AACN News—November 1999—Practice

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Vol. 16, No. 11, NOVEMBER 1999


Patients Make a Difference in Our Lives Too

Loralie Yzerman, RN, CCRN, is a staff nurse in the critical care unit at Palomar Medical Center, Escondido, Calif. She received a 1999 Excellence in Caring Practices Award. Following are excerpts from the exemplar that Yzerman submitted in connection with her award, which is part of AACN’s Circle of Excellence recognition program. For more information about Circle of Excellence awards, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org and click on “awards.”

By Loralie Yzerman

Talking about making a difference in the lives of your patients and their families is impossible unless you also talk about the difference they make in your life.

I had worked in my ICU for a little more than a year when Nina and her family entered my life. At age 35 and eight months pregnant, Nina had been admitted to the labor and delivery unit with acute abdominal pain. Suspecting cholecystitis, her physician ordered an ultrasound. The results of her gall bladder test were negative, but a large mass was discovered on her liver.

Nina was to remain in the labor and delivery unit for both pain control and to allow her pregnancy to come to term before interventions were attempted. However, her condition deteriorated to the point that delivering the baby became necessary. Her liver enzymes, amylase and ammonia levels were critically elevated, and she now required large doses of pain medication.

Nina was taken to the operating room, where she gave birth by cesarean section to a healthy baby girl, Francesca. Nina was brought postoperatively to our unit. During surgery, it was discovered that the mass involved not only half her liver, but also a portion of her pancreas.

As Nina’s husband Kurt waited to talk to the physicians, he sat at her bedside and tried to comfort her. He was torn between staying with his wife and being with his daughter in the neonatal ICU. I stayed with Nina while Kurt visited his daughter.

When Nina awakened, she was crying. She said she was having nightmares, which I explained could be caused by the medications she was receiving. She rejected that explanation, and I sensed that she knew, in her heart, the gravity of her condition. I held her hand and smoothed her hair to comfort her, and she went back to sleep, but fitfully.

Nina’s biopsy result was positive, indicating a poorly differentiated, rapidly growing cancer. It was then that Kurt was told that Nina was dying. He turned to me and sobbed inconsolably. The physicians, shedding tears of their own, offered supportive hugs. The afternoon was spent alternately nursing a grieving husband and a critically ill patient. I was heartbroken to think that Nina’s newborn daughter would never know her mother.

Nina had more frequent periods of lucidity the next day. I collaborated with the physicians to determine the combination of medications that would not only achieve optimal pain control, but also allow for some measure of lucidity. At the beginning of one of these lucid times, we brought Francesca to Nina. We placed Francesca on Nina’s chest and watched as she shared those first precious moments with her daughter.

As is common with postoperative shock or trauma patients, Nina was incredibly “third-spaced.” I encouraged Kurt to bring in photos of Nina, and we hung a large collage that Nina had made, depicting their time together.

Because Kurt was at times with his daughter or in meetings with physicians, I obtained a pager for him from the surgery department. This way I could alert him when Nina was awake and asking for him, or when the physicians wanted to meet with him.

Kurt cried on my shoulder many times over the next few days. He was waiting for his mother to arrive from out of town, and thanked me for “being my mom” in the meantime.

The need to nurse both the husband and the wife was challenging. Our goal was to provide quality time for Nina to share with Kurt and Francesca, but the balance between comfort and lucidity was delicate. I coordinated Francesca’s discharge with social services and the discharge planner. Kurt’s mother was of help when the time came to take Francesca home, and she arranged for a nanny. Kurt operated his business from home, which was helpful.

When Nina was lucid and sufficiently stable to be transferred to our step-down unit, I took a few days off to visit a friend. While I was away, Nina suffered a cardiopulmonary arrest, and was returned to the ICU, comatose and on a ventilator. She never regained consciousness.

Kurt’s first words to me when I returned were, “Where were you when I needed you?” He immediately apologized, realizing that the outcome would have been the same had I been there.

I was in my garden at home several days later, when I experienced an overwhelming feeling that I should check on Nina. Her nurse said she was “slipping away.” I arrived at the hospital just as her cardiac rhythm became asystolic. Kurt again cried on my shoulder, and I grieved with his family, offering as much support and comfort as I could. I cut locks of Nina’s hair for Francesca and for her mother.

