AACN News—February 2001—Practice

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Vol. 18, No. 2, FEBRUARY 2001

Use Advocacy Every Day in Every Deed

By Donna L. Luebke, RN, CNP, CCRN
Member, Ethics Work Group

Clinical ethical issues are fraught with overwhelming emotion, sometimes insufficient critical analysis and incomplete discussion regarding what is truly the right thing to do for the patient. All the individuals who care for critically ill patients, as well as the patient and family, contribute their life experiences, personal beliefs and prejudices.

Most healthcare personnel will note that the most difficult ethical dilemmas can occur when the patient cannot express his or her own wishes. The question then becomes: Who will speak for the patient? Beyond the patient and family, the nurse must be the patient’s voice. This case study shows that advocacy for patient’s needs and wishes occurs not only for a day, but also for every day.

Rita, a 42-year-old woman, was admitted to the coronary ICU with a dilated cardiomyopathy and nonsustained ventricular tachycardia. She had chronic renal failure and had received hemodialysis three times per week. She was currently febrile and disoriented.

At a meeting with her family, the patient’s durable power of attorney for healthcare, the attending cardiologist and the nursing staff, there was a discussion about Rita’s diagnosis and possible treatment options. The challenge that was faced was the need to stabilize Rita during this acute period before proceeding with a complex and risky plan of care.

The plan was that once she was stabilized, she was to be discharged to the university transplant center to await a combined liver and kidney transplant. As her nurse I knew that the evaluation and preparation for transplant required extensive services from many departments, including cardiology, genetics, infectious disease, nephrology, hepatology and the liver transplant team.

During team rounds, the physicians and transplant coordinators were updated regarding Rita’s status. The comprehensive medical plan was discussed, challenged, and re-evaluated. The nursing plan of care involved implementation of the medical plan, as well as issues related to patient comfort, sleep, nutrition, pulmonary care, skin care and patient and family concerns.

Every minute was critical to Rita’s physical survival daily challenges and hurdles. Although I knew that my education and experience had prepared me to care for this critically ill patient, much was still unknown to me. What would the next minute bring? What if she did not respond to treatment? What if she was too sick for transplant? Were we wasting valuable resources on a patient with minimal chance of long-term survival? What did I know about her disease, Type I primary hyperoxaluria?

Although these unknowns were frightening, I proceeded with the “knowns” of my nursing knowledge and critical care skills. I accepted the responsibility for Rita’s care, as well as the responsibility to understand her care. I found myself seeking to learn more about this disease by contacting the Biochemical Diseases Laboratory at the University of British Columbia in Vancouver, searching the Internet and retrieving articles from the medical library, providing copies to the interdisciplinary healthcare team. My commitment to know more improved my involvement with this team and proved to be extremely rewarding, because I was accepted and valued as a knowledgeable caregiver.

As a nurse, I had had an opportunity to form a special bond with Rita and I was determined to help her win this battle over her disease and its devastating long-term effects. I became her protector and her voice. I took the responsibility to represent the healthcare team to the patient and her family, and, in turn, I represented the patient and family to the healthcare team.

Rita spent two months in the transplant center, with admissions to the coronary ICU, the surgical ICU, the special care unit and telemetry unit. After one month, she underwent a liver and kidney transplant. During the second month, a defibrillator was implanted and she was discharged to a rehabilitation center. After the third month, Rita was discharged home in the care of her family. Her care continues to be a collaborative effort between the transplant center and the medical center.

Even today, I can say that caring for Rita was the greatest challenge of my 20-year career. The days were draining and emotional for both the staff and her family. It was incredible to watch a healthcare system achieve peak performance and a patient heal, both physically and emotionally. Every day was special then, though even more so now.

What made Rita a memorable patient for me? It was not her determination to live as much as what she taught me: Do not give up. Find hope, even if only a tiny thread. Because of her, I found hope in each sign that Rita was holding steady or making progress.

