RESEARCH

doi: 10.1111/nicc.12160

The impact PICU nursing expertise

has on a child’s unplanned
extubation
Matthew Norridge and Alison E While

ABSTRACT
Aim: The study aimed to examine the impact of PICU nursing expertise on the unplanned extubations of children.
Background: Unplanned extubations in PICU are used as a measure of quality in clinical governance strategies. While many factors, such
as sedation or unit activity, impact negatively on unplanned extubations, high nurse-patient ratios reduce adverse patient events and improve
patient safety. However, optimal nurse-patient ratios and the impact of the level of nursing expertise on the quality of care are unknown.
Design: Audit and analysis of existing adverse event patient and nurse workforce data.
Method: This single-centre study examined unplanned extubations at a mixed general and cardiac tertiary PICU in the UK. Routinely collected
data from nursing and adverse incident databases were examined. The dataset included over 74,477 nurse allocations between August 2006
and April 2011. Unplanned extubations were the adverse event of interest.
Results: A total of 78 unplanned extubations occurred between April 2006 and April 2011. The majority of unplanned extubations occurred
when patients were looked after by junior nurses. The seniority of the nurse in-charge and the qualifications of the patient’s nurse were not
related to unplanned extubations. However, more unplanned extubations occurred at times of higher patient occupancy.
Conclusions: Nursing expertise and nurse-patient ratios were not related to unplanned extubations in this study. Further research is needed
to explore the non-workforce factors such as the securing of endotracheal tubes, sedation levels and unit activity and their relationship with
adverse events.
Relevance to Clinical Practice: In paediatric intensive care units where nurse-patient ratios are high, further investigation is needed to
establish what impact non-workforce factors have on unplanned extubations.
Key words: Adverse events • Nursing workforce • PICU • Unplanned extubation

BACKGROUND FOR THE STUDY
A Bridge to the Future [Department of Health (DH)
1997a) made the first recommendations relating to
the qualifications and experience of nurses on pae-
diatric intensive care units (PICU) and caring for
patients of varying acuity as defined in the Framework
for the Future (DH 1997b). These recommendations
Authors: M. Norridge, BSc, MSc, RN (Child): TCH Lecturer Practitioner,
King’s College London, Florence Nightingale Faculty of Nursing and
Midwifery, London, UK and Evelina London Children’s Hospital, Guy’s &
Thomas’ NHS Foundation Trust, London, UK; A.E. While, BSc, MSc, PhD,
RN, RHV: Professor of Community Nursing, King’s College London,
Florence Nightingale Faculty of Nursing and Midwifery, London, UK
Address for correspondence: M. Norridge, King’s College London,
Florence Nightingale Faculty of Nursing and Midwifery, 57 Waterloo Road,
London SE1 8WA, UK
E-mail matthew.norridge@kcl.ac.uk
have been more recently endorsed by the Paediatric
Intensive Care Society (PICS) Standards (2010) and
Royal College of Nursing (RCN) (2013). In paediatrics,
much of the literature investigating patient safety in
PICU has focused on the factors related to unplanned
extubations, as this is seen as a marker of care quality
(Penuelas et al., 2011). While there is no current bench-
mark, unplanned extubations are monitored as a part
of clinical governance and by commissioners of PICU
services (NHS Commissioning Board 2013).
There are a number of factors which potentially
underpin unplanned extubations such as medical
staffing, unit activity, sedation levels and nursing
workforce factors. Therefore understanding the factors
influencing unplanned extubations in the PICU at the
unit level may enable quality improvement initiatives
and decrease the occurrence of this adverse event and
ensure patient safety (Rachman et al., 2009).

