Pediatric

Emergencies

The Essence of Pediatric Critical

Care Nursing
The Essence of Pediatric Critical Care Nursing

Outline

Introduction.

Evolution of the pediatric critical care nursing

 First Units
 Patient Population
 Levels of PICU Care
 Literature
 Professional Organizations
 Certification in Pediatric Critical Care Nursing

The Synergy Model

 Patient Characteristics of Concern to Nurses

 Nurse Competencies Important to the Patient
 Optimal Patient Outcomes

Current Environment
How to maintain critical care nurses in the PICU?
References

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The Essence of Pediatric Critical Care Nursing

Introduction

Pediatric critical care nursing (PCCN) is a major component of excellent pediatric

critical care. The provision of this specialized nursing entails significant training and
administrative support while, continually drawing on ongoing PCCN clinical innovations
and research to adapt nursing care to new understandings of the needs of critically ill
children and their families. The strength of a PCCU’s service is inescapably tied to the
quality and rigor of care that the nursing team can provide, in collaboration with the
entire pediatric critical care team.

The essence of pediatric nursing is to provide exquisite care for children, their
parents, and families, while creating a supportive healthcare environment. Indeed, the
goal of pediatric nursing is to provide quality healthcare for children and their families
through family-centered care. Creating partnerships with parents enhances care by
building supportive relationships between parents and pediatric nurses to create a
nurturing environment in which children receive quality healthcare that is grounded in
research evidence.

Pediatric nursing practice is dynamic and multifaceted including innovative,

developmentally appropriate interventions for improving care and health outcomes for
children and families, sensitive communication to explain the nuances of illness and
treatment, teaching children and families about health and illness-related care, while
reducing the stress associated with illness and healthcare to improve coping ability.

Evolution of the pediatric critical care nursing

The evolution of pediatric critical care nursing is presented based on a historical

context, the current state, and future projections.

First Units

 The first PICUs opened only after patient outcomes were realized when
specialized care was provided to critically ill neonates and adults. Actually, the

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early PICU programs were not conducted in the US. These pioneers are from
Sweden (1955, 1961), France (1963), Australia (1963), and London (1964). In
January 1967, Dr John J. Downes and his colleagues opened the first physician
directed multidisciplinary PICU. This first PICU was an outgrowth of a
hospital-wide respiratory intensive care service and consisted of 6 fully
monitored beds, with an adjacent procedure room and laboratory.
 By the end of the 1970s, medical training programs developed for pediatric
intensivists, and in 1985, the American Board of Pediatrics recognized Pediatric
Critical Care Medicine as a specialty.
 Nursing programs followed suit, and by the mid-1980s, advanced practice/acute
care nursing programs were established at Yale University, the University of
Pennsylvania, and the University of California in San Francisco.
 Today, PICUs are found in every major medical center that provides care for
critically ill pediatric patients around the world.

Patient Population

In the past, many children with chronic or critical illnesses did not survive the
disease that put them in the PICU. As medical knowledge and technology have
advanced, so have the survival rates of children with congenital and acquired

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diseases. This increase has created a population of children with chronic comorbid
conditions, not unlike adults, who are repeat recipients of critical care services. It is
estimated, for example, that more than 800,000 patients with congenital heart disease
have now survived to adulthood. This same trend has been seen in patients with sickle
cell disease, cystic fibrosis, childhood cancer, and other diseases.
The number of technology-dependent patients who survive past infancy has
also increased. For large children’s hospitals, the prevalence is quite high, estimated
at 20%, such that 1 in 5 children discharged from the hospital depends on technology
in some way. And more alarming is the fact that 1% of the technology-dependent
children needed a ventilator. Providing care for these patients requires the coordinated
effort of many team members because their needs are often complex.

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Levels of PICU Care

The original guidelines for Level I and Level II PICUs were initially presented by
the American Academy of Pediatrics and the Society of Critical Care Medicine.

Level I PICUs

Provide definitive care for a wide range of complex, progressive, rapidly

changing, medical, surgical, and traumatic disorders, often requiring a multidisciplinary
approach (Management of long-term ventilated child, non-invasive ventilation (BiPAP)
and CPAP).

