nicu-picu/SOPs/SOP-003-Training.md

Standard Operating Procedure: Training and Competence

Document ID	SOP-003
Title	Training and Competence - NICU/PICU
Revision	1.0
Effective Date	[DATE]
Author	[AUTHOR]
Approved By	[APPROVER]
Department	Nursing Education / Quality

---

1. Purpose

To ensure personnel caring for critically ill neonates and children are competent based on appropriate education, training, skills, and experience.

2. Scope

This procedure applies to:

• All NICU/PICU clinical staff (nurses, physicians, NPs, PAs, RTs)
• Support staff (pharmacists, social workers, child life specialists)
• Contract and temporary personnel
• Students and trainees

3. Responsibilities

3.1 Unit Leadership/Managers

• Identify training needs for NICU/PICU personnel
• Ensure training is completed before independent practice
• Evaluate competence of personnel
• Maintain department training records

3.2 Nursing Education

• Coordinate NICU/PICU orientation programs
• Maintain central training database
• Track training compliance
• Archive training records

3.3 Quality Assurance

• Develop QMS-related training
• Approve clinical training curricula
• Audit training compliance

3.4 Clinical Staff

• Complete assigned training on time
• Maintain current certifications (NRP, PALS, ACLS)
• Report training needs to supervisor
• Participate in annual competency validation

4. Required Certifications

4.1 NICU Staff

• Neonatal Resuscitation Program (NRP) - every 2 years
• STABLE Program (post-resuscitation care)
• Electronic Fetal Monitoring (OB/NICU)

4.2 PICU Staff

• Pediatric Advanced Life Support (PALS) - every 2 years
• Advanced Cardiovascular Life Support (ACLS) if applicable

4.3 All ICU Staff

• Critical care orientation
• High-risk medication administration
• Ventilator management competency
• Central line care
• Sedation assessment
• Pain assessment tools

5. Procedure

5.1 Training Needs Assessment

1. Identify competence requirements for each role
2. Document requirements in job descriptions
3. Assess current competence of personnel
4. Identify training gaps
5. Consider regulatory and accreditation requirements

5.2 New Employee Orientation

All new NICU/PICU staff shall complete:

1. General Orientation (1-2 days)

   • Hospital policies
   • Safety and emergency procedures
   • Quality system overview

2. Unit Orientation (4-12 weeks depending on role)

   • Unit tour and equipment
   • Documentation systems
   • Communication protocols
   • Family-centered care principles

3. Clinical Competencies (validated during orientation)

   • Patient assessment
   • Medication administration
   • Respiratory support
   • IV access and management
   • Emergency response

4. Required Certifications

   • NRP or PALS (must be current before start)
   • Unit-specific competencies

5.3 Annual Competency Validation

All staff shall demonstrate competency annually in:

1. Code/emergency response
2. High-alert medication administration
3. Sedation scoring
4. Pain assessment
5. Equipment operation (vents, infusion pumps)
6. Documentation requirements
7. Infection prevention practices

5.4 Training Documentation

Training records shall include:

• Employee name and ID
• Training title and date
• Trainer name and qualifications
• Assessment results (minimum 80% passing for written tests)
• Practical demonstration verification
• Signatures

5.5 Retraining Requirements

Retraining is required when:

• Significant protocol revisions occur
• Performance deficiencies identified
• Extended absence from unit (>6 months)
• New equipment or technology introduced
• Sentinel event or serious safety concern

5.6 Preceptor Qualification

Preceptors must:

• Have minimum 1 year ICU experience
• Complete preceptor training program
• Demonstrate teaching ability
• Maintain current certifications

6. Training Records Retention

• Training records maintained for duration of employment
• Records retained 7 years after employee departure
• Records available for Joint Commission and regulatory inspection

7. Related Documents

• FRM-004 Training Record Form
• FRM-005 Clinical Competency Checklist
• Job Descriptions
• Preceptor Manual

---

Revision History

Rev	Date	Description	Author
1.0	[DATE]	Initial release	[AUTHOR]