© 2015 British Association of Critical Care Nurses 1

 The impact PICU nursing expertise has on a child’s unplanned extubation
LITERATURE REVIEW
A literature search was performed to understand
adverse events in the intensive care setting and
their relationships with nursing workforce factors.
Studies were included from adult ICU settings as
well as PICUs as there is a dearth of current liter-
ature that specifically examines these issues in UK
PICUs. Studies were identified that considered the
impact of nursing workforce factors on many adverse
events (Tibby et al., 2004) including: patient outcomes
(Amaravadi et al., 2000), length of stay (Pronovost et al.,
1999), mortality (Tarnow-Mordi et al., 2000; Pronovost
et al., 2001), respiratory complications (Dang et al.,
2002), health care-associated infections (HCAIs)
(Hugonnet et al., 2007) and unplanned extubations
(Marcin et al., 2005; Ream et al., 2007). Unplanned extu-
bations were chosen as they are considered quality
markers in both adult and paediatric ICUs.
Six studies in the adult ICU setting examined
the relationship between nurse-patient ratios and
patient outcomes (Pronovost et al., 1999; Amaravadi
et al., 2000; Tarnow-Mordi et al., 2000; Pronovost et al.,
2001; Dang et al., 2002, Hugonnet et al., 2007). A large
American study examined the impact of nurse-patient
ratios upon post-cardiotomy patient outcomes with the
ratio of 1:2 emerging as the optimum ratio (Pronovost
et al., 1999). This study reported a significant reduction
in ICU length of stay with higher nurse-patient ratios
(p < 0.05) (Pronovost et al., 1999). Another American
study concurred with these findings (Amaravadi et al.,
2000) and found that lower nurse-patient ratios were
associated with significantly higher costs (p < 0.001)
due to a significant increase in length of stay (p < 0.001)
and more complications. These findings suggest that
investment in the nursing workforce may reduce
overall expenditure by reducing length of stay and
avoidable costs.
A small single-centre observational Scottish study
found that an increased workload resulted in a sig-
nificant increase in mortality (p < 0.05) (Tarnow-Mordi
et al., 2000). Conversely, Pronovost et al. (2001) strug-
gled to demonstrate a causal link between mortality
and nurse-patient ratios; however, they reported a
significant relationship between increased respira-
tory complications and lower nurse-patient ratios
(p < 0.001). Similarly Dang et al. (2002) reported that
a lower nurse-patient ratio resulted in increased
respiratory complications. A large Swiss study
has also reported a 30% reduction in health care
associated infections with increased staff num-
bers (Hugonnet et al., 2007). This study estimated
that 26.7% of all infections could be avoided if the
nurse-patient ratio was maintained at greater than
1:2.
2 © 2015 British Association of Critical Care Nurses
Many conclusions from adult ICU studies indi-
cate improved patient outcomes with an increase
in nursing workforce. However, of the four studies
exploring aspects of the nursing workforce in the
paediatric setting, only one reported upon the rela-
tionship with patient outcomes with the remaining
three studies investigating aspects of patient safety.
Notably, none of the studies investigated the role of
nurse training/education upon patient outcomes.
Tibby et al.’s (2004) study examined nursing work-
load, skill mix and staff support in relation to adverse
incidents in PICU. They reported an increase in adverse
events during day shifts compared to night shifts due
to increased activity during day shifts. They noted
that more rostered permanent staff was associated
with a decrease of adverse events. Tibby et al. (2004)
also found a reduction in adverse incidents when a
senior nurse (Clinical G Grade) was in-charge. They
suggested that the nursing staff composition was an
important factor, both in terms of the nurse seniority
and the proportion of permanent staff on duty.
Marcin et al.’s (2005) retrospective case-control study
found a significant relationship between patient agita-
tion levels and unplanned extubations (p < 0.01). How-
ever, other factors that may impact on this, such as
methods used to secure the endotracheal tube (ETT)
and types of restraints used to reduce activity in the
agitated patient, were not considered in this study.
They found no relationship between the nurses’ years
of experience and unplanned extubation rates but
they reported a positive relationship between high
nurse-patient ratios and reduced unplanned extuba-
tions.
Unplanned extubations were also investigated by
Ream et al. (2007). Using logistic regression modelling,
this single-centre cohort study found a positive asso-
ciation between unplanned extubations and nursing
ratios (p = 0.03). This study found increasing numbers
of unplanned extubations with nurse-patient ratios of
1:2 as compared with 1:1.
Using secondary data Hickey et al. (2010) investi-
gated the relationship between nursing staff, skill mix
and Magnet hospital recognition. They found no rela-
tionships between mortality rates and nursing staff fac-
tors including skill mix, and it is unclear on what basis
they asserted the merits of Magnet hospitals and higher
nurse qualification ratios.
The influence of nursing staff factors upon patient
outcomes in the intensive care setting has attracted
limited research. Yet the professional societies of
adult and paediatric intensive care recommend a 1:1
nurse-patient ratio for ventilated patients, suggesting
the importance of nursing care including the avoidance
of adverse events such as unplanned extubation.