Level II PICUs

Provide stabilization of critically ill children before transfer to another center or,
to avoid long-distance transfers. Provide care for disorders of less complexity or lower
acuity (deliver intravenous bronchodilators, or continuous nebulizer for severe asthma,
post-operative child with mild cardiovascular instability requiring fluid resuscitation,
chest physiotherapy for child with respiratory diseases, delivery of intravenous
anticonvulsants to stop seizures).

Literature

The rapid evolution of pediatric critical care nursing required nurses to be self-
motivated learners accountable for their own education. Pediatric critical care nurses
would occasionally find an additional chapter on pediatrics or an appendix on normal
pediatric vital signs placed at the end of a critical care nursing text.

In 1981, the first pediatric critical care nursing texts were published: Pediatric
Critical Care Nursing, edited by Katherine W. Vestal, and Critical Care Nursing of
Children and Adolescents, edited by Annalee R. Oakes and sponsored by the American
Association of Critical-Care Nurses (AACN). These were followed by Janis Bloedel

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Smith's Pediatric Critical Care and then Mary Fran Hazinski's AACN-endorsed first
edition of Nursing Care of the Critically Ill Child; Journal articles about pediatric critical
care nursing are sporadically found in both pediatric and critical care journals.

As we enter a new millennium, pediatric critical care nurses have many options.
In addition to a selection of nursing and medical pediatric critical care textbooks, the
Society of Critical Care Medicine and the World Federation of Pediatric Intensive and
Critical Care Societies released its inaugural journal Pediatric Critical Care Medicine at
the Third World Congress in Pediatric Critical Care. In addition to print media, pediatric
clinicians now have the World Wide Web. PCC Meds (http://PedsCCM.wustl.edu/)
provides a multidisciplinary educational and practical resource for the subspecialty. The
web site contains original peer-reviewed content and is linked to numerous associated
sites on the Internet.

Professional Organizations

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The Essence of Pediatric Critical Care Nursing

1.American Association of Cardiovascular Nurses (AACN)

First organized in 1969 as the, has a long history of supporting critical care
nursing across the lifespan. The mission of AACN is to provide and inspire leadership
to establish work and care environments that are respectful, healing, and humane.
AACN is committed to providing the highest quality resources to maximize nurses'
contribution to caring and improving the healthcare of critically ill patients and their
families. AACN's vision is to create a healthcare system driven by the needs of
patients and families whereby critical care nurses make their optimal contribution.
2. Special Interest Groups (SIGs)

In 1982 the AACN introduced Special Interest Groups (SIGs) to respond to

members expressed needs for specialized information, networking, and education. The
pediatric SIG, later known as the Neonatal and Pediatric Special Interest Group
(NAPSIG).
3. Neonatal and Pediatric Special Interest Group (NAP SIG)

Provided the first opportunities for pediatric critical care nurses to collectively
gather and share their expertise. Priorities for the NAPSIG included the provision of
high-level programming to meet the specific educational needs of its members. Other
priorities of the NAPSIG included developing a resource file of consultants,
audiovisual programs, policies and procedures, care plans, and teaching programs and
support of separate critical care certification examinations for neonatal and pediatric
critical care nurses. In 1989 AACN restructured all SIGs into a national network of
Special Interest Consultants (SICs).
4. Special Interest Consultants (SICs)

Acknowledging the unique and separate needs of neonatal and pediatric nurses,
distinct neonatal and pediatric SIC positions were established. Pediatric SICs specifically
focused on issues related to pediatric critical care nursing and were readily available to
AACN as regional experts on issues related to pediatric critical care nursing practice. The
pediatric SICs have now been phased out and replaced the pediatric Board Advisory
Team (BAT).

5. Board Advisory Team (BAT).

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Communicates electronically using e-mail.

6.Society of Pediatric Nurses (SPN)

Established in 1990, the mission of the SPN is to promote the optimal health of
children and excellence in nursing care of children and their families

7.Critical Care Medicine (SCCM)

Established in 1970, the mission SCCM of is to secure the highest quality care for
all critically ill patients by promoting the superiority of a multidisciplinary, ICU-based,
intensivists-directed team for delivery of the highest quality, cost-efficient critical care.

