Critical Reflection in the Critical Care Unit- Part 1

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Finding out I was going to be placed in the Cardiac Intensive Care Unit (ICU) at the Hospital for Sick Children (SickKids) originally brought upon mixed emotions. It was daunting to think that after having spent a significant amount of time in adult care I would once again be going back to pediatrics, where at times it often feels overwhelming caring for the tiniest and often most vulnerable of humans. However, I was excited for the opportunity to be able to consolidate at one of the top pediatric hospitals in the country and can further explore my passions of going into pediatric nursing as well as working in a critical care setting. These feelings of being overwhelmed are consistent with the literature with new graduate nurses often reporting feeling overwhelmed with the role of the registered nurse and often unaware and feeling unprepared for the clinical expectations and skills needed to care for critically ill patients (Lewis-Pierre, Amankwaa, Kovacich, & Hollis, 2014, pg. 47).  In comparison to my term last semester in a general critical care unit where I was learning basic cardiac rhythms, it was daunting to think of having to enter a cardiac unit where this would become the norm and would be an expected skill. 

I am 6 shifts into my consolidation at SickKids and only now am I starting to feel a bit more comfortable with the role and expectations being placed upon me. It has been an amazing experience getting to work and learn alongside the nurses on my unit. Each, who place an immense amount of detail, time, and professionalism into the care of these tiny humans. On the cardiac side, the predominant patients are infants and young children as most serious cardiac congenital defects tend to be addressed earlier on in life (Mayo Clinic, 2018).   This is largely since these defects become evident soon after the birth of the child (Mayo Clinic, 2018). Many of my patients exhibit signs and symptoms which include increased respiratory rates, shortness of breath and often pale blue or grey skin colour (Mayo Clinic, 2018).

To walk through a clinical experience that has most stood out for me so far, this term I will use John’s Model of Structured Reflection. As a student preparing to enter independent professional practice I have slowly spent my first few initial shifts working on small tasks and building confidence in my ability to perform accurate head-to-toe assessments. It was during one of these opportunities I heard on the overhead system that there was a code blue in one of the patients’ rooms down the hall and I began to peer down the hall to see where all the staff were running to. It was then that my preceptor looked over and asked if I wanted to go watch the code and become familiar with the process.

I was reluctant to go at first, but realized the invaluable learning experience I could gain from this opportunity in being able to observe and in the case my assistance would be needed in the future I would have some confidence in knowing what role I could participate in during a code. Upon entering the room, I quickly found a corner to stand in that was out of the way to stand in and observe what was going on. To put it lightly, it was a chaotic environment standing in a room of 15-20 people all knowing what their roles were in either recording everything, participating in compressions, residents and fellows focusing on interpreting the cardiac rhythms, someone tasked with calling the family, another with preparing the medications and of course the team lead clearly articulating instructions to those around her. 

Although I had observed and participated in several code blues during my time in critical care last semester, there was something quite a bit more emotionally wrenching watching them perform compressions on a child and feeling the tension in the room when interventions weren’t performing as expected. Watching the events unfold I began to feel anxious feeling uncertain about the outcome, what role I would be expected to take if it had been my patient that coded as a professional, and a sense stress at the thought of being put in a high stress situation in which I feel like I have little preparation for. When reviewing the literature to see if my feelings were founded, it was evident that my feelings were consistent amongst nursing students who had witnessed and taken part in sudden cardiac resuscitations (McDonough, Callan, Egizio, Kenney, Gray, Mundry & Re, 2013). It was somewhat comforting to know that I was not alone in my feelings and that through time and experience I would be able to participate to the fullest of my abilities. 

As a soon to be new graduate nurse, it was an eye-opening and rewarding experience to witness the team dynamics that had been at play particularly at a large urban hospital centre. One of the other observations I was glad to have witnessed was that of the team encouraging the family to come to the bedside after the child had been somewhat stabilized and was preparing to be rushed for emergency surgery. It was encouraging to know that one aspect of the code wad ensuring the family had access to seeing what was going on and giving them the opportunity to watch should they choose to in a sense to help them see what the team undergoes in putting everything on the table to save the patient. In the literature, it is well supported that family should be encouraged to be present during a resuscitation. Organizations including the American Academy of Pediatrics, American Association of Critical Care nurses and The American Heart Association all support the use of this practice, permitted that written policy supports this and the availability of multiprofessional support for the family (Kirkland, 2007). In one Canadian study, evidence suggested that patient outcomes were not affected by the offering of family presences and that the psychological outcomes were noted to be either neutral or improved amongst family members (Oczkowski, Mazzeti, Cupido, & Fox- Robichaud, 2015). It was noted that family presence during resuscitation should be an important component to promoting both patient and family-centred care (Oczkowski, Mazzeti, Cupido, & Fox- Robichaud, 2015).

Having witnessed my first pediatric code blue, I have learned the importance of both positive team dynamics and the benefits of keeping up-to-date with training. One of my goals upon graduation of the nursing program is to undergo my PALS and PEARS training into order to ensure I am prepared both personally and professionally to help in these situations. It also emphasizes the point of how important family-centred care is when working in pediatrics because of the vulnerability each child possesses. I am therefore looking forward to applying my observations and putting them into practice as I grow more confident in my role as a new graduate and hope that in the future I will not feeling as overwhelmed in my abilities should a similar situation arise in the care of my patients. 

Works Cited

Kirkland, L. (2007). Lasting benefit…or haunting memory?. The Hospitalist, 5. Retrieved February 6, 2020, from https://www.the      hospitalist.org/hospitalist/article/123270/lasting-benefit-or-haunting-memory

Lewis- Pierra, L.T., Amankwaa, L., Kovacich, J., & Hollis, L. (2014). Workplace readiness of new  ICU nurses: a grounded theory study. Global Journal of Human- Social Science, 14(2).  Retrieved from https://globaljournals.org/GJHSS_Volume14/7-Workplace-Readiness-ofNew-ICU-Nurses.pdf

Mayo Clinic. (2018). Congenital heart defects in children. Retrieved February 6, 2020, from https://www.mayoclinic.org/diseases-conditions/congenital-heart-defectschildren/symptoms-causes/syc-20350074

McDonough, A., Callan, K., Egizio, K., Gray, G. Mundry, G., & Re, G. (2012). Student perceptions of sudden cardiac arrest: a qualitative study. British Journal of Nursing, 21(9). DOI: 10.12968/bjon.2012.21.9.523

Oczkowski, S. J., Mazzetti, I., Cupido, C., Fox-Robichaud, A. E., & Canadian Critical Care Society   (2015). Family presence during resuscitation: A Canadian Critical Care Society position paper. Canadian respiratory journal22(4), 201–205. doi:10.1155/2015/532721