Annex A > Chapter 15 - Post-operative Care > The management of post-operative care > Skill mix
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Skill mix
74 Mr Andrew Darbyshire [90] said that the differences between nursing adult and paediatric patients are that, although there are similarities in the physiological care, the anatomy of children is not as straightforward. Also, there is the additional need to understand and deal with the interactions between the parents and the child, so as to deliver `family-centred care': [91]
`But in terms of delivering that physiological care, I think experienced adult nurses, provided they have made the adjustments into paediatrics and the anatomical and physiological problems of the child, could deliver that.' [92]
75 Mr Leslie Hamilton [93] was asked whether in his opinion a nurse might not pick up the more subtle signs from a child that there may be a problem or deterioration in condition, if that nurse is not paediatrically trained. [94] He replied:
`Personally, I think the key is that they are used to dealing with patients who have the abnormal physiology that we see after coronary pulmonary bypass, or after repair, closed surgery. I think that is very specific to cardiac patients. As Andrew [Darbyshire] said, if you are an adult nurse, as long as you are in that paediatric environment, your skill will be in picking up those subtle signs.
`I think, again, the background of the person is less important than how they are integrated into the unit. To me, paediatric intensive care is very much a team thing and everyone has their own input. The role of the intensivist is to bring all that together. The nurses are the key at the bedside; they are the ones who pick up, usually first of all, that something is not quite right. It may be a surgical problem, it may be something else, but I think it is very much an integrated thing.' [95]
76 Dr Barry Keeton [96] gave his view of the paediatric training and experience required of nurses as follows:
`On the nursing side, clearly it is very desirable that the nurses have had paediatric training, but we must not ignore the very experienced nurses who became very adept at looking after both adults and children within the intensive care environment. Although they may not have had paper qualifications, they have looked after children, and families, for many years and done it very well. Clearly things have changed in more recent years, where they now go off on courses and get their paediatric qualifications, but our senior nursing staff were very expert with the children.' [97]
77 Dr Duncan Macrae [98] told the Inquiry:
`I think on the question of first of all nursing skills, some of the best paediatric cardiac intensive care nurses I have come across have actually been adult nurses who have come to paediatric intensive care nursing, adult nurses with intensive care training, who have been absorbed and trained within the unit by the paediatrically trained people there who really have been excellent nurses.
`Having said that, the overall feel of the paediatric nursing needs to come from nurses with paediatric training, so it is possible for units to function with a proportion of intensive care trained nurses who are not specifically paediatric nurses but there very definitely needs to be a balance, or indeed a majority, of paediatrically skilled people to set the overall tone and policy of the unit.' [99]
78 Mr Darbyshire took up the point:
`I take on board the point that Duncan [Macrae] made, that an adult ICU nurse may well be able to offer very good physiological care for children within the ICU, and maybe from a medical perspective that is how you would judge a good nurse; what information you get to enable you to do your job. I think from a paediatric nursing perspective there is a little bit more to it and I think paediatricising a unit is something that paediatric nurses are qualified and trained to do.
`I think the support of the family, again, is something specific to paediatrics, and the involvement and the relationship between the patient and their parents is very important and is an important facet of, if you like, paediatric training.
`I think there is a bottom line underneath all the statements I have made that is what is really important is that you have a skilled, experienced paediatric intensive care nurse, and they can come from an adult background. They can come from a paediatric background. It is the experience that they have within the PICU that I think is of fundamental importance.
`There are all sorts of arguments about what sort of ratio do you need of paediatric trained staff to non-paediatric trained staff; I do not know the answers to those questions. I know recent guidelines have been published that state that a very large percentage should be paediatrically trained.
