Preceptorship Workbook for PICU staff

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Preceptorship Workbook for PICU staff Powered By Docstoc
					             PICU
       Band 5 Nurses
  Preceptorship programme




Name……………………………………………………………

Team…………………………………………………………….

Preceptor/ Mentor……………………………………

Team Leader………………………………………………
                                            Contents Page


  WELCOME ..................................................................................................................... 3

  GREAT ORMOND STREET HOSPITAL FOR CHILDREN .............................. 4

  PICU Profile.................................................................................................................. 6

  PICU WARD PHILOSOPHY ..................................................................................... 8

  PRECEPTORSHIP......................................................................................................... 9

  THE PRECEPTORSHIP PATHWAY ...................................................................... 10

     Stage 1 - Orientation ............................................................................................ 10

     Stage 2.......................................................................................................................11

     Stage 3...................................................................................................................... 12

     Stage 4...................................................................................................................... 13

  Essential Competencies ........................................................................................... 15

  Band 5 Competencies .............................................................................................. 20

  Reflection Sheets .................................................................................................... 27




H Drennan & H Prendergast     May 2008
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                                       WELCOME
Welcome to the Paediatric Intensive Care Unit at
Great Ormond Street Hospital. This booklet aims to
provide you with clear guidelines to orientate you to
our unit.

During your supernumerary period you will become
familiar with the equipment, procedures and care
delivered to our patients.

We acknowledge that everyone will have different
learning needs and these can be identified with your
preceptor/mentor     and   documented      in   your
competency book.

This is a self-assessment tool for you to complete as
opportunities become available.

If you have not completed the essential competencies
by the end of your supernumerary period please
discuss them with your preceptor/mentor or a senior
member of the nursing team.



                        GOOD LUCK!
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      GREAT ORMOND STREET HOSPITAL
              FOR CHILDREN

Dr Charles West founded Great Ormond Street hospital
(GOSH) in 1852. GOSH is a world-class children‟s hospital,
with the broadest range of paediatric specialists under one
roof anywhere in the UK.

GOSH welcomes around 150,000 patient visits each year
treating children with the most complex, life-threatening
and life-limiting conditions. GOSH is committed to finding
treatments and cures for some of the rarest and most
difficult illnesses.


GOSH provides a broad portfolio of education and learning
opportunities for all staff.


Staff can develop their knowledge and skills through a
variety of opportunities designed to support competence
and career development.
(http://www.ich.ucl.ac.uk/education/gosh/index.html)




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GOSH is a post-graduate teaching hospital and is linked for
the purposes of research, development, teaching and
training to the Institute of Child Health, part of the
University of London. The Institute is in effect the medical
school of the hospital.


Nursing education is affiliated to South Bank University,
which offers a wide range of graduate and post-graduate
courses.




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                                       PICU Profile

The PICU at GOSH is an eleven bedded unit admitting
children from 0-16 years. It is a tertiary referral centre
with specialities that include neurology, neurosurgery,
respiratory, renal, surgery, ENT & metabolic disorders. Due
to these specialist services, children are admitted from all
over the UK and overseas and often have very complex
disorders.


Services we are able to provide include, conventional
ventilation, high frequency oscillation, nitric oxide therapy,
continuous veno-venous haemofiltration, neurosurgical care.
PICU is also part of an intensive care retrieval service
(CATS). In service training courses are provided for all of
these services.


There is a diverse team of staff on PICU with around 90
nursing staff, a large medical team, family liaison sisters,
practice educators and housekeepers.


Initiative and innovation are encouraged and we hope that
nurses will take on research and teaching projects to
update and improve knowledge and clinical practice.




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In order to facilitate personal and professional
development of all staff we use a system of individual
performance review. All members of staff are regularly
appraised by their preceptor/mentor and individual
objectives are agreed at each appraisal.


The nursing staff are divided into ten teams, there will be
regular shifts allocated to work with your team.


We recognise that each child is unique and is part of a
family. To ensure the child and family‟s needs are met, we
use the partnership philosophy of nursing care to encourage
parents and significant others to participate in care as
they feel able.