Certification in Pediatric Critical Care Nursing

Bachelor of Science in Nursing education and Critical Care Registered Nurse

certification significantly impact pediatric patient outcomes. Recognition of nursing and
organizational characteristics that are associated with improved pediatric patient
outcomes is important to patients, their families, and society. Clinical leaders must
commit to facilitating pathways for hiring candidates with Bachelor of Science in
Nursing as a minimum to practice in PICUs and supporting a culture of professional
certification.

In 1975 the AACN Certification Corporation was established to formally

recognize the professional competence of critical care nurses. The mission of the AACN
Certification Corporation is to certify and promote critical care nursing practice that
optimally contributes to desired patient outcomes. The program establishes the body of
knowledge necessary for CCRN certification, tests the common body of knowledge
needed to function effectively within the critical care setting, recognizes professional
competence by granting CCRN status to successful certification candidates, and assists
and promotes the continual professional development of critical care nurses.

Because critical care nursing practice is constantly changing, a Role Delineation

Study (ROS) is conducted every 3 to 5 years to define the dimensions of current critical

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care nursing practice and to identify the actual tasks required of a competent critical care
nurse. The tasks serve as a framework for the CCRN examination blueprint. Examination
questions are linked to the study data and evaluate the knowledge and skills required of a
nurse to perform the tasks at a competent level of critical care nursing practice.

Before 1992 content and construct validity of the CCRN examination was
established for critical care nurses who primarily cared for adult patients. Pediatric
critical care nurses who sat for the CCRN examination were tested on content that did not
reflect their practice. For example, the cardiovascular system, which reflected 19% of the
CCRN examination, contained questions on myocardial infarctions and
angina/atherosclerosis, a rare phenomenon in pediatric critical care.

In 1989 AACN Certification Corporation began new RDS. The purpose of the
study was to refine the existing adult CCRN examination and define the tasks,
knowledge, and skills fundamental to neonatal and pediatric critical care nursing. Major
differences among neonatal, pediatric, and adult critical care nursing practice were
identified in the types of patient care problems for which direct bedside care is provided
and in the amount of time spent caring for the patients with specific problems. The
results, for the first time, described the practice of pediatric critical care nursing and
justified the need for separate pediatric, neonatal, and adult CCRN examinations.

The 1989-1990 RDS described the diverse practice of pediatric critical care
nursing and communicated it in terms that could be equated with neonatal and adult
critical care nursing practice. The first CCRN examination, specific for pediatric critical
care nursing, was administered in July 1992. Almost 75% of the first 848 pediatric
critical care nurses who sat for the examination passed it.

In 1997 the unique competencies of pediatric, neonatal, and adult critical care
nurses were rearticulated using the Synergy Model as a conceptual framework.

 To date, over 1200 pediatric critical care nurses hold CCRN Pediatric certification.

 In 1999 AACN also initiated a certification program for clinical nurse specialists in
pediatric critical care (CCNS Pediatric). The CCNS program validates an advanced
practice nurse's qualifications and knowledge for practice as a clinical nurse

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specialist. The examination also uses the Synergy Model as a conceptual

framework and consists of questions designed to reflect general knowledge needed
in the CNS role and questions covering age-specific content.

 To date, 14 pediatric clinical nurse specialists hold CCNS-Pediatric certification. It

is anticipated that a Pediatric Acute Care Nurse Practitioner certification program
will soon be initiated.

The Synergy Model: Describing What Nurses Do

The AACN Synergy Model for Patient Care is a conceptual framework that aligns
patient needs with nurse competencies. Originally developed in 1996 as a new framework
for AACN’s certification programs, the Synergy Model shifted the assessment of nursing
skills from the prevalent body systems/medical model — which didn’t consistently match
actual practice — to a “nurse competencies” framework.

