AACN News—August 2001—Practice

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Vol. 18, No. 8, AUGUST 2001

Funds Support Nursing Research

AACN awards several grants to fund studies that are relevant to critical care nursing practice. The deadlines to apply for some of these grants are approaching. Read on for more information about these grants:

Agilent Technologies-AACN Critical Care Nursing Research Grant
Cosponsored by AACN and Agilent Technologies, this grant awards up to $35,000—including $33,000 for the research and $2,000 toward travel expenses associated with presentations of the study findings. In addition, up to $3,000 of the grant may be used to purchase a computer, software and a printer to support the study.

The preferred topic for this grant is the information technology requirements of patient management in critical care. The award selection will be based on the scientific merit of the project, the scientific and professional background of the applicant, the adequacy of facilities and resources available for the research, originality and potential benefits to the care of critically ill patients. Applications must be received by Sept. 1, 2001.

Evidence-Based Clinical Practice Grant
This grant funds up to $1,000 to stimulate the use of patient-focused data or previously generated research findings to develop, implement and evaluate changes in acute and critical care nursing practice. Eligible projects may include research utilization, CQI or outcomes evaluation. Interdisciplinary and collaborative projects are encouraged. The next application deadline is Oct. 1, 2001.

AACN Clinical Practice Grant
This grant awards $6,000 to support research that focuses on one or more of AACN’s research priorities. Applications are due by Oct. 1, 2001.

AACN-Sigma Theta Tau Critical Care Grant
Cosponsored by AACN and Sigma Theta Tau, this grant awards up to $10,000. Applicants must be members of either AACN or Sigma Theta Tau. Applications are due Oct. 1, 2001.

To obtain grant application materials, call (800) 899-2226 and request Item #1013, or visit the "Clinical Practice" area of the AACN Web site at http://www.aacn.org.

Members Respond to ‘Practice Resource Network: Frequently Asked Questions’ Column Advice

AAACN recently received letters from members regarding our response to a question posed to the Practice Resource Network about how to handle a situation involving an abusive physician. Our initial response was published in the “Practice Resource Network: Frequently Asked Questions” column that appeared in the June 2001 issue of AACN News. Following are these letters, as well as some additional information regarding this complex issue.

Abusive Behavior Must Be Documented
Your advice regarding how to handle an abusive physician (AACN News, June 2001) was poor. In effect, your answer further victimized this nurse. Suggesting that she confront the abuser at a time that is “good for him” only exposes her to more potential abuse. Suggesting that she do talk with him in private sets her up for a “she said, he said” situation.

You also suggest that the entire department set up standards for behavior and sign a contract. Why do nursing administrators insist on dragging everyone down instead of confronting the one problem-maker?

This nurse needs to talk with her immediate supervisor and document this conversation. She needs to then talk with her supervisor’s supervisor and let her or him know that she expects to be provided a work environment free from abuse. She needs to document the abuse behavior and report her employer to the labor board in her area.

Most states have laws about workplace abuse. This nurse has been abused twice: once by the physician and again by her own colleagues. You really goofed.
Dee Harari, RN, ADN, BA, CCRN
Orange, Calif.

Conflict and Abuse Are Different Issues
In the June 2001 issue of the AACN NEWS, a question was posed to the Practice Resource Network regarding how to handle the abusive and hostile behavior of a physician. The answer given was somewhat unsettling to us. We are amazed that the first five interventions listed are directed at changing the behavior of the person receiving the abuse, at finding out what she is doing to elicit this behavior.

Conflict and abuse are very different concepts. If there was a conflict in the situation the nurse describes, she might need guidance or assistance in dealing with the situation in a positive manner. However, the behavior described is verbal abuse, also known as harassment.

The fact that one staff member has already left the unit as a result of this physician’s behavior indicates that the unit management, as well as the hospital administration accept staff abuse as part of the staff nurse’s job. It is also apparent that the administration of the hospital has made this a part of the hospital culture. Where is the hospital’s “Disruptive Practitioner Policy? Why does the manager tolerate such behavior?

We expect the answer given by our professional organization to be based on what is morally, ethically and legally right on the issue presented: What will make working conditions more tolerable for the whole.

There is a new generation of women entering college and the workplace with a whole new perspective and a new way of handling hostile work environments. They just move on to another profession. We think it imperative that we change this “doctor/nurse” culture if we wish to attract qualified people to our profession.
Denise E. Antle, RN, MSN, CCRN
Davenport, Iowa
Kaaren Nelson, RN, BSN
Sherrard, Ill.

We Heard You! Read on for More Strategies
Thank you for taking the time to share your thoughts about our response to the question about managing an abusive physician. Your views helped us to realize that our response to this critical practice issue was incomplete. We apologize for not recognizing this at the time.

The response that was published was only a first-level strategy to deal with abusive behavior. In rereading the question, the situation described seems to have gone on unaddressed for a long time and, therefore, as you suggested, more aggressive strategies are warranted.