With other staff members, I attended the memorial service for Nina at the family home. The fact that Nina was an artist was evident, not only in her pottery, but also in the layout of the gorgeous garden. Kurt thanked us for making the worst time of his life more bearable. He sent me a heartwarming thank you note, enclosing poetry Nina had written.

I called my mother that night in tears and said, “You see; this is why I am a nurse.”

Deadlines Near to Apply for Nursing Research Grants

Following are nursing research grants for which application deadlines are approaching. For application materials, call (800) 899-AACN (2226) or visit the AACN Web site at http://www.aacn.org. Click on “Research.” For more information, call the AACN Practice and Research Department at (800) 809-2273.

Clinical Inquiry Grants
Funded by an anonymous donor, this grant awards up to $250 each for clinical research projects that will directly benefit patients or their families. Funds are awarded to projects that address one or more AACN research priorities and link with AACN’s vision.

The principal investigator must be an RN, a current AACN member, employed in a clinical setting and directly involved in patient care.
Applications must be received by Jan. 1, 2000.

Small Projects Grants

Sponsored by Medtronic/Physio-Control Corporation, this grant supports projects that focus on aspects of acute myocardial infarction and resuscitation. Up to $500 will be awarded to projects selected.

Eligible projects can include patient education; staff development or competency-based educational programs; continuous quality improvement or outcomes evaluations; and small research studies.

Applicants must be an active or affiliate member of AACN and not currently conducting another study funded by an AACN research grant.

Applications must be received by Jan. 15, 2000.

Critical Care Research Grant
This grant provides for one award of up to $15,000 to a nurse investigator who is actively involved in acute and critical care nursing practice. The study selected must be relevant to critical care nursing practice.

The principal investigator must be an RN and a current AACN member. The proposed study may not be used to meet the requirements for an academic degree.

Proposals must be received by Feb. 1, 2000.

Mentorship Grant

Cosponsored by AACN and Mallinckrodt Inc., this grant awards up to $10,000 to a novice researcher to work with an experienced research mentor on a study that is relevant to critical care nursing practice.

The novice research applicant, who must be an RN and current member of AACN, should have only limited or no experience in the area proposed for investigation. The research funded may be used toward an academic degree.

The mentor must have research expertise in the area proposed for study by the novice researcher. The mentor cannot be designated as a mentor on another AACN mentorship grant for two consecutive years and cannot be conducting the research toward an academic degree.

Proposals for this grant must be received by Feb. 1, 2000.

AACN Certification Corporation Research Grants
These grants, funded by AACN Certification Corporation, provide up to $10,000 each for four studies related to certified practice. Examples of eligible projects are studies that focus on continued competency; the Synergy Model; the value of certification as it relates to patient care or nursing practice; and credentialing concepts. The proposed research may be used to meet the requirements of an academic degree.

Although AACN members are encouraged to apply for this grant, AACN membership is not required. However, if all other factors are equal, AACN member applications will be given preference.

Proposals must be received by Feb. 1, 2000.

Practice Resource Network: How to Get Started in a Career in Critical Care

Q I am a nursing student who is interested in a career in critical care nursing. How do I get started?

A A good first step is to seek networking opportunities with practicing critical care nurses. Their support, as well as the “war stories” they can share, will give you insight into exactly what critical care nursing entails, and help you to evaluate whether it is a good fit for you. Networking can assist in identifying potential mentors, who can take you “under his or her wing” and be a role model as you transition into this role.

Membership in a professional organization will help you to keep up with the latest critical care nursing information. This type of affiliation not only looks good on a resume, but also signals that you take your role as a professional nurse seriously. Professional associations are also an excellent source of information.
For example, AACN members receive free two, bimonthly critical care nursing journals—Critical Care Nurse and the American Journal of Critical Care. The AACN Web site (www.aacn.org) provides some free CE offerings, as well as opportunities to access a wealth of nursing information.

In addition, AACN members get a discount on registration for the National Teaching Institute, AACN’s annual educational conference, where a wide range of topics are presented. (The NTI in 2000 is scheduled for May 20 through 25 in Orlando, Fla.) Employers are always seeking applicants who have baseline knowledge and skills. AACN members receive discounts on a variety of resources, including books and pocket reference cards, that can help you get started.

