemic, and distribu-tive shock)

● Identifies and initiates treatment forlife-threatening electrolyte and acid-base disturbances

● Initiates, manages, and weans pa-tients from mechanical ventilationusing a variety of techniques and ven-tilators

● Titrates therapy in the PICU usingappropriate invasive and noninvasivemonitoring devices

● Identifies and implements appropriatenutritional support (that is, enteraland parenteral)

● Identifies and implements sedationand analgesia therapies

● Implements medication safe practiceguidelines and determines cost-effec-tiveness of therapeutic interventions

2. Comprehensive andSupportive Child/Family Care

● Communicates effectively in verbaland written form with the healthcareteam

● Communicates effectively with thechild and family

● Recognizes and evaluates the psycho-social needs of critically ill childrenand their families

● Identifies and provides access to sup-portive resources

● Demonstrates respect, sensitivity, andskill in dealing with death and dyingwith the child, family, and otherhealthcare professionals

3. Case Management Content

● Acts as the primary healthcare pro-vider and coordinates patient carewhile in the PICU

● Communicates with multiple consult-ants involved in patient management

● Initiates specialty consultations● Provides daily communication and

education to family members● Initiates and coordinates discharge

planning needs

4. Cognitive Content

The following global list of criticalcare disease states may not be present inall PICUs, and the curriculum contentshould be tailored to meet the needs ofthe particular unit. The curriculum con-tent as outlined reflects subject matterthat the NP should be familiar with, butdoes not necessarily indicate proficiencyin these areas.

● Cardiovascular physiology, pathology,pathophysiology, and therapy

● Shock (hypovolemic, cardiogenic, dis-tributive)

● Cardiac rhythm and conduction dis-turbances

● Indications for and types of pacemakers● Vasoactive and inotropic therapy (ini-

tiation, titration, and weaning)● Cardiac tamponade● Congenital heart disease and the

physiologic alterations associatedwith surgical repair

● Pulmonary hypertension● Diagnosis and treatment of acquired

heart disease● Recognition, evaluation, and manage-

ment of hypertensive emergencies● Respiratory physiology, pathology,

pathophysiology, and therapy● Principles of oxygen transport and

utilization● Acute respiratory failure● Hypoxemic respiratory failure, in-

cluding acute respiratory distress syn-drome

● Hypercapneic respiratory failure● Acute or chronic respiratory failure● Status asthmaticus● Aspiration● Bronchopulmonary infections (that

is, bronchiolitis, pneumonia)● Upper airway obstruction● Obstructive sleep apnea● Pulmonary embolism—thrombus,

air, fat● Pulmonary mechanics and gas ex-

change● Oxygen therapy● Noninvasive ventilation (that is, bi-

level mask ventilation, continuouspositive airway pressure)

● Mechanical ventilation● Pressure and volume modes of me-

chanical ventilators● Synchronized intermittent manda-

tory ventilation, continuous positiveairway pressure, high frequency ven-tilation, pressure support ventilation,volume support, airway pressure re-

lease ventilation, pressure-regulatedvolume control, pressure control, vol-ume control

● Ventilatory muscle physiology, patho-physiology, and therapy

● Pleural diseases● Empyema● Pleural effusion● Pneumothorax● Hemothorax● Chylothorax● Nitric oxide● Positional therapy (that is, prone po-

sitioning, rotational therapy)● Renal physiology, pathology, patho-

physiology, and therapy● Renal regulation of fluid balance and

electrolytes● Renal failure: prerenal, renal, and

postrenal● Electrolyte disturbances● Acid-base disorders and their manage-

ment● Principles of renal replacement ther-

apy and associated methodologies(that is, hemodialysis, peritoneal dial-ysis, continuous veno-venous hemo-filtration)

● Central nervous system physiology, pa-thology, pathophysiology, and therapy

● Coma● Hydrocephalus and shunt infection

and malfunction● Central sleep apnea● Status epilepticus● Perioperative management of patient

undergoing neurologic surgery● Management of increased intracranial

pressure, including intracranial pres-sure monitors

● Neuromuscular disease causing respi-ratory failure (that is, Guillain-Barre,myasthenia gravis)

● Traumatic brain injury● Acute spinal trauma● Space-occupying lesions (that is, tu-

mors, vascular malformations)● Stroke● Conscious and deep sedation● Pain management● Neuromuscular blockade, including

polyneuropathy of the critically ill andprolonged effect of neuromuscularblocking agents

