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Nursing is a career that requires collaborative relationships among professionals that assist nurses to provide the best possible care for the client and family. These interprofessional relationships may involve a wide range of health care professionals of multiple members that work collaboratively together to deliver quality care. Nurses are required to work with other professionals on a daily basis on the floor whether it is with a doctor, a lab tech, a respiratory therapist, physiotherapists or even a fellow nurse. Registered Practical Nurses (RPN) and Registered Nurses (RN) work together on a daily basis and work in partnership with one another to provide the level of care that is required in order for a patient to meet their outcomes.
Pediatric palliative care is a specialized setting that requires constant teamwork or consultations and majority of the centers only allow RN`s to work on that floor, however; some centers allow for RPN`s to care for these children. Crozier and Hancock (2012) state that “it has been estimated that 13.9% of all children are living with a chronic health condition … and palliative care can be provided to these children as well” (p.2). This paper will discusses the role of the RN in pediatric palliative care in relation to family support through the three factor frame work which involves the client, the nurse and the environment.
The Three Factor Framework
The three factor frame work is used in many different settings to determine whether a RN or a RPN will be caring for a certain client. This framework consists of the client, the nurse and the environment (College of Nurses of Ontario [CNO], 2011). These three factors are implemented and have an impact on decision making related to care provider assignment for the RPN and RN. It takes into consideration the client’s needs, the needs for consultation as well as collaboration among care providers (CNO, 2011). The three factor framework document is available to “help nurses, employers and others make effective decisions about the utilization of individual nurses in the provision of safe and ethical care” (CNO, 2011, p.3). It also helps with outlining expectations for nurses that highlight similarities and differences of nursing knowledge and its impact on both personal and professional responsibility (CNO, 2011). This framework comes extremely important in specialized settings, such as the critical care unit, the emergency department, the operating room and especially pediatric care.
The client aspect of the framework focuses on the complexity of the client, the predictability and the risk for negative outcomes with the client (CNO, 2011). The client factors are combined to create a representation of a client that can be placed on a continuum that: …goes from less complex, more predictable and low risk for negative outcomes, to highly complex, unpredictable and high risk for negative outcomes …. the more complex the care requirements, the greater the need for consultation and/or the need for an RN to provide the full spectrum of care (CNO, 2011, pg. 2). In pediatric care there comes many different types of clients that a nurse may encounter and a topic that is not touched upon too often is pediatric palliative care.
This type of patient would be considered to be on the more complex side of the spectrum which would require a RN to care for this child. Ferrell, Malloy, Uman, Virani, and Wilson (2006) tell us that “no one spends more time at the bedside observing, critically thinking, consulting, and providing direct care then the pediatric nurse” (p.1). This statement reinforces that a RN is more suitable for this task since the child’s health condition is unstable and constantly fluctuating, their coping mechanisms and supports are unknown, and the fact that they require frequent monitoring and reassessments (CNO, 2011). Pediatric care is a very complex area to work and requires a RN to care for these clients due to their needs not being well defined or established and their condition can change rapidly.
Children can be unpredictable in their natural world and when it comes to their health they can be even more unpredictable. Crozier and Hancock (2012) tell us that “it is important to acknowledge that death occurs in pediatrics …” (p.1) and those nurses caring for these children need to be aware that this could be the final outcome. The CNO (2011) document on the three factor frame work emphasizes the fact that a RN is needed when the client may have unpredictable outcomes as well as unpredictable changes in their health condition. With this being said this puts the risk for negative outcomes with this child at a high risk.
Risk for negative outcomes comes with all types of nursing but it is a higher risk when talking about palliative care especially in children. Nurses are more likely to be aware of symptoms of a dying elderly client or an adult client rather than a child since this topic is not discussed that often. The CNO (2011) tells us that a RN is involved in care when the client is unpredictable, systemic or wide ranging responses, they have subtle signs and symptoms that are often difficult to detect and they are at a high risk for a negative outcome. Research studies have been done that create guidelines for nurses to follow in order to provide and meet the needs of the patient and their families when the child cannot benefit from intensive, life extending support especially when the family is dealing with a dying child (Anita & Rushton, 2002). In order for pediatric palliative care to be successful this framework is used in order to give the child the best care possible.
When we discuss pediatric palliative care we are not just talking about the patient themselves, we are talking about the entire collaborative team including RPN’s, RN’s and most importantly the family of the patient. Not only do these nurses have the child to care for they also need to be there for the family and help them through their struggles they may be having. The nurse factors of the framework include leadership, decision-making, and critical thinking skills (CNO, 2011). Leadership is a quality that all nurses require in order to succeed in their career but being a pediatric nurse requires this skill on multiple levels. Anita and Rushton (2002) tell us that there is a need for increased leadership capacity in end of life care for children and their families. Nurses need to have the leadership skills to be an advocate for their client who may not be able to speak up for themselves depending on how ill they are.
Ferrell, Malloy, Uman, Virani, and Wilson (2006) state that “pediatric nurses have a distinctive role in advocating, promoting, and providing excellent care to these children and their families” (p.4), they also emphasize the fact that education is key to the skills and confidence they need to perform this task. RN’s need to assume the role of a leader within the interprofessional team and they need to lead the team in order to develop plans of care to achieve client and family goals when overall care requirements are more complex (CNO, 2011). With the role of leadership also comes decision making in collaboration with the family and other health care members. The treatments at the end of life are something that is not easy for anyone to make let alone when it has to do with a child. Nurses have a key role in decision making when it comes to what treatment is provided, and they are there to guide the family in this process.
