Pediatric nurse practitioners in the care of terminally ill children

¶ … Pediatric Nurse Practitioner in the Care of Terminally Ill Children

Pediatric nurse practitioners provide a valuable contribution to the care of chronically and terminally ill children. This position is essentially a subtype of advanced practice nurse, whose function is to provide the best possible patient care for ill children. This position functions within a pediatric hospital setting, in which the goal is to provide cost-effective patient care that meets and exceeds the needs of patients and their families. Although the pediatric nurse practitioner may work with children that present with acute or chronic illnesses, there is a critical need for nursing practitioners that are motivated to work with terminally ill children. Terminally ill children and their families present unique needs and situations that require knowledge, expertise, and intervention skills beyond what conventional nurses can offer. This population requires specialized care that can be fulfilled by a trained pediatric nurse practitioner.

Terminally ill children and their families require attention and services that are different from those of other clinical populations. The pediatric nurse practitioner can provide terminally ill children and their families with crucial information regarding the status and course of the child's illness. The pediatric nurse practitioners can also link families with resources that can help inform and support during the stressful experience of caring for a terminally ill child, as well as directly provide parents with information as to how they can best aid in the care of their terminally ill child. Furthermore, the pediatric nurse practitioner would provide families with the psychological and spiritual support required before and after the death of a terminally ill child.

This discussion will center around the position of pediatric nurse practitioner, and the roles and responsibilities inherent to the position. A review of some of the relevant literature surrounding this position and advanced nursing in general will be presented. My individual strengths and competencies will also be discussed in relation to the pediatric nurse practitioner position. Also, theoretical approaches in regards to the practice of the pediatric nurse practitioner will also be addressed.

Roles and competencies of pediatric nurse practioners

What exactly is a pediatric nurse practitioner? The role of the pediatric nurse practitioner is and extension of the role of the advanced practitioner nurse. The roles of advanced practitioner nurses have continually been demonstrated to be associated with cost effectiveness, patient satisfaction, and high quality patient care through research (Teicher et al., 2001). Initially the roles encompassed by nurse practitioners were developed due to primarily economic reasons, including the aim to improve the practice of nursing as well as to improve the care that patients receive (Teicher et al., 2001). The nurse practitioner role was initially developed in the 1960s to accommodate a shortage of physicians in the domain of primary care, and 1964 saw the establishment of the first pediatric nurse practitioner program at the University of Colorado (Teicher et al., 2001).

In general, nurse practitioners are equipped to effectively deliver direct patient care, as well as perform duties such as assessment, diagnosis, and condition management, as well as the prescription of treatments (Teicher et al., 2001). As outlined by Teicher et al. (2001), the American Nurses Association states that "advanced practice nurses perform comprehensive health assessments and demonstrate skilled autonomy in the diagnosis and treatment of individuals, families, and communities to manage acute and chronic illness and promote wellness." In the case of pediatric nurse practitioners specialized in working with terminally ill children, assessment, diagnosis, and treatment extend beyond the ill child to their families.

There are numerous advanced roles involved in the position of pediatric nurse practitioner. These include case management, the development of clinical pathways, educator and consultant, research, as well as collaboration (Teicher et al., 2001). In regards to case management, pediatric nurse practitioners assist the healthcare team and patients in the pediatric setting in order to ensure quality outcomes while remaining attentive to continuity of care and cost-effectiveness (Teicher et al., 2001).

Essentially, models use in case management are designed to cost-effectively provide high quality patient care. There are two case management models that are adhered to in the domain of nursing (Teicher et al., 2001). First, the New England Medical Center model centers around controlling resources utilized during the hospitalization of a patient. This enhances care given to the patients, increases satisfaction among healthcare providers, patients and their families, and keeps the cost of care delivery in check (Teicher et al., 2001). Secondly, the Professional Nursing Care Management model integrates the services provided by nurses across the continuum of care (Teicher et al., 2001). Through case management, pediatric nurse practitioners are able to use critical thinking skills and advanced knowledge of illness among children to better promote holistic care with patients and their families (Teicher et al., 2001).

