AACN News—April 2001—Practice

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Vol. 18, No. 4, APRIL 2001

At Loggerheads: Understanding Patient Autonomy

By Rosemary Lee, RN, MSN, CCRN
Member, Ethics Work Group

Jim was a 51-year-old businessman, who had just returned from an extended Caribbean cruise with his wife Betty. During the last few days of the cruise, he had not been feeling well and, upon docking in Miami before going home to Pennsylvania, he became seriously ill with fever and severe abdominal pain. He came to our emergency department, where he was diagnosed with acute necrotizing pancreatitis and was admitted to our critical care unit. Jim was moderately overweight and had a history of bipolar disorder, which was deemed under control.

Fluid resuscitation, hemodynamic stability, pain control and arresting the progression of the pancreatitis were goals of Jim’s physical care. Because he was accustomed to being in control, he actively participated in his care. Nevertheless, he and his wife were in a vulnerable position, because they were away from home and the support of friends and family.

Jim’s condition deteriorated rapidly. Multiple complications, including acute respiratory distress syndrome (ARDS), acute renal failure and coagulopathy, added to his instability. His initial complication was ARDS, which required a prolonged period of mechanical ventilation with our sedation protocol. He required a tracheostomy and developed pleural effusions requiring chest tubes. He required dialysis for approximately one month and his coagulopathy required the infusion of many blood products.

Our Social Services Department found a nearby hotel where Betty could stay. She was joined by their two children, both in their 20s. However, as Jim’s illness dragged on, the children needed to get back to their lives, and Betty was left on her own.

Initially, the nurses in the unit invited Betty to their homes for meals or took her laundry home to bring back freshly cleaned and pressed. Finally, one of the nurses asked Betty to move in with her for the duration of Jim’s illness. The caring practices of the staff made one so proud to be part of the team.

During Jim’s more than two-month stay in the unit, the collaboration among the healthcare disciplines was admirable. We were determined to get Jim through all the hurdles he faced. With time, he was weaned off the ventilator, his kidney function returned, he became hemodynamically stable and his coagulopathy was resolved. We clapped and cheered when he was transferred out of the unit to a regular nursing floor. Awed by his fighting spirit, we felt that we were all a part of his victory.

Unfortunately, less than a week later, Jim was back in our unit in a septic state. He was diagnosed with a large pancreatic abscess. Given the almost certain mortality associated with a pancreatic abscess, the surgeon told Jim that surgery was necessary to save his life. Jim asked if “that tube” had to go back down his throat. The surgeon responded that it did and that he might be on the ventilator for a few days. Intubation and a possible prolonged ventilator stay terrified Jim. He adamantly refused the surgery and went on to sign his own
do-not-resuscitate (DNR) form.

Betty was heartbroken. Reactions from the nursing staff varied. Many were sad and angry. The surgeon made numerous attempts to convince Jim to go through with the surgery, especially after coming so far. It was as if Jim came to his last hurdle and finally “hit the wall.” There was just no convincing him.

At this point, the nursing staff and the surgeon asked for an ethics consult. The group that was convened involved the Ethics Committee chairperson, a member of the Pastoral Care Dept., two physicians, Jim’s primary nurse and me, the critical care clinical nurse specialist (CNS). We requested that a psychiatric evaluation be ordered, with Jim’s approval, to ensure that his bipolar disorder was not interfering with his decision-making skills. He was deemed competent and able to make his own decisions.

Two members of the committee discussed the case with Jim. Although he was fully aware that he would probably die without the surgery, he considered that preferable to going back on the ventilator. He adamantly refused the pleas of his wife and children to undergo the surgery. He was convinced that, if he went back on the ventilator, he would never get off it, and he did not want to live like that. The Ethics Committee recommended that Jim be allowed to exercise his autonomy, though the fact that he had options and could change his mind was stressed to him.
Our psychiatric CNS was called in to assist not only the family, but also the staff in dealing with their feelings regarding Jim’s refusal of surgery. We were allowed to vent our frustrations and feelings, and we learned how we could be of support to each other. The psychiatric CNS also gave us insight into the thoughts and feelings Jim was experiencing and, though we may not have agreed, we learned to respect his decisions.