PICU can be a very stressful environment to work in. We
aim to minimise the stress by use of reflective practice,
the preceptorship programme, psychosocial meetings and
regular social events, as well as close co-operation and
teamwork. There is also a „band 5 group‟ meeting every 3
months.
For further support you can also contact:

                 Occupational Health – extn 8554

                 Ward Psychologist - bleep 1023

                 OASIS – tel 020 7380 9800

                 Practice Educators – extn 6721


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                       PICU WARD PHILOSOPHY

We acknowledge the child as a unique functioning
member of society. Each child and family that enters
into our care are respected and treated as individuals
with their own specific needs and desires.

We recognise the importance of the family unit and
strive for a holistic approach to care, encompassing
religious beliefs, cultural differences, development
and growth. Access to information is an integral part
of this approach.

We aim to promote health and recovery, maintaining
dignity, privacy and quality of life. However, we
recognise that if the fight is lost, the child has the
right to die with dignity, free from pain and
surrounded by love.




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                                   PRECEPTORSHIP


Introduction-The concept of Preceptorship was introduced into
the United Kingdom in 1990 as an integral component of the UKCC‟s
„Post registration and Practise‟ project consultation document.
(UKCC 1990)
The document defines Preceptorship as a „period of support for all
newly registered practitioners to consolidate the competencies or
learning outcomes achieved at registration‟.

This is also extended to those practitioners that are new to
clinical areas or those undertaking new, more senior roles. Each
new practitioner should be assigned to a particular preceptor in
order to experience day-to-day practise with a role model and
resource immediately available within the clinical setting.

In order to achieve this, the preceptor and preceptee must
work together at least 3 shifts per rota.

The intention of the following programme is to provide a structure
for both the preceptor and the individual new starter in terms of
learning requirements and development.




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             THE PRECEPTORSHIP PATHWAY

                                      Week 1
                              Orientation programme.
                   3-5 days according to individual requirements.


                               Stage 1 - Orientation


Orientated to the following

- Emergency contacts
  2222 – medical emergency
  5999 – non-medical emergency
          (Security & fire)
- Fire procedures including:
   Exits, extinguishers, alarm location, torches
   Role in unit evacuation
   Different alarm sounds
- How to bleep
- Emergency alarms & location of resuscitation trolley
and defibrillator
-   Codes for doors

Sign and date………………………………………….(Preceptee)
Sign and date …………………………………………(Orientator)




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                                       Stage 2
               Weeks 2-6: Date……………………………..
   Supernumerary shifts to grasp principles of patient safety in
                             PICU.
                 Complete hospital orientation.
                Complete essential competencies
                Commence Band 5 Competencies.
Commence and aim to finish IV/Oral drug administration booklets.
Final week of supernumery period- formal assessment based on
                    essential competencies.

                   Initial interview with Preceptor/Mentor.




Preceptor………………………………………………………………(Sign and Date)

Preceptee……………………………………………………………….(Sign and Date)

     Preceptor to inform Training & Development that this IPR has been completed




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                                       Stage 3
                 Weeks 6-12 Date………………………………
                  Continue Band 5 Competencies.
           At 6 weeks complete performance review and
          set 6-month objectives with Preceptor/Mentor.
    IV/Oral drug administration must be completed by this stage.


                     Performance review and objectives set




Preceptor……………………………………………………………

Preceptee……………………………………………………………..
(Sign and Date)




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                                       Stage 4
             3-6 months Date:………………………………………
                 Complete Band 5 Competencies
   Demonstrate competent practice in the care of stable intensive
              care patients with single organ failure.


     Individual Performance Review with Preceptor/Mentor




Preceptor………………………………………………………………………..

Preceptee…………………………………………………………………………
(Sign and date)




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                              Orientation checklist
The following is a checklist of issues to discuss during the orientation period
when appointed as band 5 within PICU.

