Whilst at Boston, I was delighted to be given the opportunity to shadow one of the nurses on the Medical Surgical ICU. Unfortunately due to insurance purposes etc, I wasn’t actually allowed to do anything as both me and the lovely nurse I was shadowing would have liked but it was a great chance to see how an American ICU differs from an English one and to see how family centred care is incorporated into practice.
We were allocated two HDU patients and the biggest surprise for the whole morning was that in the U.S.A, patients with complex medical conditions do not transition to adult care like in England but stay under the care of the paediatric team and one of the patients was older than myself. The unit is made up of single rooms so every patient has privacy but I’m not certain that if I was unwell I would want to be treated around young children!
Other than that I was very impressed! There are definite differences between UK and US nurses, they can do more clinical skills, such as cannulation and they have a strong ANP presence which was really good but where we have a lot more involvement with using the ventilators and with intubation, they have respiratory therapists who deal with all things ventilator and ventilation. When I told the nurse I was working with that we did not have RT’s, one of her first questions was who secured the ETTs, and was very shocked to hear that it was normally the nurses and that it was one of my favourite jobs (I like neat tapes)!
The parents are encouraged to stay at all times on the unit and each room has a dedicated space for them with a sofa bed and I also noticed lots of decorated rooms which was lovely to see. On talking to my nurse, she explained how they try and incorporate family centred care into their practice and the unit had a strong emphasis on it. The CLS was not on that day but she said that the CLS normally came and saw most the patients everyday and that they frequently have musicians play on the unit, including harpists! I was particularly interested to hear about how they facilitate parental presence during procedures (see the next blog post for more description) and was told that it has become standard practice, unless the procedure was a sterile one. I was then lucky enough to see it in practice as a new admission came in, not ventilated but very unwell and requiring several interventions. The family that came with the child did not speak any English but an interpreter was called and came within ten minutes and one of the nurse practitioners immediately came, sat them down just outside the patients room where they could still see the child and explained everything that was going on to the family and reassured them as they were clearly upset. They seemed much calmer after the conversation and at no point were asked to leave their child.
View from the beautiful simulation lab!
On asking about education for nurses, I was told that newly qualified nurses get a whole 6 months supernumerary and all others get 3 months. There is a range of educational sessions available to them and I was invited to come and observe an end of life simulation session. This session was open to any of the more junior ICU nurses and at the session I was at, there were a couple of newly qualified nurses starting on ICU, a nurse who had been working for a few years but had never experienced a death and another that had just had her first death. There were three scenarios surrounding the same family, played by actors, of a child with complex needs who’d had an out of hospital arrest: the first was the initial conversation when the family are informed the child has sustained severe brain damage as a result of the arrest and the decision is made to withdraw and how they want to proceed with the withdrawal; the second was the actual withdrawal, giving the meds, turning off the monitor and getting the parents in bed with the child; the third was saying goodbye to the parents before the child went to the mortuary. For each of these scenarios, two nurses went in with a Dr, they were videoed and we watched them do the scenario then afterwards had a discussion about how it went, how they felt and there was a group discussion where everyone talked about their own experiences, what had and had not worked for them in the past, what resources were helpful etc. At the end, there was also a trip to the mortuary for anyone who hadn’t yet been. I was really impressed by this session, it was an incredibly safe, supportive and confidential environment for nurses to practice their skills in the area that most new nurses dread and a great way to improve their confidence so that when they actually face a death they will feel more prepared and aware of the support they can access.
There is a very strong research emphasis in Boston and I met with some of the senior nurse researchers who told me about how the nurses were encouraged to keep an inquiring mind about the work they do and to look at the research and find the evidence base for the practice they undertake. They have a nursing fellowship which is a two year program allowing nurses with any role or level of experience to participate in a mentored experience and undertake research projects. Some of these projects have impacted new practice implementations and have been disseminated both internally and externally. They have had over 50 nurses enrol now and have found it to be a really positive experience. Some of the research projects have been about improving the family experience, including a project on gathering information on patients that come in very regularly for clinics or admissions, including information about the child’s general condition and also their likes, dislikes etc so that those caring for that family are aware of the details important to that family and don’t need to keep asking the same questions.
Apparently you can do this fellowship from abroad and just visit Boston a couple of times a year for the forums – I’d be lying if I said I wasn’t tempted!