Eventually, his family and the healthcare team accepted Jim’s decision. The surgeon inserted a catheter to drain the abscess, but let Jim know that this was only palliative and not curative. Jim was placed on antibiotics and, eventually, stabilized and was transferred out of the unit. He was on a regular nursing floor for more than a month, undergoing repeated catheter changes and irrigations of the abscess site. His strength was still sapped. Finally, he asked to see the surgeon and told him: I can’t live like this either, I will take my chances and have the surgery.

After Jim revoked his DNR order, we began to see his resiliency surface again. He underwent the surgery, was extubated within 24 hours and recovered without complication. After nearly four months, he was finally ready to go back home to Pennsylvania.

The healthcare team was left with a new understanding of patient autonomy. Despite their disagreement with Jim’s initial decision, they became his advocate. In preparing this ethics case study, I asked several colleagues to critique it. One said: I am always interested in the fact that we rarely worry about a patient’s competency, if they are agreeing to do what we want.

Practice Resource Network: Frequently Asked Questions

Q:Where can I find information on the national standard for nurse-patient ratios in (ICU, step-down, telemetry) units?

A:This is a timely question, because the issue of nurse-patient ratios is on everyone’s mind. However, where you look for an answer depends on what you need or want to do with the information.

AACN’s position is that, because staffing should reflect the number and type of staff needed to meet a group of patients’ needs, expressing staffing numbers as a single staffing ratio or mix would be difficult.1 At best, a staffing ratio can be used to describe the use of human resources at different levels of care. If you are looking for ways to develop optimal scheduling or staffing numbers, refer to AACN’s Staffing Blueprint: Constructing Your Staffing Solutions.2 The blueprint is available by calling (800) 899-2226 (request Item #300117) or online via the “Bookstore” area of the AACN Web site at http://www.aacn.org.

If you want to know how your unit compares with staffing at similar units, you are looking for benchmark data, also called “dashboard indicators.” This is the administrative equivalent of the clinician’s evidence-based practice. How do we measure up to what others are doing? Benchmarking is defined as “a performance measurement tool used in conjunction with improvement initiatives to measure comparative operating performance and identify Best Practices.”3 A familiar example of benchmark data would be data on the length of stay numbers for a particular diagnosis-related group (DRG). The Health Care Finance Administration maintains the database against which you can compare your hospital’s length of stay for a particular diagnosis to determine if it is consistent with the national guidelines for that DRG.

There are no true national benchmark numbers for information such as nurse-patient ratios. These numbers would be useful only if you compared your unit with a similar unit at another hospital (same number of beds, same level of patient acuity, university vs. community hospital, etc.). Your hospital may already belong to a group made up of similar hospitals, such as your state hospital association, which may be able to give you this type of information.

Again, consider what you want to do with the information and then reframe the question to get that information. Understand that patient needs and acuity, the competencies of the staff, and the availability of resources are the best indicators for appropriate unit staffing.

Do you have a practice-related question? Call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or visit the “Practice” area of the AACN Web site at http://www.aacn.org.

1. Maintaining Patient-Focused Care in an Environment of Nursing Staff Shortages and Financial Constraints. A Statement from The American Association of Critical-Care Nurses.
November 2000.

2. Medina J, ed. Staffing Blueprint: Constructing Your Staffing Solutions. Aliso Viejo, Calif.:American Association of Critical-Care Nurses. 1999.
3. Information on benchmarking. Available at http://www.benchmarkingnetwork.com/Files/General.html. Accessed February 26, 2001.

Apply for a Nursing Research Grant

Several nursing research grants are available each year through AACN. Following is brief information on grants for which the deadlines to submit proposals are approaching.