What makes this story even more important for me was that Rita and I had a unique bond that existed long before her illness. I knew and loved her. Rita was more than my patient; she is my sister. I was her caregiver and her family. I was vigilant in providing care and overseeing her care. The fact that I could be her voice and participate in her care was comforting to her. The opportunity to have input into the nursing and medical decisions at an institution that was not my own was healing for me.

Being Rita’s advocate would have been difficult without the support and acceptance of the transplant center and its team. At another institution where Rita had been earlier in her illness, I had not been recognized as the advocate or patient voice. My only choice was to move Rita and coordinate her care with new caregivers. I took ownership.

This case is not so different from the everyday world of critical care nursing and its demands for advocacy. Advocacy means doing what needs to be done and doing what is right for the patient. Advocacy involves dealing with people in crisis and acting to safeguard and advance the interest of others.1

Stories of advocacy are prominent among the exemplars that are submitted each year in connection with AACN’s Circle of Excellence awards program. Through these exemplars, critical care nurses demonstrate numerous ways to make a difference in the areas of clinical practice, advanced practice, education, administration, community service and research.

Critically ill patients and their families require the best practices of highly skilled nurses, yet much of what is really important sometimes seems routine. Examples include:
• Clarifying medication orders
• Calling pharmacies to discuss dosing and administration of an unfamiliar medication
• Participating in medical and multidisciplinary team rounds
• Initiating consults to social service or pastoral care
• Teaching patients and families
• Creating a healing environment with pictures and music
• Allowing flexible visiting hours for the family and the family pet
• Facilitating communication and sharing information
• Decreasing environmental stressors
• Implementing research into practice
• Most importantly, providing safe passage for our patients and families

Beyond the routine is “knowing” our patients—their hopes and dreams, their beliefs and values, and their desires and wishes regarding the outcomes of care. When complicated ethical issues surface or dilemmas occur, the nurse must continue in the pivotal role between the patient, family and healthcare team. This is advocacy in the everyday.

AACN acknowledges and supports the nurse as the patient advocate. The Ethics Work Group reviewed and updated AACN’s position statement on the “Role of the Critical Care Nurse as Patient Advocate.” This position statement is expected to be available on the AACN Web site in the next few months. The key behaviors noted are to monitor and safeguard the quality of care and to represent, support, help, intervene, respect and act as liaison to and for the patient.

The Synergy Model´┐Ż also addresses advocacy as a nurse competency. Assume the role, advance from novice to expert, model the behavior, work in environments that foster and support, take risks, and advocate for patients, families and nursing colleagues. Create and maintain a healthcare system driven by the needs of patients where critical care nurses make their optimal contribution. In this, you will see advocacy every day in every deed.

Donna L. Luebke is with the Arrhythmia Service at MetroHealth Medical Center, Cleveland, Ohio.

1. Rushton C. The Critical Care Nurse as Patient Advocate. Aliso Viejo, CA. Crit Care Nurs. 1994:6-104-6.

Practice Resource Network: Frequently Asked Questions

QHow much blood should be drawn from central lines prior to obtaining a blood sample for a laboratory test involving an adult patient?

AAccording to the recently revised AACN Procedural Manual for Critical Care, Fourth Edition, the amount of blood that should be wasted is approximately two-and-a-half times the catheter’s dead space volume, from the catheter tip to the port where you are drawing the blood. However, several other factors that affect the amount of blood wasted must also be considered, including fluids being infused through the central line port where the sample is being taken; the amount of heparin flush in the catheter or port; and the type of lab test for which the blood is being drawn. Note that the recommendation is that blood drawn for any coagulation study should be through a peripheral vein, instead of a central line. If this is not feasible, the recommendation is to draw six times the dead space volume of blood.