Strategies that have been successfully used by others in this situation include:
• First, gather strength in numbers. Collaborate with three to four of your colleagues who will agree to join you in bringing this unacceptable situation to the attention of the administration of the organization. Having a chorus of voices saying the same thing is often the most effective way to get people’s attention and provides peer support in this difficult situation.
• As a group, go to your manager, the director of the area and the medical director of the unit. Let them know the situation has become intolerable and must be addressed. Obviously, the physician’s behavior is having a dramatic negative effect on the work environment that will lead to the resignation of nurses in a time of a national shortage, and the safety of patients is being jeopardized because of ineffective communication between the physician and the nurses who are driven by fear and abuse. The chief nursing officer is another person who should be informed about the situation, and you may want to consider a separate appointment with him or her after you have met with your manager and directors.
• If this strategy does not result in a timely response by your administrators, make an appointment with your Human Resources administrator to explore other avenues to bring this situation to the forefront. Ask for information on laws governing harassment in the workplace, whistleblower protections, regulatory bodies in your state where physician practice issues can be addressed, and other bodies within the organization or state to which you can bring this complaint. Your state nurses association can be another avenue for state-level resources for reporting this situation.

Thank you again for raising the issue and providing feedback. If you or any other members need additional consultation in implementing an action plan to bring this type situation to the attention of your organization, feel free to contact the Practice Resource Network at (800) 394-5995, ext. 217.

Submit Abstracts for NTI 2002

Sept. 1, 2001, is the deadline to submit research and creative solutions abstracts for AACN’s National Teaching Institute™ and Critical Care Exposition, scheduled for May 4 through 9, 2002, in Atlanta, Ga.

Accepted abstracts will be designated either as an oral presentation or as a poster presentation. Presenters of selected abstracts receive a $75 reduction in NTI registration fees. All other expenses are the responsibility of the presenter, who can be either the first author or a designate of the author.

To obtain abstract forms, call (800) 899-2226, and request Item #6007, or visit the “Clinical Practice” area of the AACN Web site at http://www.aacn.org.

Chronic Critically Ill Patients Pose Special Challenges

Barbara Daly delivered the
Distinguished Research Lecture
at NTI 2001 in Anaheim, Calif.

One of the most complicated issues facing critical care nurses today is how to care for patients who are chronically critically ill. This subset of critical care patients presents a challenge to the standard ICU, largely because long-term dependency on technology has acute physical and emotional effects.

Improving outcomes for these patients has been a special area of interest for Barbara Daly, RN, MSN, PhD, FAAN, the 2001 AACN Circle of Excellence Distinguished Research Lecturer Award recipient. Her Distinguished Research Lecture presentation, titled “Perspectives on the Chronically Critically Ill,” was delivered at AACN’s National Teaching Institute™ and Critical Care Exposition in May 2001 in Anaheim, Calif.

Now, Daly is part of a team of researchers at Case Western Reserve University, Cleveland, Ohio, who are studying an intervention designed to reduce healthcare costs and improve outcomes for chronically critically ill patients who are discharged from hospitals. Daly is associate professor of nursing at the Frances Payne Bolton School of Nursing at Case Western Reserve University.

The $1.6 million, three-year study, funded by the National Institute of Nursing Research of the National Institutes of Health, Bethesda, Md., is the first to test an outpatient intervention targeting this costly patient population.

The study will follow 400 patients who have been discharged from University Hospitals of Cleveland to either extended care facilities or to their homes with the assistance of home healthcare services. The patients will be randomly assigned to either a control group, which will receive the usually prescribed post-discharge care, or to an experimental group, which will receive this care under the supervision of an advanced practice nurse serving as a case manager.

This study will build on earlier studies in which Daly has been involved, including research that demonstrated improved clinical outcomes and reduced inpatient costs for chronically critically ill patients who were cared for in a unit designed specifically to meet their needs. That 1996 study showed that 40% of the chronically critically ill patients in the traditional ICU died, compared to 30% in the specially designed ICU.

“That is a big difference when discussing patients survival rates,” she said.

The new study will use some of the effective features of this type of special care unit in the first two months of the postdischarge period.

Long-Term Care
“The typical ICU patient gets sick quickly and requires a significant amount of aggressive treatment,” Daly said. “While the patient who is chronically critically ill also gets sick, they remain sick and in need of intensive care for a long time.”

The critical care staff cannot control every aspect of these patients’ lives, she said. Taking into consideration factors, such as stress, depression and disruption of sleeping patterns, will help the staff support patients through a difficult period of recovery.

Daly stressed that patients who are chronically critically ill are at a higher risk for morbidity than patients who have short-term acute illness.

“There is no question that anyone who goes into the trajectory of a long ICU stay while being hooked up to a ventilator is going to be a high-risk patient,” Daly said.

The most immediate and widely recognized effect of long-term dependency on a ventilator unit is weakened respiratory muscles. Other effects include cardiac problems brought on by the constant inflation of the lungs by the ventilator unit, gastrointestinal problems resulting from the positive chest pressure and the psychological effects of reliance on a mechanical system for one of the body’s most primary functions.