American Nurses Foundation Research Grant
May 1, 2001, is the deadline to submit proposals for the $5,000 American Nurses Foundation (ANF) grant, sponsored by AACN. Available to both beginning and advanced nurse research, this grant requires that the principal investigator be an RN who has obtained at least a baccalaureate degree in nursing. Principal investigators who have received previous ANF funding are eligible to reapply three years from the date when the last grant was completed.

For more information about this grant, contact ANF at 600 Maryland Ave., SW, Suite 100W, Washington, DC 20024-2571; phone, 202) 651-7298; e-mail, anf@ana.org.

Medtronic Physio-Control AACN Small Grants Program

The Medtronic Physio-Control AACN Small Grants Program awards up to $1,500 to qualified individuals who are carrying out projects that focus on aspects of acute myocardial infarction resuscitation, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretative 12-lead electrocardiogram.

To be eligible for these grants, the principal investigators must be nurses who are current AACN members. Principal investigators who have received funding from AACN are ineligible to receive additional funding from AACN during the lifetime of the original award.

Proposals must be received by July 1, 2001.

To obtain a grant application for the Medtronic Physio Control AACN Small Grants Program, call (800) 899-2226 (request Item #1013), or visit the AACN Web site at http://www.aacn.org.

Research Corner: NINR Awards Invigorate Nursing Science: 62 AACN Members Receive Research Grants

By Patricia A. Grady, RN, PhD, FAAN
Director, National Institute of Nursing Research

Fifteen years ago, a small staff group within the nation’s foremost biomedical research organization—the National Institutes of Health (NIH)—came together to begin a nursing research center. It was at this center, which became the National Institute of Nursing Research (NINR), that the ongoing process began within the mainstream of biomedical and behavioral research to fund and conduct studies focusing on nursing research questions.

From an initial budget of about $16 million, the NINR has grown and expanded to a budget today that exceeds $104 million. Research findings continue to build the scientific evidence base that informs the practice of the nation’s 2.7 million nurses and impacts the health of the nation’s people. These findings include both clinical and basic investigations directed at patients and individuals within the context of their environments, including the home, family, community and institution—all of which are important influences in health and illness. A special emphasis is on subpopulations with special health needs, including older people, minorities, women, people in rural areas and those who are economically disadvantaged.

To maintain top quality nursing science, there must be a synergy between practice and research communities so that findings are useful to healthcare practitioners and the myriad health issues they confront. It is therefore important to sustain productive connections between the NINR and AACN, which so ably represents the critical care nursing community.

The support for research by AACN members has been heartening, as evidenced by the 62 members who have received research and training grants from the NINR.(See list of recipients and research projects below.) Their scientific projects are already helping to invigorate nursing science and advance nursing practice to a higher level on a number of fronts.

For example, AACN members are investigating the role of gender in silent ischemia; evaluating infants at risk for sudden death syndrome; examining, developing and testing health promotion strategies for children with cardiovascular risk factors; and testing interventions such as endotracheal suctioning in adults with head injuries. In addition, they are helping family caregivers deal with technological care in the home, including care involving ventilators.

More than 125 million Americans are living with at least one chronic condition, according to a recent Partnership for Solutions study led by Johns Hopkins University and the Robert Wood Johnson Foundation. That figure is expected to rise to about half the U.S. population by 2020. Nurse researchers are in the forefront of chronic illness research as they focus on managing symptoms, developing self-management techniques for patients and helping patients make the transition from hospitals to home settings.

Investigators have determined that disrupted sleep patterns may be an important factor in fibromyalgia. This finding provides hope for developing remedial nursing interventions to ease the occurrence and effects of abnormal sleep. Nurse researchers have tested a successful arthritis self-management program for Spanish-speaking patients. Participants showed significant improvements in their health, particularly in such areas as range of motion, pain relief and self-esteem. They have evaluated a Transitional Care Model, which utilizes advanced practice nurses in comprehensive discharge planning and home follow-up for patients hospitalized for various conditions. One use of the model has reduced by 48% rehospitalizations and length of hospital stays for elderly patients with common medical and surgical conditions, and has resulted in reduced costs to the healthcare system.