An important issue to keep in mind is the problem of nosocomial blood loss. According to an article titled “A QI Project to Reduce Nosocomial Blood Loss,” which appeared in the March-April 1998 issue of Dimensions of Critical Care, two studies have shown that between 62.6 and 73.9 mL is the mean range of blood withdrawn per day from indwelling catheters in ICU patients. A Center for Disease Control regulation states that blood withdrawn prior to the sample from anywhere except a closed-loop system must be discarded. A closed-loop system with a blood conservation system is the best way to avoid excessive blood loss. (Reference AACN Clinical Issues: Advanced Practice in Acute and Critical Care, May 1996.)

The AACN Procedural Manual for Critical Care, Fourth Edition, can be ordered by calling (800) 899-AACN (2226). Request Item #128150. The manual can also be ordered from the AACN Online Bookstore at http://www.aacn.org. The price is $66 for AACN members or $75 for nonmembers. Back issues of AACN Clinical Issues: Advanced Practice in Acute and Critical Care are available from Lippincott Williams & Wilkins at (800) 638-3030.

API Topics Tailored to Advanced Practice Nurses

By Mary Fran Tracy, RN, PhD, CCRN, and Sheila Melander, RN, DSN, ACNP, FCCM
Members, Advanced Practice Work Group

As a strong supporter of the advanced practice nurse (APN) role in critical care, AACN has long recognized the need for educational resources that meet the unique needs of this group of practitioners. Establishing the Advanced Practice Institute (API), which debuted in conjunction with the 1998 National Teaching Institute™ was one way AACN addressed this need.

The API, which enters its fourth year in conjunction with the NTI in May 2001 in Anaheim, Calif., offers APNs the opportunity to attend separate sessions that focus specifically on advanced clinical, technical and procedural skills. The API also highlights APN role component skills, such as managing quality outcomes, improving care of patient populations and utilizing research.

API sessions are provided in a variety of ways, including through both self-directed and facilitated sessions in a classroom setting, mastery sessions, poster displays, computer-assisted learning and technical exhibits. To ensure that the topics presented are relevant to today’s APN role, one member of the Advanced Practice Work Group serves as a liaison to the NTI Work Group, offering suggestions and providing feedback on prospective API sessions and topics.

The advanced practice topics selected for presentation at API 2001 are timely and varied. Included are sessions focusing on surgical skills for APNs, the care of complicated cardiac surgical patients, diagnosing pediatric cardiovascular disease, antimicrobial resistance, diagnostic studies, the APN and the media, mentoring staff through the clinical nurse specialist role, APNs in the acute care setting and business information for the APN.

In addition to providing educational sessions, the API is an opportunity for APNs to network and learn first-hand about new programs and skills that are being used by their advanced practice colleagues across the country. The annual API reception, sponsored by Stryker Corporation, and networking event enhances this opportunity to meet colleagues from different parts of the country and different settings and to personalize their networking groups.

As part of its efforts to continuously assess and address the needs of its advanced practice members, AACN seeks feedback from API participants. This input is an important consideration in planning future APIs.

In addition, AACN is planning to conduct a comprehensive survey of all member needs, including education and programming.

The Advanced Practice Workgroup wants to hear from APNs regarding specific educational needs. What topics do you need more information about? Clinical practice topics? Reimbursement issues? Coding? Role issues? Leadership strategies? Research utilization? Comments and suggestions can be e-mailed to the Advanced Practice Workgroup at practice@aacn.org. Use “RE:APWG” in the subject line. Including specifics in your ideas will help the work group members better serve their APN colleagues.

Mary Fran Tracy is a critical care clinical nurse specialist at Fairview-University Medical Center, Minneapolis, Minn. Sheila Melander is associate professor of nursing at the University of Southern Indiana, Evansville.

Research Corner: Grant Money Available for Smaller Projects

By Karen Gaertner, RN, MSN, CCRN
Member, Research Work Group

AACN offers a variety of resources to assist members in conducting research projects and using research to shape their practice. Included is the small grants program, which provides funding of up to $1,500 to members who are carrying out research utilization studies, continuous quality improvement (CQI) projects or outcome evaluation projects that directly benefit patients or their patients’ families.