While the importance of nurse-patient ratios was
highlighted in the studies, none of the studies offered a
definitive ratio to improve patient outcomes. Only one
study suggested that a ratio of 1:2 was preferable to 1:3
(Amaravadi et al., 2000) which would clearly have cost
implications. Without robust evidence implementing
increases in nurse-patient ratios may be difficult in the
current fiscal climate with the emphasis upon provid-
ing optimal patient outcomes and patient safety within
existing resources (Tibby et al., 2004). Thus there is a
need for more evidence of the impact of nursing work-
force factors upon care quality.
METHODS
Aim
The study aimed to examine the impact of nursing
expertise and shifts on unplanned extubations as a
quality marker within one PICU.
Study Site
This single-centre study examined unplanned extuba-
tions on a 20-bedded tertiary PICU in the UK which
is currently funded for 18 beds. For this study an
unplanned extubation was defined as an extuba-
tion where the ETT was displaced or removed from
the trachea by either the patient (self-extubation)
or by medical personnel at a time outside the plan
of care.
The study PICU provides care for children requiring
various general and cardiac critical care needs, for
example, respiratory failure and post-cardiotomy. The
nurses work twelve-and-half-hour shifts (day and
night shifts) and rotate between these shifts through-
out the month. On joining the PICU, a new nurse
undertakes a 6-month, mandatory in-house orienta-
tion programme as an introduction to the foundational
aspects of nursing care specific to PICU. Six weeks of
supervised practice with an associated competency
document guides their development with all new
nurses required to complete core competencies prior
to practising independently, such as safe airway man-
agement. Anecdotal evidence suggests that nurses
commence a nationally recognised PICU qualification
after approximately 12–18 months’ experience in
PICU. Courses leading to the PICU qualification, as set
out in the PICS Standards (PICS 2010), are delivered
by local universities. Additionally the study PICU
offers ongoing clinical education and support with a
dedicated nurse education team.
On gaining the PICU qualification, the nurses at
the study PICU will typically apply for promotion
to Senior Staff Nurse (Clinical Band 6). Two years
following promotion to Band 6, the nurses undertake
© 2015 British Association of Critical Care Nurses
The impact PICU nursing expertise has on a child’s unplanned extubation
further training and complete a competency document
assessing their ability to take charge of the PICU dur-
ing a shift. This progression is specific to the study
PICU and may differ from other PICUs in the UK.
The study PICU provides a regional, integrated
PICU retrieval service with one to two specially
trained retrieval nurses allocated within the nurs-
ing numbers on each shift. Other unit characteristics
that may impact upon the service provision and
nursing workload include a health care assistant
on each shift, whose role is primarily focussed on
house-keeping and little patient contact. There is
also a dedicated PICU Play Specialist available for
7.5 hours, Monday to Friday. Additionally a pharmacy
centralized intravenous additive service (CIVAS) pro-
vides pre-ordered antibiotics, morphine and milrinone
infusions.
Data Collection methods
The study PICU has a nurse allocation database com-
pleted on each shift by the nurse in-charge which
includes nurse allocations to roles/patients, patient
acuity and dependency levels, admissions, discharges
and ward events. This database was accessed ret-
rospectively in January 2012 to collect data relating
to nurse allocations to role (including shift nurse
in-charge) and patients on each shift (n = 74,477).
Patient and unplanned extubation data were collected
