AACN News—July 2001—Practice

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Vol. 19, No. 7, JULY 2002

Research Corner: Distinguished Research Lecture Celebrates 100th Birthday of ECG

Barbara J. Drew
delivered the 2002
Distinguished Research

For Barbara J. Drew, RN, PhD, FAAN, a positive and interesting first-job experience in a coronary care unit led to an impressive career in which she has not only saved lives, but also helped improve medical technology and traveled around the world. Today, the nationally known researcher is professor and vice chair of academic programs in the Department of Physiological Nursing at the University of California, San Francisco, School of Nursing.

As recipient of the 2002 Distinguished Research Lecture Award, Drew shared her experiences and discussed advancements she hopes will be made in cardiac care at AACN�s National Teaching Institute and Critical Care Exposition in May 2002 in Atlanta, Ga. Her Distinguished Research Lecture presentation, titled �Celebrating the 100th Birthday of the Electrocardiogram: Lessons Learned From ECG Monitoring Research,� was sponsored by Philips Medical Systems. (See the July issue of the American Journal of Critical Care for an article by Drew on this research topic.)

Drew has made cardiac care her life�s work, after being disappointed at the important clinical problems she saw being missed by doctors and nurses. She turned to research to identify ways to improve cardiac monitoring technology for better patient diagnosis. As a result of her findings, many manufacturers made improvements to their cardiac monitors.

Drew has been studying reduced lead-set technology that will allow for monitoring multiple views of the heart without the need to place electrodes in different anatomical locations. Under the standard method of recording ECGs, patients who require continuous monitoring must suffer the impediments of wearing 10 electrodes and 10 lead wires. These wires and electrodes not only interfere with sleep and resuscitation and lead to skin breakdown, but also are cumbersome for the nurses to maintain. To improve the ECG recording system, Drew has been working with engineers to develop a five-lead ECG technique.

Drew also hopes to help improve cardiac monitoring in the prehospital phase of acute myocardial infarction. Plans are to equip ambulances in Santa Cruz County, Calif., with a new system that will continuously monitor patients en route to the hospital, automatically dial up the destination hospital via a cell phone and print out an ECG in the emergency department whenever a significant change in cardiac activity is noted. This new technology will allow physicians and nurses to be better prepared when a heart attack patient is on the way.

�Hopefully, this new technology will reduce treatment time and save patients from more heart damage,� Drew said. �We hope to prove that this machine results in better outcomes by earlier detection and treatment.�

Drew also educates other nurses on the correct anatomical placement of electrodes. Inaccurate electrode placement can change a patient�s diagnosis and result in inappropriate treatment, she noted. In 1990, she surveyed AACN members regarding electrode placement. The 350 responses she received showed that most inaccurately place electrodes.

The impact of her work has spread, with the technology that she has been helping to develop being used to monitor astronauts at the international space station. She also is the only nurse invited to speak in the Netherlands at the Willem Einthoven Foundation�s celebration of the 100th birthday of the ECG.

Grants: Apply for Research Funding

Oct. 1, 2002, is the deadline to apply for three nursing research grants that are available through AACN:

AACN Clinical Practice Grant�This grant awards up to $6,000 to support research focused on one or more of AACN�s research priorities.

AACN-Sigma Theta Tau Critical Care Grant�Cosponsored by Sigma Theta Tau, this grant awards up to $10,000. Recipients must be members of either AACN or Sigma Theta Tau.

Evidence-Based Clinical Practice Grant�This grant awards up to $1,000 for studies that include research utilization studies, CQI projects or outcome evaluation studies. Collaborative research teams are encouraged.

To find out more about AACN�s research priorities and grant opportunities, visit the AACN Web site at http://www.aacn.org. The grants handbook is also available from AACN Fax-on-Demand at (800) 222-6329. Request Document #1013.

Individual Beliefs Must Be Respected: Cultural Diversity Presents Healthcare Challenges

By Nancy Seymour, RN, BSN, CCRN
Ethics Work Group

Cultural diversity has created significant gray areas in the daily challenges of healthcare. In healthcare, cultural diversity is a concept describing professional care that is culturally sensitive, culturally appropriate and culturally competent.