Anita and Rushton (2002) tell us that “the goal of palliative care is achievement of the best quality of life for patients and their family regardless of the outcome” (p.2). In order for the nurse to make decisions that will benefit the client and the family nurses need to communicate therapeutically and make the focus on the client and their family (Palliative Pain and Symptom management, 2007). The RN then needs to take the information gathered from communicating with the family and make decisions actively as well as anticipating any possibilities and making proactive decisions (CNO, 2011). Communication is a key tool when it comes to care between patients and family, different health care professionals and those that are caring for the child directly (Crozier & Hancock, 2012). With communication and decision making comes critical thinking which is a crucial aspect when caring for a dying child.
Not only does the nurse need to critically think about the child’s health and final outcomes but they also need to think about how to help the family through this process. Everyone critically thinks on a daily basis especially in the health care profession, but RPN’s and RN’s working with children need to think critically at all times. As a RN they are required to anticipate and recognize subtle changes in the child’s health, assess further, identify relevant factors, understand the significance and manage the situation and family members appropriately (CNO, 2011). As a RN working in pediatric palliative they need to be knowledgeable, be able to make decisions in consultation with the family and other health care professionals and most importantly be able to critically think while managing multiple nursing interventions in rapidly changing situations (CNO, 2011).
Pediatric palliative care is an area of nursing that can occur in multiple settings including the home of the child, a hospital setting, hospice centers and even nursing homes. In Bartell and Kissane’s article from (2005) they show that “72% of pediatrics die in the hospital (56% in patient and 16% as outpatients mostly in emergency rooms), 11% die at home, and just 0.4% in nursing homes” (p.2). The environment factors of the three factor framework include practice supports, consultation resources and the stability and predictability of the environment. The need for RN staffing is required when these factors are less stable. Pediatric palliative care is an area that is considered to be less stable and the practice supports vary. A RN is required if there are unclear or unidentified procedures, policies, medical directives, protocols, plans of care, care pathways and assessment tools (CNO, 2011). The CNO also tells us that a RN is needed if there is a low proportion of nurses familiar with the environment and if there is a low proportion of expert nurses or a high number of novice nurses.
In Cox’s article in (2004) she talks about how the expert nurse may also support the developing nurse by sharing personal experiences and strategies. Having a RN work in pediatrics can allow the practice supports to become more of a stable environment by increasing the knowledge of all nurses and family members from hands on experience. Consultation or collaboration with health care professionals is a skill that is used every day but is very important when it comes to children’s health. Nurses need to be aware of the resources that are available to them and use them to their advantage to help provide better care to the children and their families. Ahmann and Dokken (2006) tell us that nurses need to view parent’s as partners in care rather than a visitor. Not only is it important that nurses collaborate with health care professionals but they also need to be communicating and consulting with the family. Involving the family in the child’s care makes them feel more a part of the care rather than a by stander (Boyle & Roberts, 2005).
According to the CNO (2011) document a RN is needed when there are little consultation resources available to manage outcomes. With consultation comes how predictable and how stable the environment is that the child is being cared for. Death is a topic that many do not like to talk about but it is a reality of life that can cause for a high turnover rate in the health care system. Pediatric palliative care can have high turnover rates along with unpredictable events no matter how many assessments the RN performs (CNO, 2011). RN`s need to be aware of the type of environment that they are working in order to provide the appropriate care to the child. Even if the environment is at a high turnover rate the nurse still needs to be able to apply their knowledge, critically think, make decisions and care for the patient and their family. The three factor framework set out by the CNO is important when it comes to determining the role of the RN in pediatric palliative care along with the support that is given to the family.
Even though the three factor framework is needed when assigning patient assignments we need to keep in mind that with young children, a family centered model of care is a key concept (Bartell & Kissane, 2005). The more complex the client situation and the more dynamic the environment, the greater the need for the RN to provide the full range of care, continually assess changes, establish priorities and determine the need for additional resources or consults (CNO, 2011). By considering the client, the nurse and the environment factors, it can be determined whether a RPN or RN is more suited to care for a certain client. RN’s require advanced critical thinking skills along with a large depth of knowledge in order to provide appropriate care to the children as well as their families. According to the three factor framework and research that has been done a RN is more suitable than a RPN to work in pediatric palliative care.
Ahmann, E., & Dokken, D. (2006). The many roles of family members in “family-centered care” – part 1. Pediatric Nursing, 32(6), 562-565. Anita, C., & Rushton, C. H. (2002). Pediatric palliative care: The time is now!. Pediatric Nursing, 28(1), 1-9. Retrieved from http://moxy.eclibrary.ca/login?url=http://search.proquest.com/docview/199391320?accountid=12792. Bartell, A. S., & Kissane, D. W. (2005). Issues in pediatric palliative care: Understanding families . Journal of Palliative Care, 21(3), 1-16. Retrieved from http://moxy.eclibrary.ca/login?url=http://search.proquest.com/docview/214198065?accountid=12792. Boyle, L. A., & Roberts , K. E. (2005). End of life education in the pediatric intensive care unit .Critical care nurses , 25(1), 1-6. Retrieved from