for the period April 2006 to April 2011 from the hos-
pital databases. Nurse workforce data included shift
type, start time, end time, nurse clinical grade (band),
nurse qualification, rostered staff or agency, alloca-
tion type (i.e. patient or role). Anonymized patient
data included: patient acuity and patient depen-
dency. Unplanned extubation data were obtained
in January 2012 from the PICU adverse incident
database which is a self-reporting system of patient
incidents.
Data Analysis
The data were analysed using IBM SPSS Statistics
21. The Pearson’s chi-square test was used to explore
whether there was a relationship between two cat-
egorical variables (Field, 2009). The data were not
normally distributed and therefore the appropriate
non-parametric statistical test was selected.
Validity and Reliability
This study utilized retrospective organizational data.
The allocation data were scrutinized for accuracy, but
its accuracy depended upon the correct documentation
of individual roles by the shift in-charge nurse at the
time of data input.
3
 The impact PICU nursing expertise has on a child’s unplanned extubation
Figure 1 The number of unplanned extubations by shift type and day of the week.
Ethical Considerations
Permission for the study as a service evaluation was
granted through the NHS Trust’s Research and Devel-
opment Department. All the study data were routinely
collected so that no ethical approval was required.
All nurse and patient details analyzed were fully
anonymized.
RESULTS
During the period April 2006 to April 2011 there
were 78 unplanned extubations recorded in the study
PICU, 42 during day shifts and 36 during night shifts
(Figure 1). An examination of unplanned extubations
by day of the week showed that most (n = 20) occurred
on Mondays. On Tuesdays, Fridays and Saturdays 12
extubations occurred with Sundays having the least
(n = 8).
A notably higher number of unplanned extubations
occurred during 2010 compared to any other year
(Table 1) which was also the year with the highest bed
occupancy. The winter months had the highest number
of unplanned extubations at the same time as there was
high bed occupancy. The months of April and Septem-
ber had a high number of unplanned extubations, yet
the bed occupancy in both months was lower than in
the other months.
Although most extubations occurred when the
patient was being looked after by a junior staff nurse
4 © 2015 British Association of Critical Care Nurses
(Clinical Band 5) (accounting for 47% of nursing work-
force), the clinical grade of the patient’s nurse was not
significant (p = 0.46) (Table 2). Four more unplanned
extubations occurred when the patients were being
cared for by nurses holding a PICU qualification
(Table 2) (n = 41) although this was not statistically
significant (p = 0.44).
Examination of nurse-patient ratios showed that
most extubations occurred when there was a ratio of
1:1 (n = 70) with only a 1:2 ratio occurring on 10% of
the shifts. The clinical grade of the shift nurse in-charge
was not related to unplanned extubations (p = 0.59)
(Table 3).
DISCUSSION
The Impact of Day Shifts and Night Shifts
This study found no significant difference in the
number of unplanned extubations between the day
and night shifts in contrast to Hamilton et al.’s (2007)
reported increase in adverse patient events at night
and weekends. However, a direct comparison of the
findings may not be helpful as the practice environ-
ment and demographics of each area vary. In Hamilton
et al.’s (2007) review, many of the studies were from
the USA which has distinct teams for unsocial and
social shifts respectively with more senior nurses
working less unsocial shifts, thus creating an envi-
ronment where experienced nurses work day shifts
 The impact PICU nursing expertise has on a child’s unplanned extubation