   Basic Nursing Care of the PICU patient
   Assessment and Monitoring of PICU patients
   Daily Ward Routine
   Ward Round / Nurse-led handover
   Layout of PICU and a bedspace
   Patient Safety Checks
   Nursing Shift Handover
   Admission Procedures
   Discharge Planning and Process
   Emergency Procedures: including fire, cardiac arrest & security
   Bereavement documentation and procedures
   Hospital Orientation
   The Bleep System
   Sickness Notification
   Annual Leave/Flexi Time/Off Duty
   Team Meetings & Events
   Communication Issues
   Oasis
   Role of the Multi Disciplinary Team
   Parental Support Available / Family liaison Team
   Intercom system
   TOMCAT
   Electric bath
   Store room shelving
   Infection Control Policy
   Study Leave Policy
   Risk management
   IV Policy
   Location of Policy and Procedure Files



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                             Essential Competencies
                       TO BE COMPLETED DURING SUPERNUMERY PERIOD




                                                          Explained   Competent
                                                          Date &      Date &
                                                          Sign        Sign

1 Initial safety checks                                   ///////     ////////
Airway drawer –correct size guedal airway & face
mask, yankeur sucker, goggles and pen torch ONLY
Bagging Circuit
Bag-valve-mask (Ambubag)
Suction (set up, alter pressure & change inner liner)
Alarm limits
Check ETT or Tracheostomy tapes
Stethescope
Complete and document initial patient assessment
2 Ventilation                                             ///////     ////////
Complete respiratory assessment – look at chest
movement, air entry, colour, oxygen saturations. ETT
size and position
Demonstrate safe bagging using Ayres T-piece
Understand basic modes of ventilation including, CPAP,
BIPAP and SIMV
Basic understanding of blood gases
Perform ETT and Tracheostomy suctioning safely
Familiarise yourself with at least one type of
conventional ventilator
3 Cardiovascular                                          ///////     ///////
Understand normal parameters for heart rate and
blood pressure and significance of any changes
Cardiovascular assessment looking at perfusion,
pulses, capillary refill, colour
Invasive blood pressure monitoring – set up arterial
line, sample from line, care of site & zero transducers

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                                                         Explained   Competent
                                                         Date &      Date &
                                                         Sign        Sign

4        Fluids
Competent in NG tube testing and familiar with
feeding protocol
Calculation of fluids in % or mls/kg/day
Calculate drug volumes and remaining fluid allowance
Calculate urine output ml/kg/hr and maintain accurate
fluid balance
Record blood sugar and know normal parameters
5        Neurology                                       ///////     ///////
Carry out a neurological assessment on a neurological
patient a) awake, b) sedated c) paralysed
Carry out a neurological assessment on a non-
neurological patient a) awake, b) sedated c) paralysed
Identify parameters which help assess pain
Check pupil size and reactions and understand changes
6        Drugs                                           ///////     ////////
Check drug infusions – including prescription, rate,
dose and carevue documentation
Check drug chart, dose, route of administration and
frequency
Identify the common sedatives and analgesics used,
their dosage and side effects
7        Pressure area care, skin & hygiene              ///////     ////////
Assess pressure areas and document on carevue
Know when to change probe sites and electrodes
Complete all aspects of personal hygiene, washing,
mouth care, eye care and catheter care
8 Handover                                               ///////     ///////
Give a systematic and holistic nursing handover
Handover your patient on nurse-led evening ward
round
Complete handover checklist

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                                                          Explained   Competent
                                                          Date &      Date &
                                                          Sign        Sign

9 Calling for assistance                                  ///////     ///////
Identify when to call for help
Know when to inform appropriate person about
changes in your child‟s condition i.e. nurse in charge,
„out nurse‟ and medical staff
Check resuscitation trolley and defibrillator
Communicate effectively with all member of the
multidisciplinary team
How to use emergency buzzers
10 Supporting families                                    ///////     ///////
Orientate parents to the unit
Participate in update meeting between consultant and
parents
Communicate changes in child‟s condition to their
family

Arrange accommodation
11 Carevue, bedspaces & equipment                         ///////     ///////
Familiar with all aspects of using bedside & transport
monitoring
Use carevue competently and document correctly
Set up a bedspace for an admission
Clear a bedspace following discharge
Check glucometer
Use handset for electric bed & CPR lever
IVAC infusion pumps – set up, set rate, volume to be
infused, flow sensors, pressure alarms, clear volume
infused, cleaning & storage
Syringe drivers - set up, set rate, drug calculations,
give bolus, set volume to be infused

Graseby pumps – set up, set rate & test
Use ISTAT & use appropriate cartridge
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                                        Explained   Competent
                                        Date &      Date &
                                        Sign        Sign

12 Infection control                    ///////     ///////
Awareness of cross infection
Comply with universal precautions
Use correct hand washing technique
Perform aseptic non-touch technique




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                  Congratulations
          on completing your essential competencies.

