AACN News—September 1999—Practice

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Vol. 16, No. 9, SEPTEMBER 1999


Advocate Humanity in a System Driven by Technology

Editor’s note: Jeanne Miller, RN, MSN, a clinical ethicist with the Singing River Hospital System in Pascagoula, Miss., received a 1999 Excellence in Caring Practices Award. Following are excerpts from the exemplar Miller 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 Jeanne Miller

Critical care nursing is more than the application of technology to diagnose and treat traumatic illnesses or injuries. It includes constant psychosocial support not only for patients, but also for their family members.

Critical care nursing is exemplary in its standards of care, always balancing the tasks in taking “care of” and practicing the art of humanity in “caring for.”

In the past decade, critical care research has revealed the multitude of uncertainties experienced by family members while in a critical care environment. Current research shows that family needs are simple: They want the truth; they want to be heard; and they want to understand. Becky’s family was no exception.

Nine-year-old Becky was admitted to the adult critical care unit with a closed head injury sustained in a motor vehicle accident. She and her family faced very real fears. Most of the family members had never been inside a critical care unit, and found the array of pumps, tubes, machines, monitors and lines, as well as the rush of staff members overwhelming.

I learned from conversations with Becky’s family that her 5-year-old brother, who had been in the back seat with her, had not slept, expressing that he was afraid he would “never wake up.” He continually asked his parents, “Why was it Becky and not me?” Becky’s 7-year-old sister would not enter Becky’s bedroom at home and insisted that the light remain on.
I concluded that these siblings needed to see, touch, smell and be with their sister. They needed to be allowed to grieve and participate in the bereavement process surrounding their sister’s trauma. However, there were barriers, because our institution’s written policy was to not allow anyone under the age of 12 to visit patients.

Three days after the accident, I approached Becky’s parents about scheduling an educational conference for the family, including Becky’s brother and two sisters. Although they agreed to include aunts, uncles and grandparents, there was reluctance about involving the children. I suggested that, if the children exhibited fear or discomfort, they could be removed from the conference.

At the conference, I sat with the children at the table and provided them crayons and paper. The adults sat in audience chairs. Coffee and cookies were available and the lighting was subdued. I wanted the atmosphere to be gentle, quiet, methodical and conducive to learning.

We began the session by discussing definitions of grief, mourning, loss and coping. The adults shared that this was the first trauma in their family. They were giving the children explanations such as “Becky is asleep and God may take her” and “Becky may never wake up.” I then asked them to quietly sit and listen to the children.

I asked the children to talk about a time when they had been sick. They drew pictures of lungs, a heart, a brain and a rib cage. We went over what each part of the anatomy did and how they worked together. When the children drew Becky, they placed wires and tubes in her organs. I asked the children if they knew what a bruise was. They showed me their bruises from summertime play. Even the adults did not understand about the injury to Becky’s brain and appreciated the education.

As the clinical picture become clearer, the children surprised us by asking if they could see Becky. The family members decided that a visit by the children might be beneficial.

I was now confronted with the hospital policy prohibiting children in the critical care unit. I asked Becky’s parents to bring the children to the ICU door, while I informed the staff about the plan. I assured the staff members that I would take full responsibility for violating the policy.

The children entered the unit with wide eyes and stood at their sister’s bedside, where they told about every tube and its purpose. Becky’s 7-year-old sister softly took her sister’s hand and cried, as did the entire staff. Except for the hum of ventilators, the unit was quiet as these children of hope surrounded their sister’s bed, held hands, stroked her hair, sang her a song and said goodnight with prayers. I savored this moment in Becky’s journey. As a critical care nurse, there is nothing superior to this type of care giving.

Following the visit, Becky’s 7-year-old sister moved into Becky’s room to “keep things in order until she comes home.” Her brother slept for the first time in three nights. Her 4-year-old sister asked if she could have some of the tubes after they were removed.

Critical care nurses will continue to practice the highest standards of professionalism, including risk-taking. Making a difference is what critical care nursing exemplifies, particularly when the art of humanity in a technologically driven healthcare system is advocated.

The unit manager is currently revisiting the hospital’s visitation policy and the nurse council is advocating a nursing bereavement committee. As a critical care giver, I often ask, “If humanity is something we find meaningful only in the beginning of life and again only in the end, does that mean that everything that takes place during the journey means nothing?” Not for Becky and her family.

Oct. 1, 1999, Is Deadline to Apply for Grants

Several grants to fund research that is relevant to critical care nursing practice are available through AACN. The deadlines to submit proposals for three of these grants are approaching.

Sigma Theta Tau-AACN Critical Care Grant
Cosponsored by AACN and Sigma Theta Tau, this grant awards up to $10,000 to support research relevant to critical care nursing practice.

The principal investigator must be an RN, with preference given to members of AACN or Sigma Theta Tau. The proposed study may be used to meet the requirements of an academic degree.

Proposals must be received by Oct. 1, 1999.

AACN Data-Driven Clinical Practice Grant
Six awards of up to $1000 each are presented each year under this grant.