Table 1 Average patient occupancy and unplanned extubations by month In the study PICU much effort is directed at nor-
and year malizing the children’s activities where possible so
that during a day shift there is an increase in the
Year: 2006 2007 2008 2009 2010 2011 Total number of visitors and interventions to stimulate the
patient which in turn may increase the chance of
January Patients 730 704 747 916 839 3936
the ETT becoming dislodged. In contrast, during a
UPE 0 1 2 4 3 10
night shift, where the patient’s condition allows, light-
February Patients 652 494 633 841 760 3380
ing is significantly lower and both the patient and
UPE 2 0 0 1 1 4
March Patients 695 556 773 852 857 3733
unit activities are reduced to assist the children to
UPE 1 1 1 1 1 5 maintain near normal day/night sleeping and activity
April Patients 497 625 688 728 694 75 3307 patterns.
UPE 3 1 2 0 3 0 9
May Patients 464 675 739 622 889 3389 Variability in Unplanned Extubations and the
UPE 0 0 1 0 3 4 Day of the Week
June Patients 465 677 651 612 635 3040
There were no differences between the days of the week
UPE 1 1 1 1 0 4
and the number of unplanned extubations, albeit a
July Patients 528 757 769 548 834 3436
slight increase occurred on Mondays which contrasts
UPE 1 2 0 2 1 6
with an increase in the number of adverse events at the
August Patients 491 641 673 607 660 3072
weekend reported elsewhere (Hamilton et al., 2007). It
UPE 2 0 0 0 1 3
September Patients 554 634 662 711 814 3375 is unclear why Mondays had the highest number of
UPE 1 1 1 3 2 8 unplanned extubations as there are no activities which
October Patients 609 737 749 790 842 3727 are specific to Mondays. One factor which may account
UPE 0 0 0 6 3 9 for this variation is high staff changeover due to nurses
November Patients 724 740 789 711 785 3749 requesting to work clustered weekend shifts separately
UPE 2 1 0 0 2 5 from weekday shifts. This shift pattern is also mirrored
December Patients 735 761 777 913 891 4077 by medical staff. However, a larger dataset would be
UPE 2 5 2 2 0 11 required to determine whether the day of the week was
Total Patients 5067 8324 8251 8395 9653 2531 42221 associated with the frequency of unplanned extubation
UPE 12 14 9 17 21 5 78 events.
UPE, Unplanned Extubations.
Variability in Unplanned Extubations
and Month
and new or inexperienced staff work night shifts. In The study found that the largest number of unplanned
the study PICU there is internal rotation between day, extubations occurred between October and January
weekend and night shifts with all Clinical Band 5–7 which was unsurprising as other studies have shown
nurses working all shifts in any given month so that that increased patient workload, due to the seasonal
the experience level and skill mix is consistent. variation of the winter months, results in an increased
As in Tibby et al.’s (2004) study, an increased num- number of adverse events (Tarnow-Mordi et al., 2000;
ber of adverse events occurred during day shifts which Tucker et al., 2002; Tibby et al., 2004). There is raised
Tibby et al. concluded was the result of increased activ- activity during October to January (Table 1) due to an
ity including an increased number of multidisciplinary increased number of patients with respiratory patholo-
team members present during a day shift. When specif- gies, primarily infants with bronchiolitis, all of whom
ically focusing on unplanned extubations, there are are usually ventilated.
a number of other factors which could influence the The number of unplanned extubations that occurred
occurrence of unplanned extubations, for example, in April and September was unexpected but may
patients are more likely to be transferred for scans and reflect the new rotation of medical staff on the unit.
admitted from theatre during the day shift. Transfer- New doctors start in August and towards the end of
ring an intubated patient has the potential to disturb February. During their first few weeks on the study
the ETT position and thus the potential for unplanned PICU, they are closely supervised by the consultants as
extubation is higher. This study did not account for part of their induction prior to being given more auton-
these activities. Future research should measure activ- omy and reduced scrutiny of their practice. The April
ity levels to understand the full context of adverse and September unplanned extubations peaks coincide
events. with the independence level of the new PICU medical