You should now be working independently. The
following „Band 5 competencies‟ are to assist your
progress and development in PICU in line with your
KSF framework.



These competencies should be completed by six
months in order to set some objectives for your
individual performance review (IPR) with your
mentor/preceptor.



It will be helpful to use these competencies as a
guide to your learning. There are some useful
references at the back of this booklet and many
experienced staff on the unit who will be willing to
help with your learning.




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                              Band 5 Competencies

                                                                 Preceptee   Preceptor
                                                                 Date &      Date &
                                                                 Sign        Sign
Respiratory care competencies                                    ///////// /////////
Recognise normal respiratory function in children

Identify the signs of respiratory distress & suggest ways of
intervening to prevent further distress
Describe ways in which oxygen can be administered, and the
reasons for choosing particular methods
Participate during an intubation & extubation

Explain the need for „blow off valve‟ in paediatric bag-valve-
mask
Demonstrate the ability to safely care for a child requiring
artificial ventilation, to know when to instigate hand
ventilation and demonstrate this competently
Understand the following terms- peak inspiratory pressure
(PIP), positive end expiratory end pressure (PEEP), tidal
volume (TV), minute volume (MV) & trigger sensitivity

Gain an understanding of the basic principles of artificial
ventilation, the advantages of different modes of ventilation
and common complications of intubation and ventilation



Have a basic understanding of blood gases and know the
“normal” parameters of arterial blood gases
Describe the action, normal dose range, and most common side
effects of the following inhaled drugs: Salbutamol, Atrovent
and Adrenaline
Be able to care for a child with chest drains

Assess and monitor weaning from oxygen therapy

Be able to change ventilator tubing
Have knowledge of drugs used in rapid sequence induction,
including their doses, action, half-life and reversal

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                                                                 Preceptee   Preceptor
                                                                 Date &      Date &
                                                                 Sign        Sign
Cardiovascular Care Competencies                                 ///////// /////////
Commence cardiovascular monitoring on a critically ill child,
choosing appropriate equipment and identifying the care
related to the use of such equipment
Identify the components of the normal ECG trace

Describe the ECG changes in the following arrhythmias - sinus
bradycardia /sinus tachycardia
Identify the complications associated with indwelling arterial
pressure lines
Describe the signs and symptoms of shock- using fluid
resuscitation, inotropes, CVP monitoring
Have a basic understanding of different inotropes, including
safety and rationale for usage
Neurological care competencies                                   ///////// /////////
Assess and give a rationale regarding the child‟s need for
sedation, analgesia and paralysis
Identify the common sedatives used on PICU a) dosage
b) side effects c) method of administration
Identify the common analgesics used on PICU a) dosage
b) side effects c) method of administration
Identify the common paralysing agents used on PICU
 a) dosage b) side effects c) method of administration
Discuss how to limit the effects of sensory overload on PICU-
e.g. noise, alarms and lights

Utilise sedation score and take appropriate action

Describe methods of communication for intubated/ventilated
children on PICU
Assess child and complete withdrawal chart. Understand and
follow weaning protocol
Care for a child following neurosurgery

Discuss and demonstrate the safety implications of caring for
a child with an EVD or ICP
List the signs of raised intracranial pressure



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                                                                 Preceptee   Preceptor
                                                                 Date &      Date &
                                                                 Sign        Sign
Nutritional & Gastrointestinal care                              ///////// /////////

competencies
Identify the reasons why a child in the PICU may require an
increased nutritional intake
Discuss how to optimise the nutritional status of a child e.g.
correct feeds and methods etc.
Explain the rationale for administration of total parenteral
nutrition (TPN) and to demonstrate safe practice
Demonstrate ability to re-calculate TPN at rates lower than
prescribed
Discuss medication used for gastric cover when NBM

Discuss how bowel functions are affected by conditions and
therapies in PICU and how to normalise bowel function
Renal care competencies                                          ///////// /////////
To have knowledge of the normal urea and electrolyte levels,
and to be able to identify the actions needed when levels are
abnormal
Safely perform urinary catheterisation on a boy and a girl

Discuss the significance of urine testing and complete daily

Recognise clinical signs of dehydration and fluid overload

Identify the causes and symptoms of acute renal failure in
children
Explain the following terms- Peritoneal dialysis and CVVH
(Continuous veno-venous haemofiltration)
Identify the commonly used diuretics and their dosages