Following is information about these grant opportunities:

Clinical Inquiry Grants
Grants of up to $250 each are available for projects that address one or more of AACN’s research priorities and link with AACN’s vision. Funds may be awarded for new projects, projects in progress or projects required for an academic degree.

To be eligible for these grants, the principal investigator must be currently employed in a clinical setting and directly involved in patient care. Interdisciplinary projects are especially invited.
Funds can be used to cover expenses, such as printed material, small equipment and supplies, including computer software.

Proposals for these grants are accepted twice a year and must be received by Jan. 15 or July 1.

Evidenced-Based Clinical Practice Grant
Six $1,000 awards are available 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.

Encouraged are collaborative projects that involve interdisciplinary teams, multiple nursing units, home health, subacute care, transitional care, other institutions or community agencies. Applicants are asked to describe how they currently manage the clinical practice situation they propose to study and to describe why the practice should be changed. They also are asked to explain the proposed change and summarize the data and existing research on which the proposed change is based.

To be considered for an award, proposals, which are accepted twice a year, must be received by March 1 or Oct. 1.

Medtronic Physio-Control-AACN Small Projects Grants

Up to $1,500 is available to qualified individuals for projects involving patient education, competency-based education, staff development, CQI, outcome evaluation or small clinical research that focus on aspects of acute myocardial infarction, resuscitation or sudden cardiac death, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretive 12-lead electrocardiogram.

Proposals for this grant, funded by Medtronic Physio Control, are due by July 1 each year.

For more information about these grants, call (800) 899-AACN (2226) or visit the “Research” area of the AACN Web site at http://www.aacn.org. Applications can be downloaded from the Web site.

AACN Sponsors ANF Grant

In addition to funding for small projects described above,, a number of other grants are available throughout the year to fund research relevant to critical care nursing. Deadlines to submit proposals for these grants vary.

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 researchers, 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.

Circle of Excellence: Award Honors Outstanding Educators

The AACN Excellence in Education Award recognizes nurse educators who facilitate the acquisition and advancement of the knowledge and skills required for competent practice and positive patient outcomes in the care of acute and critically ill patients and their families. Recipients of this award received complimentary registration, airfare and hotel accommodations for AACN’s National Teaching Institute™ in May 2000 in Orlando, Fla.

Following are excerpts from exemplars submitted by recipients of this award for 2000:

Jennifer Dwyer, RNC, MSN, CCRN, CS
Cicero, Ind.
Clarian Health
How does an educator spark the interest of critical care staff in research and its application to daily patient care activities? How creative can an educator be in providing development opportunities that are valued by the staff?

In September 1998, I initiated the monthly departmental Journal Club, which provides opportunities to marry research, clinical practice, critical thinking, clinical inquiry, collaboration, systems thinking, diversity and ethical issues. Articles and a flyer announcing the topic and presenter are posted for the targeted audience of RNs and licensed practical nurses.
Representatives of other disciplines, including pharmacy, respiratory therapy, physical therapy, chaplaincy, social work speech therapy, also participate, as pertinent, in the topics offered. Meals are provided via an educational grant given by a local pharmaceutical company.

The Journal Club is fun, educational, multidisciplinary, time-efficient and pertinent to practice. It also provides opportunities for interaction among the units.

Initially scheduled from 11 a.m. to noon, the hours were quickly expanded to include 10 to 11 p.m. Within 17 months, the attendance had doubled to between 40 and 45 participants.

Staff members who previously would not have considered presenting to a group have now consented, with the understanding that they could select or be assigned a topic within their comfort level or area of expertise. I assist them with literature searches, mentor them on presentation skills and article critiquing and provide moral support during and kudos and constructive feedback following the presentation

Evaluations and a survey on topics of interest are conducted at each session and used to plan future sessions. Fostering an environment in which staff can grow is my greatest satisfaction as an educator. the Journal Club has provided a new and different setting for staff education.