© 2015 British Association of Critical Care Nurses 5

 The impact PICU nursing expertise has on a child’s unplanned extubation

Table 2 Allocations to ventilated patients and extubations by nurse seniority and PICU qualification

2006-11 Patient Allocations

No Unplanned Unplanned Total Patient

Extubations Extubations Allocation
PICU
Nurse Seniority Qualification n n % n %

Junior Staff Nurse∗ No Count 30083 37 47% 30120 55%

Expected Count 30077.0 43.0 30120
Senior Staff Nurse† Yes Count 4978 11 14% 4989 9%
Expected Count 4981.9 7.1 4989
Junior Sister‡ Yes Count 15271 25 32% 15296 28%
Expected Count 15274.2 21.8 15296
Senior Sister/ Charge Nurse§ Yes Count 4266 5 6% 4271 8%
Expected Count 4264.9 6.1 4271
Total Count 54598 78 54676
Expected Count 54598.0 78 54676
∗ Band 5 Nurses.
† Band 5 Nurses with PICU Qualification.
‡ Band 6 Nurses.
§ Band 7 Nurses.

Table 3 Comparison of the clinical grade of the shift nurse in-charge over extubation during the study period. This finding
the 5-year study period and unplanned extubations was not unexpected, as junior staff nurses are the
largest group in the qualified nursing workforce in
2006-11 Shifts In-charge Allocations the study PICU although Marcin et al. (2005) found
no relationship between nurses’ years of experience
No Unplanned Unplanned Total In-charge
and unplanned extubation rates. The junior staff nurse
Extubations Extubations Shifts
Shift In-charge role is exclusively to look after patients due to the
Nurse n n % n % limitations of their experience and lack of addi-
tional qualifications which increases their patient
Junior Sister∗ Count 1218 28 36 1246 33
exposure and therefore the likelihood of experiencing
Expected Count 1220.2 25.8 1246
an unplanned extubation. Junior staff nurses have
Senior Sister/ Count 2473 50 64 2523 67
Charge Nurse† Expected Count 2470.8 52.2 2523
less experience and as a result may not have the
Total Count 3691 78 3769 skills of anticipation and management of unexpected
Expected Count 3691.0 78.0 3769 events, as they usually operate somewhere between
the advanced beginner or competent stages of practice
∗ Band 6 Nurses.
† Band 7 Nurses.
(Benner 2001). In contrast more experienced nurses are
expected to operate on a higher level of practice and to
anticipate and prevent adverse events. This highlights
staff who may not yet be familiar with all the proto- the importance of providing education and training
cols including the securing of ETTs. This contrasts with to facilitate the development of expert knowledge and
Tibby et al. (2004) who found that the arrival of new intuition together with the importance of appropriate
medical staff was a significant factor in the reduction of airway management.
adverse events. However, their study comprised data There is currently no evidence regarding the com-
for only a 12-month period compared to the 5 years in pletion of a PICU course and its effect upon patient
this study. care and this study found no relationship between the
number of unplanned extubations and a PICU quali-
Impact of Nurses Experience and Expertise fication. Conversely, Tarnow-Mordi et al. (2000) found
The majority of patients who experienced an that inadequate training and supervision resulted in
unplanned extubation were looked after by junior staff increased patient related adverse events, although
nurses, although it is noteworthy that every clinical they did not specify the nature of the training.
grade of nurse experienced at least one unplanned This study’s findings lend support to the role of