● Metabolic and endocrine effects ofcritical illness

● Nutritional support—indications, ini-tiation, and modification of enteraland parenteral nutrition

● Disorders of antidiuretic hormonemetabolism

● Adrenal crisis


● Disorders of thyroid function● Glucose management (that is, dia-

betic ketoacidosis and hypoglycemia)● Infectious disease physiology, pathol-

ogy, pathophysiology, and therapy● Recognition and management of sepsis● Identification of appropriate antimi-

crobial therapy● Meningitis● Encephalitis● Recognition and management of hos-

pital-acquired infections● ICU support of the immunosup-

pressed patient● Isolation management● Acute hematologic and oncologic

physiology, pathology, pathophysiol-ogy, and therapy

● Thrombocytopenia● Disseminated intravascular coagula-

tion● Anticoagulation; fibrinolytic therapy● Acute syndromes associated with neo-

plastic disease and therapies● Principles of blood component ther-

apy● Sickle cell crisis and acute chest syn-

drome● Plasmapheresis● Prophylaxis against thromboembolic

disease● ICU-acquired anemia● Venothromobolic event prophylaxis● Acute gastrointestinal physiology, pa-

thology, pathophysiology, and therapy● Upper/lower gastrointestinal bleeding● Hepatic failure● Perioperative management of surgical

patients● Evaluation and management of gas-

troesophageal reflux disease● Stress ulcer prophylaxis● Necrotizing enterocolitis● Acute abdomen● Environmental hazards● Recognition and initial management

of common drug ingestions and with-drawal, including:

-acetaminophen-cyclic antidepressants-barbiturates-narcotics-salicylates-other: hydrocarbons, etc.

● Skin and wound care● Trauma, burns● Smoke inhalation, airway burns● Skeletal trauma● Chest trauma● Abdominal trauma

● Immunology and transplantation● Principles of transplantation● Immunosuppression● Physiologic monitoring● Hemodynamic monitoring● Advanced pulmonary monitoring● Respiratory monitoring and oxygen

transport and utilization calculations● Central nervous system monitoring

(that is, intraventricular catheter,bispectral monitoring)

Ethics

● Consent● Study enrollment● End-of-life decision making and care● Organ procurement

Pharmacology

● Pharmacokinetics● Pharmacodynamics● Safe medication practice● Drug-dosage adjustments in renal

and hepatic failure

5. Identify AppropriateDiagnostic Modalities Basedon Disease Process

● Radiographs (that is, chest, abdominal)● Computed tomography scans● Magnetic resonance imaging● Electroencephalogram● Twelve-lead electrocardiogram● Echocardiogram● Ultrasound● Nuclear medicine studies● Doppler studies

6. Technical Competencies

● Airway management in nonintubatedpatient

● Laryngeal mask airway insertion● Intubation● Extubation● Arterial cannulation● Central venous catheter insertion● Lumbar puncture● Chest tube placement● Chest tube removal● Epicardial pacing wire removal● Intracardiac line removal● Transpyloric tube placement● Chest radiograph interpretation● 12-lead interpretation● Percutaneous inserted central cathe-

ter line placement

Measuring Competency

A critical element for successful in-tegration of entry-level NPs into thePICU is ongoing feedback and opencommunication with supervising NPsand physicians. Scheduled meetingsduring orientation ensure frequent di-alogue on clinical progress, facilitatethe development of interpersonal rela-tionships, and provide opportunities forcoaching the orientee in a nonstressfulenvironment. The evaluation processshould encompass assessment of tech-nical skills, knowledge acquisition, andcommunication skills. Documentationof achievement of technical competen-cies is necessary for credentialing anddelineation of privileges for all NPs. Inaddition, NPs should maintain a log ofskills performed to verify continuedcompetency. Evaluation of knowledgeacquisition includes assessment of theNPs ability to accurately recognizecommon PICU disorders, institute-appropriate initial interventions, evalu-ation of therapeutic interventions, andeffective communication with the inter-disciplinary team. Curriculums shouldbe tailored to address identified knowl-edge gaps. Examples of evaluation toolsare available on request from theauthors.