The central idea of the model is that a patient’s needs drive the nurse
competencies required for patient care. When nurse competencies stem from patient
needs, and the characteristics of the nurse and patient match, synergy occurs. This
synergy enables optimal outcomes. The core concept of the model is that the needs or
characteristics of patients and families influence and drive the characteristics or
competencies of nurses. Synergy results when the needs and characteristics of a patient,
clinical unit, or system are matched with a nurse's competencies. The synergy model is an
excellent framework to organize the work of patient care throughout the health care
system. The model identifies eight patient characteristics and eight nurse competencies.

Patient Characteristics of Concern to Nurses

Each patient and family, clinical unit and system is unique, with a varying
capacity for health and vulnerability to illness. Each one brings a set of unique
characteristics to the care situation. These characteristics span the health-illness
continuum.

1. Resiliency: is the patient's capacity to return to a restorative level of functioning

using compensatory and coping mechanisms.

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2. Vulnerability: is the susceptibility to actual or potential stressors that may

adversely affect patient outcomes.
3. Stability: refers to the person's ability to maintain steady-state equilibrium.
4. Complexity: is the intricate entanglement of two or more systems (e.g., body,
family therapies).
5. Resource availability: refers to resources (e.g., technical, fiscal, personal,
psychological, and social) the patient/family/community bring to the situation.
6. Participation in care is the extent to which patient/family engages in aspects of
care.
7. Participation in decision making is the Extent to which patient/family engages in
decision making.
8. Predictability: is characteristics that allows one to expect a certain course of
events or course of illness.
Nurse Competencies Important to the Patient

Nursing care reflects an integration of knowledge, skills, experience and attitudes

needed to meet the needs of patients and families. Thus, continuums of nurse
characteristics are derived from patient needs.

1. Clinical Judgement Clinical reasoning, which includes clinical decision making,

critical thinking, and a global grasp of the situation, coupled with nursing skills
acquired through a process of integrating formal and informal experiential
knowledge and evidence-based guidelines.
2. Advocacy and Moral Agency is defined as working on another's behalf and
representing the concerns of the patient, family, or community. The nurse serves
as a moral agent when assuming a leadership role in identifying and helping to
resolve ethical and clinical concerns within the clinical setting.
3. Caring Practices is defined as nursing activities that create a compassionate,
supportive, and therapeutic environment for patients and staff, with the aim of
promoting comfort and healing and preventing unnecessary suffering. Includes,
but is not limited to, vigilance, engagement, and responsiveness of caregivers,
including family and healthcare personnel.

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4. Collaboration is defined as working with others (e.g., patients, families,

healthcare providers) in a way that promotes/encourages each person's
contributions toward achieving optimal/realistic patient/family goals. Involves
intra-and inter-disciplinary work with colleagues and community.
5. Systems Thinking refer to body of knowledge and tools that allow the nurse to
manage whatever environmental and system resources exist for the patient/family
and staff, within or across healthcare and non-healthcare systems.
6. Response to Diversity is the sensitivity to recognize, appreciate and incorporate
differences into the provision of care. Differences may include, but are not limited
to, cultural differences, spiritual beliefs, gender, race, ethnicity, lifestyle,
socioeconomic status, age, and values.
7. Facilitation of Learning is the ability to facilitate learning for patients/families,
nursing staff, other members of the healthcare team, and community. Includes
both formal and informal facilitation of learning.
8. Clinical Inquiry (Innovator/Evaluator) is the ongoing process of questioning and
evaluating practice and providing informed practice. Creating practice changes
through research utilization and experiential learning.
All eight competencies are essential for contemporary nursing practice, but each
assumes importance depending on a patient's characteristics. Synergy results when the
needs and characteristics of a patient, clinical unit or system are matched with a nurse's
competencies.

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Optimal Patient Outcomes

According to the Synergy Model, when patient characteristics and nurse
competencies match and synergize, optimal patient outcomes result. Many outcome
measures have been proposed including physiologic status, psychologic out-comes,
functional measures, behavior, knowledge, symptom control, quality of life, home
functioning, family strain, goal attainment, utilization of services, safety, problem
resolution, and patient satisfaction.

Three levels of outcomes are delineated:

1. Patient level outcomes.

2. Patient-nurse level outcomes.
3. Patient-system level outcomes.

1. Patient level outcomes

 From the patient's or family's perspective, illness is associated with perceived

vulnerability and powerlessness, which stimulates the need for both
competence and caring that could inspire immediate and unqualified trust.