`I think the other issue surrounding paediatric nurses in PICU in a mixed unit is how you actually allocate those staff to the patients. Do you have an individual nurse who one day is allocated to adult patients and the next day to paediatrics? No matter how good an adult nurse is, on the first day she looks after a paediatric patient she will not be as good a paediatric nurse as she was an adult nurse and it is how you actually structurally organise that situation in a mixed unit that I think would be of great importance in the delivering of skilled nursing intervention really.' [100]
`Essentially I would agree with both the previous speakers. As a surgeon, I want a nurse at the bedside who is going to pick up the subtle changes that we see after cardiac surgery, so I want an intensive care nurse who is experienced in, and knows about, cardiopulmonary bypass and post-operative cardiac patients. I think it is very important to have the paediatric environment. Whether it is physically separate has to be clearly identified, and I think the senior nurses in the unit need to be paediatrically trained to bring that paediatric component and the care of the whole family into it, so I think those need to be wedded together.' [101]
`I would agree with the previous comments that have been made. I obviously have personal experience of evolving from working within a specific cardiothoracic intensive care unit which housed both adults and children to now the much better situation that we have of having a separate paediatric ITU.
`I think the paediatric bits of nursing - the paediatric nurses do not have a monopoly of it. There were some very good adult-trained intensive care nurses who were extremely good at looking after children and within our unit we had a group of nurses within the intensive care unit staff who liked looking after children and who did it quite well, and in fact they are the nurses now who have gone off and got their paediatric qualifications and now some of them are running the paediatric intensive care unit or the cardiac bit of the new paediatric intensive care unit which we have.' [102]
81 Julia Thomas explained how an even skill mix was ensured on the BRI ICU between 1984 and 1995:
`Each shift in the ITU and theatre is run by a G grade or F grade nurse, both day and night. The senior nurse delegates work to her team of nurses, assessing their experience in relation to each patient's needs. All students are supernumerary. Rotas are worked out every four weeks, thus allowing an even skill mix over [a]
24-hour period.' [103]
82 Julia Thomas stated that the experience and skill mix of the nurses on the ICU at the BRI varied over the period 1984-1995, but all the senior nurses from F grade to G grade had taken a recognised intensive care course and had at least three years' ICU experience. [104] The E grade staff nurses had at least one year's ICU experience and many had done an ENB intensive care or cardiac course. The D grade staff nurses were sometimes newly qualified, but had some ICU experience and an interest in gaining more. [105]
83 Although the skill mix varied during this period, the majority of the staff were graded between G and E grades, with ICU experience, and over 50% of staff had attended recognised ICU courses. As for paediatric qualifications:
`Between two and four nurses on the ITU were RSCN trained. At any one time other senior nurses had undertaken shortened paediatric courses, including SEN [State Enrolled Nurse] children trained nurses. All nurses caring for children had undertaken the Unit's in-house training in paediatric ITU nursing. This was a three-week training, undertaken on the Unit, following strict protocols laid down by a senior paediatric nurse.' [106]
`Qualified nurses undergoing post-graduate courses worked on the Unit. These nurses were never allowed to look after paediatric patients, unless they were upgrading their paediatric nursing skills, in which case they would be working alongside, and supervised at all times by, a cardiac/ITU experienced nurse. These nurses wore student uniforms so that they were readily identifiable by medical and nursing staff as supernumeraries.'