AACN members can also receive free career counseling services through Career Development Services (CDS) at (888) AACN-JOB (222-6562). You can even find open nursing positions around the country in the “Career Opportunities” area of the AACN Web site.

Begin preparing your resume now, concentrating on areas that show a competency or extra effort in the direction of critical care nursing. Mail your resume to hospitals and other healthcare institutions in the demographic areas in which you are interested in locating. Because the nursing shortage is affecting critical care areas, many facilities are offering critical care internships to new graduates.

For more information about critical care nursing or about membership in AACN, call (800) 899-AACN (2226), or visit the AACN Web site at http://www.aacn.org. AACN offers students a reduced membership rate.

Goals Aimed at Helping to Integrate Ethics Into Practice

Beth A. Glassford, RN, MS
Chairperson, Ethics Integration Work Group

A set of goals designed to help bedside nurses integrate ethics into their practice has been established by the Ethics Integration Work Group (EIWG).

Meeting in Irvine, Calif., in August 1999, the 10-member group first identified priorities for the ethics integration agenda for the year; then developed goals to address the priorities.

Following are the goals for which strategies will be developed:
• Increase AACN members’ awareness of ethics resources
• Evaluate the needs and opinions of members through existing market assessment
• Assist clinicians in complying with regulatory standards regarding ethics, advance directives, patient rights, pain management, confidentiality, organ donation and others
• Assist staff nurses in dealing with ethical issues
• Provide ethical case studies for use as teaching tools
• Ensure that there is a thread of ethics throughout AACN educational programming
• Review and revise position statements for areas related to ethics

These clinical goals stemmed from the group’s assessment that bedside nurses needed and were requesting more assistance in dealing with ethics issues. Work group members saw a need not only to increase awareness of currently available ethics resources, but also to provide values clarification and awareness assessment tools, as well as self-assessment tools. In addition, the group cited a need to better define the role of staff nurses in ethical issues and to help them develop the skills to deal with difficult situations by providing protocols, guidelines and standards of care. Opportunities to partner with other organizations will also be pursued.

The Ethics Integration Work Group is chaired by Beth A. Glassford, RN, MS. Other members are Jacqueline Fowler Byers, RN, PhD, Natalie J. Correll, RN, MN, CCRN, Mary Garman, RN, Jeanne PaPa, RN, BSN, CCRN, RRT, Lisa J. Pettrey, RN, MS, Cynthia H. Rushton, RN, DNSc, FAAN, Elizabeth A. Smith, RN, BSN, BS, CCRN, and M. C. Sullivan. Elizabeth M. Nolan, RN, MS, CS, is the AACN board liaison. AACN Clinical Practice Specialist Justine Medina, RN, MS, is the national office staff liaison.

Group members are accountable not only for helping to implement the ethics agenda, but also for acting as expert spokespeople on ethics issues.

Geriatric Corner: Partnership Promotes Best Practices in Care of Older Adults

Over a year ago, the John A. Hartford Foundation Institute for Geriatric Nursing established the Specialty Nursing Activities Partnership Program (SNAPP) for Care of Older Adults. This collaboration promotes best practices in the care of the older adult and shares resources with nurses who care for critically ill older adults. Following is a tool from the institute’s Try This: Best Practices in Care of Older Adults series.

Fulmer SPICES: An Overall Assessment Tool of Older Adults
By Meredith Wallace, RN, MSN, CS,
and Terry Fulmer, RN, PhD, FAAN

WHY: Normal aging brings about inevitable and irreversible changes, which are partially responsible for the increased risk of developing health-related problems within the elderly population. Familiarity with the prevalent problems experienced by older adults helps the nurse prevent unnecessary iatrogenesis and promote optimal function for the aging patient. Highlighting conditions for further assessment will allow the nurse to implement preventative and therapeutic interventions.

BEST TOOL: The most appropriate instrument for obtaining the information necessary to prevent health alterations is SPICES, which was developed by Terry Fulmer, RN, PhD, FAAN, of the New York University, Division of Nursing, New York. SPICES is an acronym for the common syndromes of the elderly that require nursing intervention: Sleep Disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls and Skin breakdown.