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 In part, trust results from the nurse knowing the patient and patient knowing
the nurse. Trust is a product of the nurse's clinical competency and moral
agency.

 Patients and families will be vigilant if concerned about caregiver competence

or agency.

 Fidelity to patient concerns, family empowerment, and coaching honors the

outcomes of moral agency.

 Caregiver trust is a prerequisite for the dispensing and the receiving of

information.

 Patients and families have grown in their knowledge about health and its
promotion and have gradually assumed a greater responsibility for their own
health.

 From the patient's perspective, care that comforts them, especially when they
are acutely ill, is one of the most basic services that caregivers can provide.

 Caring practices create a compassionate and therapeutic environment with the

aim of promoting comfort and preventing unnecessary suffering.

 The patient's experience of comfort is a quality of- care outcome. Patient and
family satisfaction and ratings are subjective measures of individual health or
quality of health services. Although patient and family satisfaction measures
query individuals about their expectations and the extent to which they were
attained, ratings include individual assessment of fact, for example, level of
overall health or time one waited for services.

 Patient satisfaction measures involving nursing typically include technical-

professional factors, trusting relationships, and education experiences.

2. Patient-nurse level outcomes

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 Patient-nurse level outcomes include physiologic changes, the presence or

absence of complications, and the extent to which care, or treatment
objectives are attained.

 Nurses through their vigilance and clinical judgment create healing

environments that provide safe passage for vulnerable individuals. Safe
passage mandates preventive care, for example, the prevention of iatrogenic
injury, infection, and hazards of immobility (e.g., pressure ulcers).

 Nurses coordinate the day-to-day efforts of the entire multidisciplinary team.

The nurse's role as the integrator of numerous services is critical for optimal
patient outcomes and abbreviated lengths of stay.

3. Patient-system level outcomes.

 To economically survive, healthcare systems must tighten resources that

maintain quality that is collaboratively defined by both users and providers in
the system. The goal is high-quality care at moderate cost for the greatest
number of people.

 Important patient-system outcome data include recidivism and costs/resource

use. Recidivism, that is, re hospitalizations and readmission, is rework that
adds to the personal and financial burden of providing care.

 In addition to patient and system factors, nurses can decrease the patient's
length of stay through coordination of care, prevention of complications,
timely discharge planning, and appropriate referral to community resources.

 Reducing length of stay and tracking re hospitalizations and acute care visits
ensure that cost shifting is not occurring.

PICU Environment

1. The physical Environment

A well-designed PICU facilitates the work of the entire health care team, as
well as supports the needs of privacy, comfort, and safety for the patient and family.

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It is vital for the PICU and room design to be adaptable and expandable while
maximizing the resources of space, time, equipment, communication, and people.
Although PICUs are designed within the confines of regulatory parameters,
prioritization of space usually falls under 3 categories: patient care areas, support
services, and family needs.

Today, most PICUs have only private rooms. Patient rooms are most often
designed within 3 special concepts: patient, family, and staff. This shift is driven not
only by safety, especially infection control practices, but also by the movement
toward patient and family centered. PICUs have customized the space within the
PICU patient room and the unit overall to accommodate the patient and the family.

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2. Healthy Work Environment

A stable infrastructure is required to achieve a healthy work environment. The

AACN has developed a program that can transform the environment in the PICU to
one that supports a culture of retention. The link between healthy work
environments, patient safety, and nurse retention is indisputable. An adequate supply
of appropriately trained PICU nurses must be ensured, and those nurses who already
work in the PICUs should also be retained.
The AACN Standards for Establishing, and Sustaining Healthy Work
Environments provide a solid infrastructure for this recommendation. The 6 standards
for establishing and sustaining healthy work environments represent evidence-based
and relationship-centered principles of professional performance. These standards
include skilled communication, true collaboration, effective decision making,
appropriate staffing, meaningful recognition, and authentic leadership. PICU
leadership teams and nurses should use these standards as a foundation for thoughtful
reflection and engaged dialogue about the current realities of the PICU work
environment.
How to maintain critical care nurses in the PICU