Another role of pediatric nurse practitioners involves the development of clinical pathways. Clinical pathways are multifaceted planes utilized by the healthcare team to follow the course of events for patients with the same diagnosis (Teicher et al., 2001). Through the development of clinical pathways, positive patient outcomes and satisfaction are promoted, along with decreases in cost and usage of healthcare resources (Teicher et al., 2001). In order to ensure success in the development of pathways, pediatric nurse practitioners must adhere to several responsibilities (Teicher et al., 2001). These responsibilities include the development of pathways in areas of knowledge and expertise, reviewing pathways with families of patients, ensuring the use of pathways through follow-up, reviewing the analysis of outcomes, developing a problem resolution plan regarding patient care, acting as a resource for the multidisciplinary healthcare team, organizing and attending pathway teams, and revising pathways as is required (Teicher et al., 2001).

The education and consultation roles fulfilled by pediatric nurse practitioners is crucial to effective interactions with healthcare staff, successful patient outcomes and patient, as well as family, satisfaction. There has been a dramatic increase in chronically ill children, which makes the educator/consultant role of nurse practitioners ever more important (Teicher et al., 2001). The educator role executed by the pediatric nurse practitioner involves the provision of relevant information to patients and their families, while integrating theories in order to positively influence the outcomes of patients (Teicher et al., 2001). Patients and their families may be educated regarding their specific plan of care, improved self-care, issues of prevention, discharge planning (when applicable), and follow-up procedures (Teicher et al., 2001). The education provided by pediatric nurse practitioners is solidly grounded in a theoretical foundation.

Based on areas of specialization acquired, the pediatric nurse practitioner may also act in a consultant role, in which the aim is to improve the care of patients and nursing practice regarding the patient population in question (Teicher et al., 2001). As a consultant, the pediatric nurse practitioner has the ability to analyze clinical data and discuss patient outcome with the patient and his or her family (Teicher et al., 2001). The consultant role allows pediatric nurse practitioners to enhance overall outcomes of patients through the development of teaching materials aimed at the patients and their families (Teicher et al., 2001).

Research is an important component to the functions performed by the pediatric nurse practitioner. Research is required in order to enhance and expand the roles played by pediatric nurse practitioners. Due to the ever-changing climate experienced in health care, nurses need evidence from research in order to prove that services they provide are beneficial and essential in the provision of high quality patient care (Teicher et al., 2001). The outcomes that result from the work done by pediatric nurse practitioners needs to be proven to be unique to their field, efficient, and cost-effective (Teicher et al., 2001). Practice may also be improved through innovations discovered through nursing research (Teicher et al., 2001).

Collaboration is an important function performed by the pediatric nurse practitioner. In the role of collaborator, the nurse practitioner ensures that all health care professionals involved in the care of patients are on the same page. In order to execute collaboration effectively, an understanding of the roles and responsibilities of other healthcare professionals is required (Teicher et al., 2001). Effective relationships between different professionals on a multidisciplinary team are based on respect and trust (Teicher et al., 2001). The pediatric nurse practitioner with advanced education can offer other professionals skills in prevention, health promotion, adaptation, education, counselling, as well as access to resources in the community (Teicher et al., 2001). Clinical competence and credibility are necessary for effective collaboration with a multidisciplinary medical team (Teicher et al., 2001). Collaboration benefits patients and their families by assuring them that all professionals involved in the care of patients share a common goal of positive patient outcomes and satisfaction.

The roles of pediatric nurse practitioners can be enhanced through the implementation of several strategies (Teicher et al., 2001). For instance, training of pediatric nurse practitioners should include the management of acute illnesses, chronic medical conditions, and terminal illnesses in children. Graduate education is necessary for the attainment of the skills required to perform effectively in the roles involved in being a pediatric nurse practitioner. Beyond graduate education, certification through a professional nursing organization and state licensure are also necessary to legitimately practice as a pediatric nurse practitioner, or any advanced practitioner nurse for that matter (Teicher et al., 2001). A strong background and knowledge in pediatrics and terminal illness is also required. In addition, pediatric nurse practitioners should enforce their unique role through continual collaboration with physicians and other healthcare professionals (Teicher et al., 2001). Also, active research continues to develop and establish the crucial role played by pediatric nurse practitioners (Teicher et al., 2001).