Other findings have potential to influence practice in hospital settings. Cost savings are being generated by a new procedure to ensure that feeding tubes are positioned properly. This procedure measures pH and bilirubin levels in aspirated contents of feeding tubes and avoids the need to use x-rays, which are more costly and disruptive to the patient. Although pain management for very low birthweight infants is problematic, pacifiers with sucrose or sterile water have been found to significantly reduce procedural pain in these babies, compared to other methods commonly used.

An increasingly important issue to the public is care at the end of life. Most patients die in the hospital, and critical care nurses are frequently faced with the complex issues of providing pain management, helping the patient and family make choices about care, and ensuring quality of life and dignity for the patient until life’s end. The NINR is the coordinator for end-of-life and palliative care research at the NIH. Although this is a new area of science, the response of the research community has been immediate and pertinent. The grants address such end-of-life issues as advance directives and other important decisions; ethnic and cultural differences in approaching death; use of technology to prolong life in older patients; and depression, control of pain and other typical symptoms. Findings from these studies should help practitioners manage this difficult but crucial area of patient care.

The nursing shortage is receiving considerable national attention and has significant impact not only on staffing in critical care units, but also on generating future nurse researchers. Because nurse researchers produce scientific knowledge that enriches clinical practice, there must be a sufficient number to create such knowledge and to respond to future health challenges. To meet this demand, the NINR is increasing emphasis on recruiting and training the next generation of nurse researchers. Efforts will focus on ways to attract nurses to the field of research and on programs that provide pre- and post-doctoral training and research opportunities.

Critical care nursing is in the forefront of healthcare. It is changing people’s lives and saving their lives. It is ensuring that the human and ethical aspects of care are maintained in the face of technological interventions, complex decisions and environmental distractions. And, despite the shortage, AACN is endeavoring to meet the increasing critical care needs for expertise, resilience and sensitivity.

The NINR commends AACN and looks forward to a continued close relationship in which knowledge and experience to shape and improve the healthcare system and the lives of the critically ill can be shared.

If you would like more information about nursing research and AACN’s grants programs, e-mail research@aacn.org, or visit the “Clinical Practice” area of the AACN Web site at http://www.aacn.org.

Congratulations to NINR Grant Recipients

Research Project Grants
Susan E. Auvil-Novak, RN, PhD—Efficacy of Chronotherapeutic vs. Traditional PCA Therapy
Judith G. Baggs, RN, PhD, BA—ICU Culture and Problematic Treatment Limitation Cases
Mara M. Baun, RN, DNSc, BA—Endotracheal Suctioning—Open vs. Closed Systems
Diane K. Boyle, RN, PhD, CS—Enhancing Nurse/Physician Collaboration in ICUs
Jo Ann Brooks-Brunn, RN, DNS, FAAN—Predictors of Postoperative Atelectasis Pneumonia
Angela P. Clark, RN, PhD, CS—Nursing Interventions and Mixed Venous Oxygen Saturation
John M. Clochesy, RN, PhD, CS, FAAN, FCCM—LV Function and Duration of Mechanical Ventilation
Jean E. Demartinis, RN, PhD—Exploring Women's Recovery Experience after MI
Cindy Dougherty, RN, PhD, NP—Nursing Interventions Following Sudden Cardiac Arrest— Exercise To Improve HRV in Arrhythmias
Kathleen Dracup, RN, DNSc, FAAN—Nursing Intervention—Infants At Risk For Sudden Death
Barbara J. Drew, RN, PhD, FAAN—Nursing Strategy For Cardiac Ischemia Monitoring
Sandra B. Dunbar, RN, DSN, FAAN—Cardiovascular Circadian Patterns in the Elderly—Adaptation to The Internal Cardioverter Defibrillator—Psychoeducational
Intervention or ICD Patients