TARGET POPULATION: The SPICE instrument has been used to assess the elderly population. Members of the Geriatric Nurse Resource Project at Yale University Medical Center, New Haven, Conn., use the tool to assess and prevent the most frequent health problems of older adults. It is also being used at New York University Medical Center. However, psychometric testing has not been done.

STRENGTHS AND LIMITATIONS: The SPICES acronym is easily remembered and may be used to recall the common problems of the elderly population in all clinical settings. It provides a simple system for flagging areas that need further assessment and provides a basis for standardizing quality of care around certain parameters. SPICES is an alert system and refers to only the most frequently occurring health problems of older adults. Through this initial screen, more complete assessments are triggered. It should not be used as a replacement for a complete nursing assessment.

INSTRUMENT:
Patient Name: Date:
SPICES EVIDENCE
Sleep Disorders
Problems with eating or feeding
Incontinence
Confusion
Evidence of Falls
Skin Breakdown
Suggested Reading
The Geriatric Nurse Specialist Role: a new model, by T. Fulmer, in Management, 1991.
Grow Your Own Experts in Hospital Elder Care, by T. Fulmer, in Geriatric Nursing, March/April 1991.
Nursing Improving the Care of the Hospitalized Elderly (NICHE) project at the Hartford Institute for Geriatric Nursing.

For more Best Practices from the Hartford Institute, check out the AACN Web site link to the Try This series, or go directly to the Hartford Foundation at http://www.nyu.edu/education/nursing/hartford.institute.

Take Advantage of Resources for Students and Faculty

A number of resources geared to the interests and needs of nursing students or faculty are available from AACN. Following is information about some of these. Additional information is available in the “Bookstore” area of the AACN Web site at http://www.aacn.org, or by calling (800) 899-AACN (2226).

For Both Students and Faculty
Transitions in Healthcare—designed to assist healthcare professionals in understanding the underlying dynamics of work within the rapidly changing healthcare field, and to equip them with the skills and knowledge necessary for success.
Item #122199 (individual sections also available)

Clinical Delegation Skills—ideal for anyone who deals directly with the clinical delegation process. Presents facts, research-based strategies and skill-building tools.
Item #120904

Delegation: A Tool for Success in the Changing Workplace—clarifies the role of the RN in relation to other licensed and unlicensed caregivers. Delineates nursing activities, nonnursing tasks and patient care tasks. Discusses barriers to delegation and provides tips for successful delegation. Includes a decision-making framework for nurses, administrators, advanced practice nurses, physicians and other healthcare providers for delegating tasks to unlicensed assistive personnel.
Item #150600

Delegation Grid Pocket Card—a pocket reference guide for nurses, administrators, advanced practice nurses, physicians and other healthcare providers for delegating tasks to unlicensed assistive personnel.
Item #400900

ECG Challenge Pack—provides 76 ECGs and concise descriptions of their salient points.
Item #100160

ECG Essentials—emphasizes the real world of bedside practice, with guidelines for teaching and self-learning; monitoring advice and diagnostic criteria. Includes a basic ECG self-assessment test, practice exam with answers.
Item #100162

Heart Sounds and Murmurs—A Practical Guide—provides basic information in text format and on compact disk or audio tape. Sounds are repeated with instructional information and practice. Covers systolic and diastolic murmurs, friction rubs and valve sounds.
Item #300114

Forgoing Life-Sustaining Therapy—content focuses on the clinical aspects of care while addressing ethical and legal considerations and the processes of communication and decision making. Dispels common myths about forgoing treatment, offers historical background on right-to-die cases, and provides definitions and discussions of ethical principles.
Item #100450

For Students
AACN Handbook of Critical Care Nursing—an easy-to-use resource providing basic to advanced information on the care of critically ill patients. A holistic approach to critical care nursing, addressing alternative therapies such as relaxation, stress reduction techniques, imagery and touch, is emphasized. Designed to augment critical care programs.
Item #128750

AACN Pocket Handbook of Critical Care Nursing—a practical pocket guide delivers essential information on the care of critically ill patients in an easy-to-use, quick reference format. An ideal, practical resource for delivering care at the bedside.
Item #128751

Staffing Blueprint: Constructing your Staffing Solutions—a comprehensive resource addressing staffing concerns. The blueprint emphasizes patient-focused care, and can be used to assess your knowledge, plan collaborative interventions, evaluate the effectiveness of your plan and assist you in becoming a knowledgeable resource in resolving staffing dilemmas.
Item #300117