CONCLUSION

Nurse practitioners are becoming in-tegral members of pediatric criticalcare teams across the country. SomePICUs have implemented this role with-out the benefit of a model and havebeen unsuccessful. On the other hand,many have implemented this role andhave been successful, but the road hasbeen fraught with trial and error. Thispostgraduate training model has beenformulated from numerous orientationmodels across the country. The goal ofthis model is to facilitate a successfulorientation process, provide guidancefor PICUs striving to implement thisrole, and further the subspecialty. Thismodel should be used as a guide andcustomized to meet the needs of eachspecific NP and PICU dyad. The degreeof success associated with the integra-tion of the role will impact and enhancethe delivery of high quality critical careto children. Furthermore, as these NPsgain clinical expertise, the additionalcomponents of research, leadership,and mentorship will mature and allow


these practitioners to maximize theircontribution to the care of critically illchildren.

ACKNOWLEDGMENTS

We would like to thank Alice Acker-man, MD, and Tom Bojko, MD, for theirsignificant support and guidance in thepreparation of this manuscript. Addition-ally, the support of the APNs and inten-sivists dedicated to this purpose has beeninvaluable.

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APPENDIX A

Sample Pediatric Critical CareNurse Practitioner JobDescription

General Role Responsibilities

The pediatric nurse practitioner incritical care practice combines primarycare needs and comprehensive medicalmanagement for patients and families re-quiring pediatric intensive care services.The care is provided in a collaborativeframework with the multidisciplinaryteam. The nurse practitioner (NP) per-forms diagnostic and therapeutic inter-ventions using guidelines jointly agreedupon by the NP and collaborating attend-ing physicians. In addition, the NP par-ticipates in various indirect patient careresponsibilities, including role modeling,clinical consultation, and resource, edu-cation, and research. The NP may alsoparticipate in other support servicesbased on the particular critical care divi-sion needs; such examples may includecall-coverage, pediatric sedation services,PICC line service, back-up transport du-ties, etc.

Specific Responsibilities

1. Practice

In collaboration with pediatric attend-ing physicians, the NP performs the fol-lowing responsibilities:

A. Elicits, records, and interprets acomplete medical, family and psy-chosocial history.

B. Assesses family dynamics and iden-tifies potential stressors, strengths,weaknesses, support, and copingabilities of each family member.

C. Performs a complete physical ex-amination.

D. Discriminates between normal andabnormal findings on the physicalexamination, records findings, andpostulates an impression of thechild’s present health status andexpected outcome.

E. Develops and implements an initialplan for differential diagnosis and


management of presenting prob-lems.

F. Performs necessary diagnostic andtherapeutic procedures as indi-cated for diagnoses and manage-ment of problems using approvedcompetencies or as directed by thecollaborating physician. Proce-dures may include:

1. endotracheal intubation2. arterial cannulation3. central venous catheter insertion4. lumbar puncture5. chest tube placement6. chest tube removal7. removal of pacing wires8. intracardiac line removal9. conscious sedation

10. transplyoric tube placement11. Percutaneous inserted central

catheter placement12. laryngeal mask airway inser-

tion

G. Orders and interprets necessary labo-ratory, radiographic, and other diag-nostic tests for incorporation into pa-tient management plans and progressevaluation.

H. Performs diagnostic and stabiliza-tion procedures as needed.

1. Initiates and directs support ofrespiratory system, includingoxygen therapy, mechanicalventilation, and drug therapy.

2. Selects and institutes fluid andnutritional support, includingappropriate supplements.

I. Assesses and facilitates resolutionof the parent’s psychosocial prob-lems and support needs, initiatingnecessary consultation and involve-ment of other healthcare person-nel.

J. Writes and effectively communi-cates appropriate orders for accom-plishing the designed plan of man-agement.

1. Documents patient progress,procedures, and updates notes asneeded. Completes necessarycomputer forms and documenta-tion to provide effective andtimely communication.

K. Performs daily reassessment anddocumentation of problems, patientprogress, and revisions in manage-ment plans.

L. Actively participates in admissions,transfers, and discharge.

M. Shares responsibility with the med-ical staff for communicating patientproblems, status, and prognosiswith parents, referring physicians,social workers, and managed careproviders.