To be eligible, research must be focused on stimulating the use of patient-focused data or previously generated findings to develop, implement and evaluate changes in critical care nursing practice.

The principal investigators must be RNs and current AACN members. They may not be using another AACN research grant to conduct research. Proposed studies may be used to meet the requirements of an academic degree.

Applications must be received by Oct. 1, 1999.

AACN Critical Care Research Grant
This grant awards up to $6000 for studies that support one of AACN’s research priorities.

The principal investigator must be both an RN and a current AACN member. The proposed study may be used to meet the requirements of an academic degree.

Proposals must be received by Oct. 1, 1999.

To obtain a grant application, call (800) 899-AACN (2226) or Fax On Demand at (800) 222-6329 and request #1013. For more information about AACN research grants and projects that have been funded, visit the “Research” area of the AACN Web site at http://www.aacn.org.

Geriatric Corner: Practice Guidelines Must Address Special Needs of Elderly Patients

By Terry Fulmer, RN, PhD, FAAN, Codirector
and Mathy Mezey, RN, EdD, FAAN, Director
John A. Hartford Foundation Institute for Geriatric Nursing

Critical care practice by necessity is focused on the physiological parameters of the patients being served. Thus, the most important effort revolves around maintaining physiological function and restoring homeostasis for the person who is critically ill. However, when the urgent episode subsides, inappropriate practice guidelines and clinical approaches are often used in the care of older adults. Older individuals have less physiological reserve than younger ones and, therefore, are more likely to have dire consequences following critical care events such as cardiac or respiratory arrest. Further, there are associated geriatric syndromes, medication issues and problems that can be prevented if they are anticipated. With that in mind, we suggest that the following areas be addressed:

Rest and Recovery
Sleep disorders are prevalent in the elderly. During a critical care episode, sleeping and waking cycles are virtually destroyed, and REM (rapid eye motion) sleep is diminished. Because of the noise in an ICU, the intervention that might be available is less clear. Less sleep and more noise may trigger delirium. In one study,1 the effect of noise on the subjective quality of sleep was demonstrated in younger patients in a critical care unit. Improving critical care practice for the elderly requires attention to sleep deficits, which means appropriate rest and recovery time. This study should be repeated with elderly patients so that appropriate interventions can be developed. This is one example of a geriatric critical care study that would help build the science for improved caring.

Altered Eating and Feeding Patterns
Tubes and other devices, which can impede the ability to obtain adequate nutrition, are common in an intensive care unit. While total parenteral nutrition lines can be inserted to provide calories, the pleasure of eating is lost, as is the sensory stimulation (i.e., smell, taste, texture) of the food, which might increase appetite. Careful attention must be paid to weight loss in the elderly during the critical care episode. Because albumin levels may already be potentially compromised, the older individual will be at risk for pressure ulcers if their nutrition falls to critically low levels. Other reasons for impaired nutrition include mouth sores; dry, cracked mouths; or a lack of dentures. These issues may be overlooked in busy units.

Urinary Incontinence and Skin Breakdown
Foley catheters are regularly inserted in patients in the intensive care unit to monitor fluid balance. Nurses should question this practice. Do we know, for example, if fluid balance documentation would be less accurate if we avoided the use of a catheter? We know of no data to prove that intake and output records are less accurate when catheters are not used. To that end, a study of this nature would be an important contribution. What is known is that urinary catheters cause urinary tract infections, which are potentially lethal to the elderly. Thus, when possible, catheters should be avoided in the ICU. In addition, the use of incontinence undergarments should be avoided, given the propensity for skin irritation and breakdown.

Delirium Prevention
The ICU environment has been linked to delirium in the elderly. Disorientation to time or place because of overstimulation, pain and metabolic imbalances frequently results in cognitive changes. Optimally, critical care nurses must obtain a baseline mental status on the older patient upon admission and follow the changes through the use of a standardized assessment instrument such as a Mini-Mental State Examination.2 With a standardized assessment, early detection of subtle mental status changes could help prevent full-blown delirium states. Early detection and intervention can reduce the use of either physical or chemical restraints.
In summary, there is much to learn about the “best practice” in critical care for the elderly, but attention to the clinical parameters mentioned above is likely to improve the subjective and objective well-being for this group. The John A. Hartford Institute for Geriatric Nursing has developed the “Try This Series” to help initiate clinical practice guides for improving care management around a number of prevalent problems that the elderly face across the care continuum.3 These clinical guides may be especially useful in the ICU setting. As critical care serves an ever-increasing number of older adults, practice patterns that are uniquely suited to that group must be put into place.

References
1. Topf M., Bookman M., Arand D. (1996). Effects of critical care unit noise on the subjective quality of sleep. J Adv Nurs; 1996;24(3);545-51.
2. Folstein M., Folstein S. E., McHugh P. R. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research; 1975;12:189-198.
3. Try This Series: Best Practices in Care for Older Adults. New York, N.Y.: Hartford Institute for Geriatric Nursing; 1998.