Daly said that the best way to help chronically critically care patients is to treat them in an environment that is designed for long-term care. Regardless of the size and amount of resources that a hospital has, steps can be taken to ensure that continuity of care is addressed.

“The chronic critical care patient does not do well with a different nurse taking care of them every day,” said Daly. “Continuity is crucial to the chronic patient’s physical and emotional well-being.”

Ethical Considerations
There is an important link between the mechanics and the ethics of caring for the patient who is chronically critically ill, Daly said. To make this crucial connection, “we must ask deeper, more fundamental questions to determine what is truly important in healthcare. If we do not, we run the risk of making decisions for the wrong reasons.”

She added that critical care nurses can help with many of these ethical issues in a way in which technology is incapable.

“In terms of research with the chronically critically ill, we have found that, although sophisticated, technologically oriented care is necessary for patients’ survival, it is not sufficient by itself,” said Daly.

The kind of care that makes a difference to the chronic critical care patient may be “as simple as figuring out how to get a patient who is hooked up to 47 different machines into a wheelchair and out to the hospital courtyard,” she added.

Daly is a proponent of setting goals for patient care, prior to any decision making about treatment.

“Knowing the desired outcome of care allows for a strategy that incorporates both ethical and scientific considerations,” she said.

Nurses Make the Difference
Daly said she considers the chronically, critically ill patient the “quintessential nursing patient,” because this patient requires the attention and continuity of care that critical care nurses are so good at providing.

“Nurses can make the difference more with this type of patient than any other,” said Daly. “It’s not the therapy, not the medication, not the social workers.

“While these factors and people are important and necessary for care of the chronically critical ill patient, it’s you [nurses] who makes the biggest difference [in patient care].”

AACN Distinguished Research Lecturer Award Goes to Barbara Drew for 2002

Barbara Drew, RN, DNSc, FAAN, of San Francisco, Calif., has been selected to receive the AACN Distinguished Research Lecturer Award for 2002. She will present the Distinguished Research Lecture at AACN’s National Teaching Institute™ and Critical Care Exposition, May 4 through 9, 2002, in Atlanta, Ga.

The Distinguished Research Lecturer Award, part of the AACN Circle of Excellence recognition program, honors nationally known researchers. The selected lecturer receives an honorarium of $1,000, as well as $1,000 toward NTI expenses.

Drew is professor and vice chair of academic programs in the Department of Physiological Nursing of the School of Nursing at the University of California, San Francisco.

In 1991, she was recipient of the first Hewlett Packard (now Agilent)-AACN Critical Care Nursing Research Grant. The study evaluated the diagnostic accuracy of a new ECG lead method and its advantages for bedside cardiac monitoring. In addition, Drew was one of the first mentors in the Wyeth-Ayerst Nursing Fellows Program.

A member of AACN since 1973, Drew has been an invited speaker and research presenter at the NTI, as well as a speaker at numerous chapter programs across the country. She is a member of the San Francisco Chapter of AACN.

Drew has contributed as an author, editorial board member and reviewer for the American Journal of Critical Care and serves as feature editor for Progress in Cardiovascular Nursing.

Practice Resource Network: Frequently Asked Questions

QI read in the “Advanced Practice” column in the May 2001 issue of AACN News that resources are available to measure practice outcomes. Can you give me more information?

AAACN is currently recommending two resources. The first is a book titled Outcomes Assessment in Advanced Practice Nursing, edited by Ruth Kleinpell, RN, PhD, CCRN, CS, and published by Springer. This is an excellent resource for any nurse who is being asked to document his or her outcomes. Covered are ways to develop reliable and valid outcomes measurement tools and examples of how outcomes measurement have been implemented in each of the four recognized advanced practice roles. This book can be ordered by calling AACN at (800) 899-2226 (Request Item # 390100), or by visiting the “Bookstore” area of the AACN Web site at http://www.aacn.org. Price is $35 ($42.95 for nonmembers).

The second resource is an article titled “Measuring Advanced Practice Nursing Outcomes,” by Kleinpell and Teresa Weiner, RN, MSN, ACNP. A limited number of reprints of this article, which was published in AACN Clinical Issues: Advanced Practice in Acute and Critical Care (Vol. 10, No. 3, pp356-368), are available for $5 through AACN, (800) 899-2226. Request the “Key Issues in Advanced Practice” reprint (Item #128621). This package also contains two other articles related to advanced practice. Subscriptions, as well as back issues of the AACN Clinical Issues journal can be purchased through Lippincott Williams & Wilkins at (800) 638-3030.

AACN Online Quick Poll

Does your hospital require CCRN certification for ICU/CCU employment?

No 97%
Yes 3%

Number of Responses: 729

The AACN Online Quick Poll is a voluntary survey on a variety of topics, and is not scitnfically projectable to any other population. AACN presents 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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