N. Functions as a role model for thestaff nurses in defining compre-hensive nursing practice in thePICU.

O. Participates in case review andMorbidity & Mortality conferences.

2. Educator

Collaborates with PICU leadership andcommittees to provide and support theeducational process of the healthcareteam including:

A. Participates in planning and presen-tation of education programs. Sup-ports the academic mission of theinstitution by contributing to educa-tion of nursing and medical staff.

B. Participates in outreach educa-tion.

C. Participates in peer review process.D. Participates in clinical mentoring

of graduate NP students and newemployees.

E. Participates in the teaching and su-pervision of rotating house staff/medical students.

F. Provides health education to fami-lies/significant others.

3. Consultant

A. Collaborates with other healthcareteam members to provide continu-ity of care to patients.

B. Serves as a consultant for nursingcare issues for children.

C. Participates on hospital commit-tees on issues relevant to criticalcare nursing and advanced practicenursing.

D. Acts as a resource and advocate forcritical care to community agencies.

E. Participates in the developmentand enforcement of policies andstandards for pediatric criticalcare.

4. Research

A. Fosters an environment of re-search-based clinical practice.

B. Engages in evidence-based prac-tice.

C. Demonstrates basic competency inreviewing research.

D. Demonstrates current knowledgefrom journal review of nursingpractice and of medical informa-tion relevant to the critical carepopulation by critically appraisingresearch data and incorporating itinto patient care decisions.

E. Collaborates with critical care phy-sicians in research and other per-tinent clinical projects.

F. Collaborates with nursing colleaguesin nursing research projects.

5. Leadership

A. Demonstrates effective interper-sonal communication skills.

B. Demonstrates effective writtencommunication skills.

C. Demonstrates effective teamwork.D. Supports activities of nursing man-

agement within the Pediatric De-partment.

E. Demonstrates a strong nursing im-age and serves as a role model fornursing colleagues.

F. Participates in interview process ofapplicants for nursing leadershippositions and critical care staff.

G. Participates in departmental and hos-pital committees and task forces.

H. Demonstrates active participation inthe quality improvement process.

I. Fulfills mandatory educational re-quirements annually, which in-clude, but are not limited to:

1. Joint Commission on the Accredi-tation of Healthcare Organizationsand other institutionally- requirededucation

2. CPR3. PALS4. Annual employee health screening5. Demonstrates service-excel-

lence behaviors

6. Professional Development

A. Maintains licensure status throughcontinuing education.

B. Participates in professional organi-zations.

C. Advances clinical expertise throughconferences, journals, etc.

D. Participates in professional educa-tion at the graduate level.

E. Maintains a professional networkamong colleagues.

F. Advocates for legislation support-ing access to quality health care forchildren and families.


7. Personal Development

A. Demonstrates ability to use leader-ship skills.

B. Demonstrates ability to use coach-ing and counseling skills.

C. Demonstrates an understandingand support of the philosophy andmission of institution.

8. Professional Qualifications

A. Registered Nurse license in thestate of practice.

B. Licensed as an advanced practicenurse/NP in the state of practice.

C. Master’s degree from an accreditedschool of nursing.

D. Successful completion of AmericanNurses Association/American Asso-ciation of Pediatrics guidelines forpediatric NP/pediatric nurse associ-ate programs or family NP program.

E. Certification as a NP.F. Minimum of two years of pediatric

critical care experience in a tertiarycare center.

G. Critical Care Registered Nurse des-ignation.

APPENDIX BSample Pediatric Critical CareNP Goals and Objectives

The critical care NP orientation is anindividualized process based on one’sprevious experiences and should be tai-lored to meet the needs of the particu-lar orientee. The following goals weredeveloped to establish a commonknowledge base for all practitioners.

Goals

1. Understand how to resuscitate andstabilize the critically ill child in thePICU setting.

2. Understand how to manage certain di-agnoses commonly encountered inthe PICU setting.

3. Understand the application of physio-logic monitoring and special technologyand treatment in the PICU setting.

4. Discuss the indications, initiation, andmodification of enteral and parenteralnutrition.

5. Discuss the indications for diagnosticmodalities.

6. Demonstrate competency of procedures(may occur after orientation).

7. Develop case management skills formedically complex patients.

8. Demonstrate comprehensive and sup-portive care to patients and families.

9. Discuss ethical and medical-legal con-siderations in the care of critically illchildren. (The appendix may be viewedin its entirety at the SCCM PediatricSection APN Website.)