Check out the Hartford Institute’s “Try This Series” clinical guides, which can be accessed through the AACN Web site at http://www.aacn.org. Click on “Practice/PRN,” then “Clinical Practice Links” and Continuum of Care.”

Practice Resource Network: Staffing Blueprint Emphasizes Patient-Focused Care

Q:Does AACN have resources that can help address staffing issues in this changing healthcare environment?

A:Adequate nurse staffing is critical to the delivery of quality patient care. As the demand for critical care services escalates, the optimal use of registered nurses’ time and expertise is an important strategy in delivering high quality care to patients and families.

This strategy involves many variables, including:
• Defining the needs of patients and allocating acute and critical care beds based on meeting those needs
• Providing adequate numbers of qualified, educated and competent RNs and support personnel
• Establishing efficient support systems
• Adhering to legal and regulatory requirements
• Evaluating the delivery of services through outcomes identification and quality measures

Staffing is both a process and an outcome. Often, it is difficult to define. Staffing can be expressed as the number of staff required to provide care to a set number of patients, or as the process in which human resources are used in an individual unit.

Solving a staffing problem involves a comprehensive strategic plan that links cost, implementation, competency and staff mix to patient outcomes. Staffing problems must first be identified, so that the descriptions of the key components and issues can be used to divide a complex problem such as staffing into more understandable and manageable parts.

Patient-focused care must begin when the patient enters the system and follow through to measure the impact that staffing makes. Included in the considerations are:
• Matching the appropriate caregiver with each patient
• Identifying systems that assist in the delivery of care
• Incorporating legal and regulatory considerations
• Measuring the outcome

The AACN Staffing Blueprint was created to assist direct care clinicians, managers and others in understanding the complexity of caring for patients in a changing healthcare environment. This resource responds to concerns about staffing issues and regulations that have been expressed by AACN members. It can be used to bridge communication, facilitate problem solving and promote patient-focused care.

Following are resources that were used in the development of this blueprint:
• Staffing Blueprint: Constructing Your Staffing Solutions. Medina J. ed. Aliso Viejo, CA: American Association of Critical-Care Nurses. 1999.
• Staffing: Nurse-to-Patient Ratios. 1995. (Document No. 2003 on Fax on Demand; [800] 222-6329.)

For more information about the AACN Staffing Blueprint, call (800) 899-AACN (2226), or visit the online Bookstore via the AACN Web site at http://www.aacn.org

Core Review Project Seeks Neonatal Nurse Participants

Contributors and reviewers are sought for the Core Review for Neonatal Intensive Care Nursing, a study reference for nurses preparing to take a national certification exam and a companion to the Core Curriculum for Neonatal Intensive Care Nursing.

Contributors must have experience writing test items and cannot currently be participating as an item writer or exam development committee member. Reviewers do not need test writing experience.

If you are interested in participating in this book project, which is cosponsored by AACN, Association of Women’s Health, Obstetric and Neonatal Nurses and National Association of Neonatal Nurses, contact the editor, Robin Watson, RN, at (310) 222-3269; e-mail, Ranboze@aol.com.

Share Your Practice Ideas With CCN

Have you found a unique or resourceful solution to a problem related to your critically ill patients? Are you using an innovative approach in caring for these patients and their families? Share your successes with your colleagues through the “In Our Unit” feature in Critical Care Nurse.

Send your ideas to: Critical Care Nurse, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, critnurse@aol.com.

Vox Populi: AACN Online Quick Poll

Have you considered looking for a job in the past 3 months?

Yes 65%
No 35%

How long is your ICU orientation for new graduate RNs?

We don't hire new grads in our ICU 21%
Less than two weeks 1%
Two to four weeks 5%
Greater than four weeks 72%

The AACN Online Quick Poll surveys a variety of topics. Participate by visiting the AACN Web site at http://www.aacn.org.

New ACNP Review Course on Video

Are you an advanced practice nurse preparing to take the acute care nurse practitioner (ACNP) Certification Exam? If so, this review course is for you.

Recorded from the 1999 NTI preconference, this 6-hour course features national clinical experts, who provide tips on how to study for the exam. The program addresses cardiovascular, pulmonary, renal, hematology, oncology, immunology and neurology topics as well as health promotion, risk assessment, professionalism and trends in acute care nurse practitioner practice.

A 95-page comprehensive syllabus accompanies the video or audio program. Included are sample questions, test-taking tips and the ACNP testing blueprint.

This program includes 8.0 contact hours of Category A CE credit.

Special introductory price*

7-videotape set, plus 95-page syllabus
Item #128881
Price $170 (nonmembers $220.00)
plus shipping and handling

4-audiotape set, plus 95-page syllabus
Item #128882
Price $79 (nonmembers $109)
plus shipping and handling

To order, call (800) 899-AACN (2226).

*Free audiotape! All orders received by Oct. 31, 1999, receive a free audiocassette, titled “The Acute Care Nurse Practitioner: Is the Role Being Utilized to the Fullest” by Stacy Gross and Maria fe Manglia.

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