Quick Critical Care Reference—a portable reference guide containing sections related to formulas and calculations, monitoring, guidelines, ECG rhythm strip rate charts, ventilator guidelines, lab values and more.
Item #128255

For Faculty
Protocols for Practice: Noninvasive Monitoring Series—designed to provide the latest research findings, which are easy to understand and integrate into clinical practice. Each of six protocols includes general information, competency issues and practice recommendations and rationales.
Item #170670 (individual protocols also available)

Protocols for Practice: Hemodynamic Monitoring Series—designed to present the latest knowledge on how to provide care for patients who require hemodynamic monitoring. Each protocol includes general information about the technology, its accuracy and precision, related occupational hazards and ethical considerations, competency issues and practice recommendations with rationales. Each of four protocols includes a concise list of recommendations, rated according to the level of information and research available to support the practice statement.
Item #170700 (individual protocols also available)

Protocols for Practice: Care of the Mechanically Ventilated Patient Series—designed to provide clinicians at the bedside with the latest research findings in patient care and the latest knowledge on how to provide care to a patient who requires mechanical ventilation. Each of seven protocols includes general information about the technology, its accuracy and precision, related occupational hazards and ethical considerations, competency issues and practice recommendations with rationales.
Item #170720 (individual protocols also available)

Critical Care in the Nursing Curriculum: Selecting and Integrating Essential Content—provides a framework for building curricula to prepare practitioners for meeting expanded needs of the critically ill. Establishes competency statements for differentiated nursing practice in critical care.
Item #120400

A Critical Day in the Life of a Student Nurse

Editor's note: The following article was written by Elizabeth Hermann, RN, BSN, during her last semester as a BSN student at the University of Texas-Houston School of Nursing. Hermann is now a pediatric critical care nurse at Texas Children’s Hospital, Houston, Tex.

By Elizabeth Hermann

After completing an eight-week critical care course required by my nursing school, I knew I had found the nursing specialty for me. Although every day of this course was memorable, I will never forget the opportunity I had to help care for an organ donor and one of the organ recipients.

The 22-year-old donor, John, had been transferred to my hospital on life support to undergo organ donation. He had been pronounced brain dead at a nearby hospital from a self-inflicted gunshot wound to the head. His family had already said their goodbyes prior to his transfer, but the absence of family made his last few hours seem remarkably lonely.

The nurse who was directing John’s care, quickly recruited my help in preparing John for surgery. The opportunity to use some of the skills I had learned in class made me feel that I was truly contributing. For example, I calculated the medication dose in micrograms per kilogram per minute, manipulated the arterial line stopcocks to obtain blood samples for lab work and, for the first time, obtained a sputum culture. I also assisted a resident in starting a subclavian line; then applied the dressing. An echocardiogram was performed to assess John’s heart for donation, and a bronchoscopy was performed to assess his lungs. We placed John on a warming blanket to maintain his body temperature, and administered four units of packed, red blood cells.

When the time came to take John to surgery, I placed him on the transport monitor and accompanied him to the operating room. After the two recipients for the heart and the lungs arrived, I eagerly accepted an invitation to watch the organ transplantation.

The transplant team had a good working relationship and recognized the value of teaching others. The surgeons and nurses allowed me to get in close and observe their work. By the time I left that evening, both recipients of the organs had completed their surgeries successfully, and were en route to the cardiovascular surgical ICU.

The next day, my instructor let me take an assignment in the cardiovascular ICU, so that I could follow the progress of the heart and lung recipients. I selected the lung transplant patient for my assignment, and I was sad that he was not doing well.

Carol, the nurse with whom I was working, was a great role model for me as she brilliantly coordinated the care of this patient. The intensity of his care was incredibly challenging; yet, Carol maintained a supportive and nurturing relationship with him and his wife, while taking the time to explain things and involve me in his care.

Although his condition was critical when I left, he was alert and communicating with his wife when I returned the next day. The team was already planning to extubate him within the next 12 hours. It was wonderful to know that, despite the sad circumstances of John’s death, the donation of his organs saved and improved the life of someone else.