`We also had general student nurses on the Ward. They were never left alone with any of the patients and worked as supernumeraries at all times with named mentors. The Unit had a core of nurses qualified to look after children. They were very well qualified. ... we would always try to recruit a children's trained nurse but there was a huge shortage, so the next best thing was to recruit a nurse with general or cardiac ITU experience and then training the nurse to look after children on the ITU. On the whole, the children were looked after by an ITU nurse with an ENB 100 qualification.' [107]
84 Julia Thomas explained that the cardiac ICU course (ENB 249) was only introduced nationally in 1992. It is now offered at the BRI. [108]
85 Catherine Warren took the general ICU course (ENB 100) in 1990 and trained as an RSCN in 1991-1992. As an F grade senior paediatric nurse, she was in charge of writing the protocols for care standards following her qualification as RSCN, and also carried out audit work. She also attended outpatients' clinics so parents could talk to her after they had seen the consultant. [109]
86 After April 1992, when Ms Warren returned to the Unit with the RSCN qualification, she worked only with children, either in the Nursery or on the CICU, [110] whereas before this she had worked on the CICU caring for both children and adults. This change came about because she was the only nurse who had both experience of cardiac care and a paediatric nursing qualification. [111] Depending on the severity of the child's condition and the experience of the other nurses, she stated that she cared for most of the children immediately post-operative. [112]
87 Catherine Warren was the only nurse who rotated between Wards 5A and 5B. [113] She worked on Ward 5B on the two days of the week when children were being operated on, caring for the children when they returned from theatre. Otherwise she worked in the nursery. Since Ms Warren had also completed the cardiac course, her knowledge was used extensively throughout the unit to advise all staff on how to care for the children. [114]
88 From 1992 there was a D grade nurse who was a newly qualified RSCN working solely in the nursery. The other nurses in the nursery were D and E grade. [115] A play leader [116] was also employed from the mid-1990s.
89 Fiona Thomas stated that since she became Nurse Manager, in 1992, she carried out skill mix reviews with the General Manager, every year or every two years, depending on workload and when expansion plans were scheduled to take place. [117] She explained that skill mixes had always been easily addressed in intensive care because of the existence of national guidelines on staffing levels. She stated that she had always found the General Managers very accommodating when discussing skill mix, and, although they may have questioned why extra members of the team were needed, she never encountered any particular problem in justifying the need to recruit. [118]
90 She went on to say that on a day-to-day basis, skill mixes were readily determined by the knowledge of the case mix of patients expected. Staffing levels and mixes were always appropriate to the case mix. [119]
91 She agreed that the overall mix and expertise of the ICU staff differed from that set out in published guidelines, because the guidelines stipulated that only paediatric nurses should at all times care for paediatric patients, which the ICU at the BRI could not meet. She put the lack of specialist paediatric nurses down to the difficulty in recruiting such nurses to a mixed adult and paediatric unit. [120]
92 When asked how frequently children in intensive care at the BRI were cared for by nurses of whom none was paediatrically qualified, Sister Sheena Disley replied:
`It would be fairly common for there not to be an RSCN, but it would be extremely uncommon for it not to be a highly skilled nurse above E grade level who had had considerable orientation and training for it. That would just not happen.' [121]
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Footnotes
[90] Expert to the Inquiry in Post-Operative Nursing Care
[93] Consultant cardiac surgeon at the Freeman Hospital, Newcastle; Expert to the Inquiry in Paediatric Cardiac Surgical Services
[96] Consultant paediatric cardiologist, Expert to the Inquiry in Paediatric Care
[98] Director of Paediatric Intensive Care at the Royal Brompton Hospital, London; Expert to the Inquiry in Post-Operative Intensive Care
[100] T51 p.57-9 Mr Darbyshire
[103] WIT 0213 0012 Julia Thomas
[104] WIT 0213 0038 Julia Thomas
[105] WIT 0213 0039 Julia Thomas
[106] WIT 0213 0039 Julia Thomas
[107] WIT 0213 0006 Julia Thomas
[108] WIT 0213 0006 Julia Thomas
[109] WIT 0213 0007 Julia Thomas
[110] Cardiac ICU
[111] WIT 0483 0001 Ms Warren
[112] WIT 0114 0085 Fiona Thomas
[113] Ward 5B contained the ICU and the High Dependency Unit, while Ward 5A contained the Admission and Continuing Care Beds and the nursery
[114] WIT 0114 0012 Fiona Thomas
[115] WIT 0114 0012 Fiona Thomas
[116] Ms Helen Passfield
[117] WIT 0114 0010 Fiona Thomas
[118] WIT 0114 0019 Fiona Thomas
[119] WIT 0114 0071 Fiona Thomas
[120] WIT 0114 0086 Fiona Thomas