Temperature control competencies                                 ///////// /////////
Explain the significance of toe-core gap and the rationale for
treatments given
Demonstrate and explain the use of heating and cooling
mattresses and other methods of temperature control
Identify the effects of alterations in body temperature in
the critically sick child and neonate


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                                                                  Preceptee   Preceptor
                                                                  Date &      Date &
                                                                  Sign        Sign
Infection control competencies                                    ///////// /////////
Identify potential sources of infection for PICU patients

Be able to identify preventative measures taken on the PICU
to reduce the risk of infection. Be aware and follow PICU
policy
Identify the resources available, including personnel who
provide information regarding infection control issues
Discuss the implications of caring for a child who is
immunocompromised
Ensure admission screening is completed

Educate family members about the importance of handwashing
and infection control
Know length of time for indwelling devices e.g. urine catheters

Family care competencies                                          ///////// /////////
Understanding and describe the common responses of the
family of a critically ill child on the PICU
Promote the involvement of the family in the care of their
child
Discuss the care of siblings within the PICU environment

Identify the resources for family support e.g. family liaison
team, psychologists, PALS and social work department
Act as advocate for the child and family, participate in ward
rounds, psycho-social meetings etc
Discuss Child Protection policy and have knowledge of trust
documents
Show sensitivity, awareness and respect to families of
different cultures and backgrounds
Discuss the care of the child and family following a non-
accidental injury
Demonstrate an awareness of procedures and policies
following the death of a child on the PICU
Demonstrate compassion and support to the family of a child
who is dying




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                                                                  Preceptee   Preceptor
                                                                  Date &      Date &
                                                                  Sign        Sign
Additional competencies                                           ///////// /////////
Ability to prioritise own workload and provide holistic care

Develop an awareness of the needs of the unit. Assist with
meal breaks and support other staff including pre-registration
nursing students
Have knowledge of policies and protocols relevant to PICU

To be able to recognise changes in patient‟s condition and take
appropriate action
Participate in audits on PICU


Further competencies                                              //////      ///////




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                                 Reflective Practice
Reflective practice is associated with learning from
experience, and is viewed as an important strategy
for health professionals.

The act of reflection is seen as a way of promoting
the development of autonomous, qualified and self-
directed professionals.

Gibbs‟ (1998) model of reflection incorporates the
following: description, feelings, evaluation, conclusion
and action plan.

Gibbs‟    (1998)    reflective   cycle    is   fairly
straightforward and encourages a clear description
of the situation. Followed with analysis of feelings,
evaluation of the experience, analysis to make sense
of the experience, conclusion – where other options
are considered and reflection upon experience to
examine what you would do if the situation arose
again.

Gibbs, G (1998) Learning by doing. A Guide to Teaching & Learning
Methods. Further Education Unit, Oxford Polytechnic, Oxford




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   These reflection sheets are for you to use as an aid to reflect on
   your practice and learn from your experiences both positive and
   negative.
   You may find it helpful to complete these alone or with someone
   who has been working alongside you.

      When completing these reflection sheets you should maintain patient

                                            confidentiality.
   Please photocopy more as required.


                                      Gibbs’ Reflective Cycle

                                            Description
                                           What happened



      Action plan
                                                                       Feelings
What would you do if a
                                                                      What were
         similar
                                                                      you feeling
 situation arose again




                                                                   Evaluation
    Conclusion                                                 What was good/bad
 What else could you                                           about the experience
    have done




                                               Analysis
                                          What sense can you
                                             make of the
                                               situation
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                                  Reflection Sheets

Date:                                      Shift: D/N
Patient details:
    Age:
    Diagnosis:
Status:
    Intubated/self ventilating:
    Ventilation mode:
    Sedation:
Aims, plans & interventions




Evaluation of Shift: Any areas of concern use Gibbs (1998) cycle




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                                  Reflection Sheets

Date:                                       Shift: D/N
Patient details:
    Age:
    Diagnosis:
Status:
    Intubated/self ventilating:
    Ventilation mode:
    Sedation:
Aims, plans & interventions




Evaluation of Shift: Any areas of concern use Gibbs (1998) cycle.




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