The true value of the pediatric nurse practitioner role must be demonstrated through the evaluation of patient outcomes, and patient and family satisfaction (Teicher et al., 2001). Teicher et al. (2001) explained how this evaluation could be conducted through "structure factors, process evaluations, outcome measurements, and through evidence of cost effectiveness." The essential elements involved in performance evaluations include education, clinical practice, consultation, professional development and research (Teicher et al., 2001).

Obstacles

The important role that pediatric nurse practitioners play, with their abilities to incorporate knowledge and skills necessary for the management of the needs of the ill child and his or her family, is increasingly recognized among all healthcare professionals (Wyatt, 2001). However, there are obstacles that may prevent the acceptance of pediatric nurse practitioners as essential to multidisciplinary healthcare teams. One of the most prominent barriers is a lack of a clearly defined role for pediatric nurse practioners among other healthcare professionals. One of the most important strategies for overcoming this barrier is active collaboration with various other healthcare professionals to make the responsibilities and service benefits of pediatric nurse practitioners known to others. Awareness of the influence that pediatric nurse practitioners have on positive patient outcomes and satisfaction among patients and their families is essential. Teicher et al. (2001) suggested that existing barriers could be overcome through the utilization of appropriate marketing strategies, continued education, evaluation outcomes, and an overall dedication to the direct care of patients.

Theoretical framework

The services delivered by a pediatric nurse practitioner are done so according to certain theoretical frameworks. One of the most appropriate and effective theoretical approaches in dealing with terminally ill children and their families is the Neuman Systems Model. Knight (1990) described the Neuman Model in terms of Fawcett's four meta-paradigms of nursing, which included person, environment, health, and nursing.

In regards to the person, Neuman understands the client as an open system, who is a dynamic combination of the interrelationships of five variables, including physiological, psychological, sociocultural, spiritual, and developmental factors (Knight, 1990). The person meets personal needs through interaction with the environment. Neuman figuratively represents the person as a core of basic structure and energy resources that are surrounded by three hypothetical circles that are representative of boundaries (Knight, 1990). The boundaries are lines of resistance, normal line of defence, and flexible line of defence (Knight, 1990). A person is continually faced with stressors from within his or her own system as well as from the environment.

According to Neuman, the environment encompasses all factors affecting or affected by a person, both internal and external (Knight, 1990). The environment is the source of stressors, but also provides the tools required to effectively deal with stressors. Furthermore, stressors can be either beneficial or harmful in nature (Knight, 1990).

In regards to health, Neuman indicates that it is the "condition in which the flexible line of defence has prevented penetration of the normal line of defence and all parts and subparts are in harmony with the whole of the person (Knight, 1990)." Health occurs when all of the person's needs are met, while illness is a state of insufficiency or instability (Knight, 1990).

Neuman defined nursing as concerning the total person with the aim of attaining and maintaining overall stability in the patient (Knight, 1990). The aim of nurses should be to reduce stressors and adverse conditions that affect, or potentially affect, the health of the patient. Therefore, it would be critical for pediatric nurse practitioners working with terminally ill children to create and sustain an environment of equilibrium around the children, with the involvement of the families and other health care professionals.

In order to effectively attain optimal environmental conditions for a terminally ill child, it is necessary for pediatric nurse practitioners to observe the family involved and identify specific needs of the patient and family, including cognitive, affective, physical, and spiritual needs (de Moutigny, 1995). An appropriate care plan is then developed through the validation of the needs held by the patient and his or her family (de Moutigny, 1995).

Pediatric nurse practitioners perform a multifaceted role in the deliverance of healthcare services, which is integral to the attainment of positive patient outcomes and satisfaction in a cost-effective manner. The complex needs of terminally ill children and their families require the expertise and resourcefulness provided by an advanced practitioner nurse. In this respect, the pediatric nurse practitioner performs a unique function as they identify, appraise, and manage the conditions of ill children in the context of a multidisciplinary healthcare team (McAtee & Silver, 1974). This role will continue to grow and evolve as new demands are placed on nurses due to changing trends in patients, illnesses, and healthcare reform.