Kathleen L. Grady, RN, PhD, FAAN—Quality of Life Outcomes≥5 yrs. Post Heart Transplant
Mary Jo Grap, RN, PhD, ACNP—Backrest Position and Oral Health—Effect on VAP
Sandra Hanneman, RN, PhD, FAAN—Biorhythms During Mechanical Ventilation and Weaning
Joanne S. Harrell, RN, PhD, BA, FAAN—Health Promotion in Children: CV Risk Factors—Cardiovascular Health in Children and Youth—CHIC II—Energy Expenditures of Physical
Activities in Youth

Lisa Hopp, RN, PhD, BA—Incremental Threshold Loading In Healthy Subjects
Nalini Jairath, RN, PhD—Risk Reduction of Sedentary Behavior Post CABG Surgery
Marguerite Kearney, RN, PhD—Estrogen/Platelet Interaction in Cerebral Ischemia
Ruth M. Kleinpell-Nowell, RN, PhD, CCRN, CS—Exploring Outcomes After Critical Illness in the Family
Dorothy M. Lanuza, RN, PhD—Quality of Life Outcomes—Pre and Post Lung Transplants
Christine L. Latham, RN, DNSc—Predictors of Successful Hispanic Diabetes Management
Sharon L Lewis, RN, PhD, FAAN—Relaxation Therapy for Alzheimer's Caregivers
Susan Ludington, RN, PhD, CNM, NP—Skin to Skin Contact for Preterm Infants and Their Mothers—Pulmonary Improvement for Preterm Infants
Kathleen A. Puntillo, RN, DNSc, FAAN—Analgesic Therapy Outcomes in the Emergency Department
Ellen B. Rudy, RN, PhD, FAAN—Endotracheal Suctioning—In Head Injured Adults—Menstrual Response to Running: Nursing Implication
Mary Jane Sauve, RN, DNSc—Patterns of Cognitive Recovery in Sudden Death Survivors
Shyang Yun Pam Shiao, RN, PhD—Oxygen Saturation Monitoring in Neonates
Carol E. Smith, RN, PhD—Technological Home Care—Costs and Quality of Life
Sue A. Thomas, RN, PhD—Psychosocial Factors in Sudden Cardiac Death
Barbara S. Turner, RN, PhD, FAAN—Endotracheal Suctioning in Newborns
Jill M. White, RN, PhD—Effects of Relaxing Music After Myocardial Infarction
Ann W. Wieseke, RN, DNS—Maternal Depressive Symptoms—Risk Factors
Jo Anne M. Youngblut, RN, PhD, FAAN—Nursing: Maternal Employment and LBW Infant Outcomes—Child and Family Functioning After Pediatric Head Trauma—Physiologic-
BEH-Family Approach To Child Chronic Illness

Julie Johnson Zerwic, RN, PhD—Recognition of a Myocardial Infarction--Reducing Delay