6 © 2015 British Association of Critical Care Nurses


the PICU Induction Programme as preparation for
the PICU nursing care setting although firm con-
clusions cannot be drawn on the basis of this study
alone.
Impact of Nurse-Patient Ratios
This study found no association between nurse-patient
ratios and unplanned extubations with 90% of the
recorded events occurring within a 1:1 nurse-patient
ratio and only 10% occurring within a 1:2 nurse-patient
ratio. This contrasts with the literature which reported
that a high nurse-patient ratio had a significant effect
on reducing patient related adverse events (Pronovost
et al., 1999; Amaravadi et al., 2000; Tarnow-Mordi et al.,
2000; Pronovost et al., 2001; Dang et al., 2002; Marcin
et al., 2005; Hugonnet et al., 2007; Ream et al., 2007;
Profit et al., 2010; Sink et al., 2011). The study find-
ings may reflect the lack of adjustment for other influ-
encing factors present at the time of the incident,
namely, physiotherapy, transfer from trolley to bed,
ETT securing methods, ETT position and sedation
levels.
At the study PICU, ventilated patients are not heav-
ily sedated as it is believed to reduce the number of
ventilator days per patient. Further the study PICU
has one of the lowest number of ventilator days per
patient in the UK (Paediatric Intensive Care Audit
Network 2010). A previous study has found a rela-
tionship between patient agitation and unplanned
extubations highlighting that, while reducing sedation
may reduce the length of ventilation time, it may
potentially increase the risk of unplanned extubations
(Marcin et al., 2005). The sedation protocol in the
study PICU is currently under review so that it may
be interesting to explore the incidence of unplanned
extubations in relation to the current and new sedation
protocols.
Transferring conclusions about nurse-patient ratios
from this study to other PICUs is difficult because the
study PICU employed consistently high nurse-patient
ratios. More research is needed to ascertain an appro-
priate nurse-patient ratio and whether 1:2 ratios over a
long period result in increased unplanned extubations.
The current recommendations are limited and focus on
the number of Registered Nurses to patients (Penoyer,
2010; PICS, 2010; RCN, 2013) without consideration of
overall staffing levels and the skill mix within the nurs-
ing team [National Nursing Research Unit (NNRU),
2012].
The Impact of the Shift In-charge Nurse
A senior sister/charge nurse (Clinical Band 7) as the
shift in-charge nurse was not related to unplanned
extubations which contrasts with Tibby et al.’s (2004)
© 2015 British Association of Critical Care Nurses
The impact PICU nursing expertise has on a child’s unplanned extubation
comparable study which reported a decrease in
adverse events when a senior nurse (equivalent Clini-
cal Band 7) was in-charge suggesting the importance of
clinical leadership. Tibby et al.’s (2004) study covered
a shorter period of time (12 months) and examined all
adverse events rather than only unplanned extuba-
tions. A larger study of all adverse events may have
yielded different findings because a senior sister/
charge nurse is always present on each shift to provide
clinical leadership, although not necessarily as desig-
nated shift in-charge nurse. As the study period only
covered the time when there was a senior sister/charge
nurse on each shift, it is difficult to draw conclusions
about their impact upon patient outcomes although
the NNRU (2008) has suggested that role-modelling
is important for the provision of quality patient care.
Further exploration of the relationship between clinical
leadership and patient care outcomes is warranted.
CONCLUSION
The focus of the health services is not just mainte-
nance of a safe and sustainable service, but on deliv-
ery of high-quality health care efficiently. The current
challenge for health services is to provide this within
limited resources for further care improvement. Fur-
ther research is needed to explore the relationships
of non-nursing workforce factors such as ETT care
protocols, patient agitation and ward activities upon
unplanned extubations alongside the impact of clini-
cal leadership in the form of senior nurse presence. The
study findings suggest that high nurse-patient ratios
provide a solid foundation upon which to deliver safe,
high quality care within PICUs.
IMPLICATIONS FOR CLINICAL PRACTICE
This study did not find a clear relationship between
the nursing workforce factors of nurse-patient ratio
and senior nurse on site clinical leadership and
unplanned extubations in the study PICU. The slight
increase in unplanned extubations on Mondays
may have implications for shift scheduling to pre-
vent ‘whole team’ changeover on Mondays. Greater
attention may be warranted regarding non-nursing
workforce factors, such as activities levels, patient
acuity and patient numbers to reduce unplanned
extubations where PICUs have high nurse-patient
ratios.
ACKNOWLEDGEMENTS
We are grateful to Joanna Philip and Andrew Durward
for assistance with access to the databases.
7
 The impact PICU nursing expertise has on a child’s unplanned extubation
WHAT IS KNOWN ABOUT THIS TOPIC
• The influence of nurse factors upon patient outcomes in the intensive care setting has attracted limited research.
• Professional societies of adult and paediatric intensive care recommend a 1:1 nurse-patient ratio for ventilated patients, suggesting the
importance of the nursing role in the provision of this care.
WHAT THIS PAPER ADDS
• There is no relationship between nursing workforce factors and unplanned extubations in a PICU within the context of high
nurse-patient ratios and a senior sister/charge nurse providing on-site leadership.
• In PICUs where nurse-patient ratios are high, further investigation is needed to establish what impact non-nursing workforce factors
have on unplanned extubations.
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