As I look back on this experience, I reflect on many things: the sadness of John’s situation, the loneliness that I felt in providing care for him, my amazement with the surgical procedures, the challenge of providing high-intensity physical and psychosocial and spiritual care, and the joy of knowing that the generosity of John’s family brought life and hope to others.

The nurses with whom I worked were awesome role models. Their ability to impart knowledge in a nonthreatening and supportive way indicated that they remember what it is like to be a nursing student. The collaborative environment of the ICU truly exemplified healthcare at its finest, and inspired me to pursue a career as a critical care nurse. I hope someday that I can inspire someone else to make a similar career choice.

What Nursing Students Say

Do you remember why you chose to become a critical care nurse? Read on to find out some of the reasons why today’s nursing students are attracted to your specialty. The following comments were collected at the 1999 National Student Nurses Association meeting.

I have seen first-hand how helpless these patients are. They need qualified, skilled nurses to give care and advocate for them.
Eileen Hermance

Although advanced in technology, critical care nursing provides a broad-based background in dealing with all illness and various modes of treatment, which would be limited in other areas of nursing.
Olive M. Brown

While working in a nonmedical hospital position for five years, I saw critical care up close on countless occasions. I believe I can make a positive impact on the lives of patients.
Rob Black

A career in this field provides an excellent opportunity to enhance my nursing skills.
Melissa Fleist

Every day, the work is new, different and exciting.
Julie Win

I like the fast pace of nursing the critically injured patient. It definitely keeps you on your toes.
Amy Owen

The acute care setting provides the thrill of being an RN and the opportunities to grow in knowledge. You are never bored because of a lack of work.
Kellene Fisher

Critical care patients are the most important and most in need of care. They are desperately in need of patient advocacy.
Steve Maxwell

I enjoy the holistic approach. Critical care nurses are involved in all aspects of patient care, and are able to give attention to each patient.
Denise Pisacone

Critical care nurses are highly respected and are given a great deal of autonomy.
Patricia Baldwin

Critical care nursing draws on your knowledge and intuitive thinking to provide the best possible care.
Janey Chu

The daily challenges, continual learning and teamwork with other healthcare experts will help me obtain my goal of becoming an expert nurse clinician.
Randy S. Oyster

I like the aspect of critical thinking and looking at the whole picture of care for one to two patients instead of skimming the surface for five or six patients. I have also noted the respect CCRNs receive from other healthcare professionals.
Alison Kaestren

I like knowing that I can help my patients through the most difficult times.
Carolyn Sieveking

Critical care is exciting and challenging every day. I want to keep learning and expanding my horizons.
Betsy Ploeger

Critical care allows me to spend more time with each patient and to maximize the use of the assessment skills I have learned.
Stacy L. Succop

Critical care nursing is extremely challenging and allows nurses to use and build on the skills they have learned.
Edgardo Gomez

I like working under pressure and constantly learning new techniques and procedures.
Kim Henry

It’s challenging, dynamic and rewarding.
Dawn Callanan

Critical care encompasses everything I enjoy about nursing. It also is a gateway to expanding your career.
Candice Beer

I enjoy being able to think on my feet, be autonomous and provide holistic care for critically ill patients and their families.
Jill M. Saycor

Your patients are never textbook, and I love the challenge of learning more every day as my patients’ diseases progress.
Marie DeLeon

I can spend more one-on-one time with my patients.
Kimberly Bonts

The nurses were so compassionate when my son was in the NICU. I want to be one of those compassionate nurses.
Jessica Bradigan

The critically ill patient is dependent on your knowledge, advocacy and compassion more than other patients.
Allison Haritan

Critical care nursing requires you to use all of your skills as a nurse.
Tracie Giannini

It takes a special kind of person to dedicate themselves to patients who are experiencing a life-threatening condition. I love my work for being a nurse, not “just a job.”
Rebecca Hall

It is a foundation or stepping stone to many specialty careers.
Natalie Adams

It incorporates all fields of nursing and gives the RN the opportunity to practice many skills and increases one’s competence and critical thinking.
Elizabeth Clements

I love the multisystem approach in ICUs.
Dawn Spivey

This field is much more specific to the patient’s needs.
Christina Capers

Critical care challenges me to stay current on all areas and continue my education in nursing.
Regina McBride

I want to be the person who delivers the care that people will never forget.
Marissa Sparks