Predoctoral Fellowships
Karen O. Badellino, RN, PhD—Metabolism and Regulation of Amyloid Protein in Platelets
Judith G. Baggs, RN, PhD, BA—Utilization of The Medical Intensive Care Unit
Rhonda M. Board, RN, PhD, CCRN—Long-Term Effects of PICU Hospitalization on Family
Laura J. Burke, RN, PhD, FAAN—Experiences of Persons with Implanted Defibrillators
Elizabeth Carlson, RN, DNSc—Patient Classification Tool for Home Care Agencies
Diane L. Carroll, RN, PhD—Recovery in The Elderly After Coronary Bypass Surgery
Dianne J. Christopherson, RN, PhD—Exercise and Hormone Therapy: Lipid Change in Menopausal
Lynn V. Doering, RN, DNSc, BA—Effect of Postural Change in Heart Transplant Patients
Cindy Dougherty, RN, PhD, NP—Nursing Therapeutics and Sudden Cardiac Death
Barbara J. Drew, RN, PhD, FAAN—Differentiation of Wide QRS Complex Tachycardias
Anna F. Gawlinski, RN, DNS, CCNS, CCRN, CS, NP, FAAN—Effect of Positioning on Sv02 In the Critically Ill
Mary Beth Happ, RN, PhD—Treatment Interference in Critically Ill Elders
Sonya R. Hardin, RN, PhD, CCRN—Applachian Widows
Lisa J. Hopp, RN, PhD, BA—Threshold & Alinear Resistive Inspiratory Muscle Training—Inspiratory Muscle Endurance Testing in COPD
Linda C. Hughes, RN, PhD—Organizational Climate For Caring In Schools of Nursing
Paul F. Langlois, RN, PhD—Quality of Life of Critically Ill Elderly Patients
Christine L. Latham, RN, DNSc—Humanistic Caring: Life Stage Values and Expectations
Cindy L. Munro, RN, PhD, NP—Exopolymers: Virulence Factors in S Mutans Endocarditis
Patricia A. O'Malley, RN, PhD, CCRN—Hemodynamic Consequences of Weaning
Nancy S. Redeker, RNC, PhD, BA—Pain in Critically Ill Patients
Ellen M. Robinson, RN, PhD—Surrogate Experience—LST Decision for Alzheimer Patient
Anne G. Rosenfeld, RN, PhD—Experience of Heart Disease: Women and Their Families
Linda F. Samson, RNC, PhD, CNAA—The Effects on Drugs on Neonatal Nursing Care
Shyang Yun Pam Shiao, RN, PhD—Nursing: Gastric Tube Placements in VLBW Infants
Marita G. Titler, RN, PhD, FAAN—Nursing Interventions for Interstitial Lung Disease
Mary Tittle, RN, PhD, AA—Utilization of Nursing Research by Critical Care Nurses
Barbara J. Waag-Carlson, RN, PhD—Sleep/Nighttime Vital Function in the Elderly
Deidre D. Wipke-Tevis, RN, PhD—Ischemia: A Critical Factor in Impaired Wound Healing
Jo Anne M. Youngblut, RN, PhD, FAAN—Nursing Assessment; Siblings of Pediatric ICU Patients

Postdoctoral Fellowships
Jo Ann Brooks-Brunn, RN, DNS, FAAN—Predictors of Postoperative Pulmonary Complications
Cindy Dougherty, RN, PhD, NP—Family Experiences Following Sudden Cardiac Arrest

Center Grant
Joanne S. Harrell, RN, PhD, BA, FAAN—Preventing/Managing Chronic Illness in Vulnerable People

Career Development Awards
Marguerite Kearney, RN, PhD—Post Ischemic Platelet Function—Young vs. Adult
Arlene Keeling, RN, PhD—Historical Investigation of Coronary Care Units
Sharon L. Lewis, RN, PhD, FAAN—Altered Immune Responses in Chronic Dialysis Patients
Ptlene Minick, RN, PhD—Nursing Expertise and Its Relationship to Patient Outcomes
Carol E. Smith, RN, PhD—Adaptation In Families with Technological Care at Home
Jacqueline E. Sullivan, RN, PhD, CCRN—Physiologic Outcomes of Positioning in Acute Head Trauma

Training Grant
Karin T. Kirchhoff, RN, PhD, FAAN—Research Training in Nursing Intervention
Jo Anne M. Youngblut, RN, PhD, FAAN—Childbearing, Childbearing, Caregiving Research Training

Be an Entrepreneur: Create Opportunities for A New Life Adventure

By Kathleen M. Vollman, RN, MSN, CCNS, CCRN
Member, Advanced Practice Work Group

Today’s significant healthcare reform offers advanced practice nurses unique opportunities to embark on entrepreneurial adventures.

Do I have what it takes to succeed? How is my business unique? Who would use my product and how extensive is the market? These are just a few of the questions nurses must ask themselves before embarking on an entrepreneurial journey.