Patricia Graham, RN, MS, CCRN
San Diego, Calif.
University of California Medical Center-San Diego

It is 1:30 in the afternoon, and time to get ready for postconference! Who should I focus on today? I survey the new group of ICU nurses. I peer into surgical ICU room one. The patient, a construction worker who had been run over by a fork lift truck, was about to be started on continuous veno-venous hemodialysis (CVVHD). I decided to focus the postconference on this patient’s acid base disturbances.

After gathering the nurses and various other health team members, we begin postconference.

The nursing intern said: “My patient is very acidic, his pH is 7.20.” Probing deeper, I asked: “What else do you want to know? What other pieces of information are we missing?” As the group of new nurses stared at me, I asked the group of experienced nurses who were listening if they had any ideas. “His electrolytes!” they responded. From there, the learning exchange proceeded.

Me: OK, which electrolytes?
Experienced Nurse: Potassium.
Me: Great. What other electrolytes do we need to pay attention to in acidosis?

At this point, neither the experienced or less experienced nurses spoke up.

Me: How about chloride and bicarbonate?

I proceeded to draw the anion gap formula and explain the rationale for its use.

Me: OK, so lets go back a few steps. You told me that the patient was getting potassium replacements. What type of potassium are you giving him?
Experienced Nurse: Potassium Chloride.
Me: A-ha! Potassium chloride! What is the clinical implication for this?
Experienced Nurse and Nursing Interns: Oh! The more chloride he gets, the lower his bicarbonate will be. We might be making his acidosis worse!
Me: Exactly! Can you see the impact critical thinking can have? We are much more than task masters here. The key to critical care nursing is critical thinking. If we had not asked the questions that we asked, we wouldn’t have found the answer.

JoAnn Panno, RNC, MSN
Stow, Ohio
Akron General Medical Center

The first priority I was given when I accepted a position as a critical care staff development instructor at a large, tertiary-care teaching hospital was to facilitate critical care education. The “norm” had been a passive, traditional classroom approach. However, as an experienced educator, I knew that an active-learning, problem-based and contextually relevant program was needed.

The existing paradigm for critical care education dictated that nurses attend a three-day critical care class before beginning orientation in their new unit. It was time for a paradigm shift that challenged the “front-end loading” and passive approach to critical care education and orientation.

The active learning plan that was developed included outcome behaviors for ECG skills and ICU medication administration, as well as knowledge of cardiovascular, neurological, hemodynamic monitoring, shock states, inflammatory syndromes and gastrointestinal-nutritional and metabolic disorders. The Synergy Model, a nursing practice model appropriate to the critical care patient, was also included in the learning and orientation plan. A variety of structured learning strategies and clinical experiences were planned to assist in the learning process.

Rethinking the education process is not only more consistent with trends in education, but also matches actual practice. By communicating the shift of responsibility for learning from the institution to the learner, and by holding the learner accountable for seeking out experiences, the orientation became an active learning experience. The orienting nurse has positive experiences about seeking opportunities to meet their needs, which is of personal and professional value.

The greatest lesson learned through this individualized, structured learning approach is that competency is not achieved by attending a critical care class or by achieving a “passing” grade on a written test. Clinical competence develops predictability over time, and basic entry level competence can be measured by observation of actual practice. Novice ICU nurses are better prepared to meet the challenges of critical care practice as a result of this new paradigm.

Vox Populi: AACN Online Quick Poll Update

How often do medication errors occur in your workplace?
Sometimes 48%
Often 24%
Rarely 19%
Don’t know 8%
Never 0%

Number of Responses: 1,022

Should there be mandatory public reporting of serious medication errors?

No 55%
Yes 45%

Number of Responses: 718

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. Participate by visiting the AACN Web site at www.aacn.org.
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