1. Nurses are attracted to, are successful in, and stay in environments where they
feel compensated, competent, and cared for.
2. It is important for nursing leadership to implement the interventions and transition
to a healthy work environment that benefits the nurses and, ultimately, the
patients and families.
3. There was also an inverse relationship between years of experience and intent to
leave. Effective leadership in the PICU is important to nurse in PICU and
significantly influences their decisions about staying in their current job.
4. Newly hired PICU nurses will typically have little or no prior PCCN training.
Such training is usually acquired on the job. Employers have a responsibility for
developing closely supervised education programs that will expediently enable

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the new PICU nurse to acquire baseline knowledge and skills to manage less
critical patients.
5. Although the direct hiring of the latter candidates is a hotly contested point, they
can successfully adapt to a PICU setting, given adequate educational, mentoring,
and administrative support. Considering these commonly diverse backgrounds,
every PICU needs to
 Maintain an orientation program for new staff that can be readily tailored
to the variable needs of new staff.
 An orientation program should consist of 1 to 2 weeks of introductory
reviews and a 3- to 4-week clinical preceptorship directly supervised by a
senior PICU nurse (4 to 8 weeks for a new graduate).
 The introductory reviews should include (1) assigned readings, drawing
selected chapters from seminal PICU textbooks; (2) lectures that review
basic critical care theory (e.g., evaluation of vital functions, hemodynamic
evaluation, blood gas interpretation, neurologic evaluation, critical care
pharmacology).
 Demonstration and practice of common procedures (e.g., airway
suctioning, manual ventilation, blood procurement from arterial catheter).
 Discussion of the role of the PICU Nurses.
 Overview of pertinent psychosocial issues.
 Introduction to key members of the PICU team.
 Review of key PICU policies and procedures and other textual resources
available to nurses.

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References

American Association of Critical-Care Nurses, & American Association of

Critical-Care Nurses. (2018). The AACN synergy model for patient care.
Cain, C. (2020). Applying the Synergy Model to Achieve Safe Staffing. American
Journal of Critical Care, 29(1), 70-70.
Carnevale F.A., & Dagenais M. (2014). Nursing Care in the Pediatric Intensive
Care Unit. In: Wheeler D., Wong H., Shanley T. (eds) Pediatric Critical Care
Medicine. Springer, London.
Carnevale, F. A. (2009). Nursing care in the pediatric intensive care unit. In Science
and Practice of Pediatric Critical Care Medicine (pp. 1-4). Springer, London.

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The Essence of Pediatric Critical Care Nursing

Christian BJ. (2013).The essence of pediatric nursing--translating evidence to

improve pediatric nursing care for children, their parents and families. Journal
of Pediatric Nursing. Apr; 28 (2):193-195.
Curley, M. A., & Moloney-Harmon, P. A. (2001). Critical care nursing of infants
and children. Miscellaneous Papers, 4.
Foglia, D. C., & Milonovich, L. M. (2011). The evolution of pediatric critical care
nursing: past, present, and future. Critical Care Nursing Clinics, 23(2), 239-
253.
Hickey, P. A., Gauvreau, K., Porter, C., & Connor, J. A. (2018). The impact of
critical care nursing certification on pediatric patient outcomes. Pediatric
Critical Care Medicine| Society of Critical Care Medicine, 19(8), 718-724.
Sener, D. K. (2018). Being a Nurse in Pediatric Intensive Care Unit: A Qualitative
Study. In 5th International Conference Quality and Its Perspectives.
University of Pardubice.
Slusher, T. M., Kiragu, A. W., Day, L. T., Bjorklund, A. R., Shirk, A.,
Johannsen, C., & Hagen, S. A. (2018). Pediatric critical care in resource-
limited settings—overview and lessons learned. Frontiers in pediatrics, 6, 49.
Ullman, A., Long, D., Horn, D., Woosley, J., & Coulthard, M. G. (2013). The
KIDS SAFE checklist for pediatric intensive care units. American Journal of
Critical Care, 22(1), 61-69.

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