Define Entrepreneurship
As an innovator, an entrepreneur must exploit change as an opportunity to provide products, services or new business enterprises. Although this involves an inventive approach, it also requires action to create viable products and services.

An entrepreneur can be described as an individual with a taste for adventure, a penchant toward risk-taking, a resiliency that allows them to jump up after being slapped down and a great independent spirit. Most advanced practice nurses I know possess these skills.

How do you identify which of your skills and abilities would contribute or serve as a barrier to creating a business? Every budding entrepreneur should perform a SWOT analysis to identify his or her strengths, weaknesses, opportunities and threats.

Assess Skills
Which skills and attributes do you need to become a successful entrepreneur?

First, you must be success-minded, because you will be the key to and driving force behind the success of your business. You must possess a passion for and a commitment to attaining what you want. Often, the new entrepreneur must straddle the demands of a “9-to-5 job” and starting a business. This will take all the energy and passion you can muster. Being success-minded requires exploring all options and alternatives until a solution is reached to accomplish the task. In addition, a detailed plan to achieve specific goals must be developed.
Self-empowerment is the second attribute necessary for success. This provides us with the authority to make or sustain change in our life, to be in control and to believe in ourselves.
The third factor leading to success is a thorough evaluation and understanding of the skills and attributes you already possess that contribute to a successful business (Table 1). Skills such as time management, problem solving and task orientation are familiar to the nurse and are essential in business. What is usually missing in most nurses’ toolbox are the general knowledge and skill of business planning and financial management. Many resources are available to help nurses acquire these missing links of knowledge. Small Business Administration (SBA) seminars, community colleges and professional associations are just a few that provide the necessary resources to obtain business knowledge.

Protect Ideas
The next step in entrepreneurship is generating an idea. Successful business ideas usually arise from developing solutions to problems that exist in our everyday work and personal lives. There are a number of ways that can be examined in discovering opportunities that work.

Look toward the future. Where will nursing practice be in 10 years and who will use nursing services? How will it be regulated? By answering these questions, opportunities for business ventures become clear.

Look for the plausible impossible. When you have an idea that would be wonderful if it was possible, you are on the edge of a discovery. Look for the obstacles in your current environment and, if you can solve a problem that once seemed unsolvable, you may have a golden opportunity.

Look for castaways. Consider ideas and products that might remain unexplored, unnoticed or left on the cutting room floor. Many of these idea castaways may have new and needed application.

Once the idea is formulated, it must be analyzed to determine the level of protection that is required. There are three levels of protection for ideas. A copyright protects the tangible expression of an idea. A trademark provides the owner with the right to exclude others from using confusingly similar product identification in commerce. A patent provides the owner with the right to exclude others from making, using or selling the invention throughout the United States. It is the granting of intellectual property rights.

Think seriously before giving away an idea. How many nurses have been engaged in conversation with sales representatives at an exhibit and shared how the manufacturer could make a product better by a simple change? Remember that an idea is intellectual property—your brain trust—and any consideration of sharing that idea needs to be classified as a consultation that requires a fee.

The concepts or ideas created must come from current knowledge, skills or abilities. If a business is launched to learn new skills the chance of success diminishes significantly. Once you have singled out an idea, hold it up to the mirror of competition. Conduct a competitive analysis, asking questions similar to a market survey. Who has it? How do they promote it? What features or advantages do they offer the customer? What is the price? Where do they get their customers? What is the quality like? Are their customers satisfied? The answers to these questions will help you determine what is needed to rise above the competition.

Have a Business Plan
A business plan is essential, because even dreams need workable plans in order to take the journey armed with as many resources and as much information as possible. A business plan forces you to take a realistic, objective look at your business. A number of computer-based, how-to programs can help you create the first draft of a business plan. Consultative services for business plan development are also available through local SBA offices. It is important to write the first draft of the plan yourself. You need to live it, breathe it and make it yours. Then, ask someone who writes business plans for a living to review and critique the document.

Once the business plan is completed, the type of legal structure used to house the business needs to be determined. How do I decide what business organization/structure would be the most beneficial or appropriate for what I am attempting to do? There are three major types of business structures: sole proprietorship, partnership and a corporation. Because the choice depends on a number of factors, seeking expert advice to determine the best option for your business and the best protection for you as the owner is highly recommended.

Keep the Drive Alive
Through all this effort, how can you keep the idea and yourself afloat? How do you keep the energy and spirit going? Who can you lean on for answers to the unknown?
The answer is networking. Find mentors who have experience in personal assessment, business startup or a skill that is missing or weak in you. Mentors can be found through association contacts, list serves and Web sites. The resources available to advanced practice nurses are endless; they just need to be tapped. Networking can also generate business and lead to other ventures.

Nurse entrepreneurial roles encompass a wide variety of options ( Table 2). A more traditional role might include starting a single product or service business, such as educational seminars, a temporary help agency or a medical-legal business.

Another type of entrepreneurial role that might be unique to nursing is called virtual nurse entrepreneurship. A virtual entrepreneur is one who services multiple industries by offering an array of skills to meet a variety of industry demands. Advanced practice nurses serve this role well. An example of this role might be an individual who lectures professionally, invents, serves as an expert witness or consults to various aspects of the healthcare industry while maintaining a clinical practice.

Regardless of the road you choose, learn to enjoy the hunt. It is in the moment of transition and rushing to a goal that the power resides. The avenues for creativity and advancement are limitless. Don’t wait to hear yourself say, “I thought about doing that,” as you stand by and watch your idea being developed and marketed by someone else. Seize the moment, for the climate for creativity and change is ripe.

Following is a list of contacts or network opportunities to seek out:
1. Nurse Entrepreneur: Building the Bridge of Opportunity
2. National Association for Female Executives (NAFE), P.O.Box 469031, Escondido, CA 92046-9924; phone, (800) 634-NAFE (6233)
3. Women's Network for Entrepreneurial Training (WNET) through NAFE
4. U.S. Small Business Administration, 1441 L Street, NW, Washington, DC 20416; phone, (800) U-ASK-SBA (827-5722); Web site, http://www.sba.gov
5. National Nurses in Business Association, (877) 353-8888, Web site,
6. Nurse Consultants Association, 414 Plaza Drive, Suite 209, Westmont, IL 60559
7. Register of Copyrights, Library of Congress, Washington, DC 20559; phone, (202) 707-3000; Web site, http://www.loc.gov/copyright
8. What is a Patent, American Bar Association, Section of Patent, Trademark & Copyright Law
9. TRW Credit Report, Box 2350, Chatsworth, CA 91313-2350
10. U.S. Patent & Trademark Office, (800) 786-9199; Web site, http://www.uspto.gov
11. IRS Publication 334: Tax Guide for Small Business, Publication 583: Taxpayers Starting a Business and Publication 587: Business Use of Your Home; Web site, http://www.irs.gov

Table 1. Nursing Skills

Priority setting

Decision making

Time management


People management

Ability to listen

Problem solving


Advanced education & training

Task orientation

Table 2. Examples of Entrepreneurial Roles

Healthcare system consultant/nursing delivery systems

Education/seminar business

Nurse practitioner business

Temporary agency

Wound care management business

Consultant to healthcare product industry

Congestive heart failure clinic


Professional lecturer

Legal/medical business

Case management system

Consulting on products, healthcare systems, professional nursing structures

Consultant to architectural firm

Wellness clinic

Product invention

Consultant to TV/film

Vox Populi: AACN Online Quick Poll Update

Do you have a clinical nurse specialist practicing in your ICU?

Yes 37%
No 63%

Number of Responses: 1,559

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. We present these surveys to give our users an opportunity to share their opinions on particular topics. Participate by visiting the AACN Web site at http://www.aacn.org.
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