Culturally appropriate means that the healthcare provider applies the underlying background knowledge necessary to provide the best possible care for a patient. Culturally competent means that the healthcare provider understands and attends to the patient�s total situation, including awareness of immigration status, stress factors and cultural differences. Culturally sensitive means that the healthcare professional possesses some knowledge of and constructive attitudes toward the diverse cultural groups found in the setting in which they are practicing.

By determining how the patient defines healthcare, we can establish a foundation for understanding how to balance his or her care within spiritual, physical, mental and cultural boundaries. However, upon admission, healthcare providers do not usually ask patients how they define healthcare, though they may ask patients about their religious belief or concerns.

Although religious beliefs are a testament to individual spirituality and free will, they can present a barrier between a nurse and his or her role as a healthcare provider. Medical decisions that arise amid religious conflicts for patients and their families during end-of-life situations are especially difficult.

Respecting individual diversity allows us to understand a patient�s spiritual needs and the traditions that mandate them, even when they are counter to established and accepted healthcare procedures.
But, what if they do not have a defined religion or concern? Or, what if they have exclusive religious beliefs that they fail to share until a crisis arises?
Here is an example:

Mrs. D., who was scheduled as an outpatient for a urology procedure, had signed blood consent and denied any particular religious beliefs, special needs or concerns. After she became unstable during the procedure, she was admitted to the critical care unit for anemia, hypertension and pregnancy of 34 weeks. She had other children at home and had been under medical care for this pregnancy.
Fluid resuscitation, lab testing, certain treatments and physical assessments were performed, but her hemoglobin was 3.1. The primary physician ordered blood transfusions to reverse the anemia. The other physicians on the case had agreed on the plan of care.

When the physician met with the patient to discuss her care, she declared that she was a Jehovah�s Witness, a religion adverse to blood transfusions at any time. She stated that she signed the blood consent �to cooperate,� because she was certain that there would be no need for a blood transfusion. At this point, the patient�s condition in relationship to the Synergy Model was highly vulnerable and minimally resilient. Her anemia, spiritual beliefs and 34-week pregnancy made her minimally stable and highly complex.

A dilemma manifested between the medical need for blood transfusions and Mrs. D.�s spiritual beliefs. The difficulties at this juncture were the medical needs not only of the patient but also of the unborn fetus.

As critical care nurses, we must comply with the wishes of the patient to refuse medical treatment, unless ordered otherwise by a court of law. As was done in this case, when a hospital has elected to override a patient�s right to refuse medical treatment, it must provide immediate notice to the court.

This case went to the hospital ethics committee, which debated the patient�s spiritual needs and the vital interests of her unborn fetus, as well as the significant burden that rested with the hospital.
Jehovah�s Witnesses can make informed refusals for accepting autologous or homologous whole blood, packed red blood cells, platelets or white blood cell transfusions. In this case, the ethical questions centered on the wishes of an unborn baby. Mrs. D. was given multiple blood transfusions. Soon after, a viable baby girl was born. Within the first year after the child�s birth, the mother appealed the circuit court order, stating that she could not be compelled to undergo a transfusion for the benefit of her viable fetus. The decision of the court-appointed guardian, who was acting in the alleged interest of the fetus, was reversed.

This complex, ethical case involved many members of the healthcare team. Throughout, the critical care nurses were at Mrs. D.�s bedside to provide comfort, give support, allow her to verbalize and provide professional care. Expressing and following patients� needs while providing the best care available is not always easy for the patient or for the healthcare team. As long as we continue to work together, we will continue to improve as nurses and continue to learn how best to protect the rights of our patients.

Choices for blood transfusions. JAMA. 1981;246:2471-2472.
Andrews MM, Boyle JS. Transcultural Concepts in Nursing Care, 2nd edition. Philadelphia, Pa: JB Lippincott; 1995.
I Know Why the Caged Bird Sings. New York, NY. Random House;1970.
Knowing My Neighbor, Religious Beliefs and Traditions at Times of Illness and Health. Springfield, Mass: Council of Churches Visiting Nurse Hospice of Pioneer Valley;1995.
Dresser N. Multicultural Celebrations. New York, NY. Three Rivers Press;1999.
Spector RE. Cultural Diversity in Health and Illness, 5th edition.
Internet sources: http://www.ajwrb.org and http://www.cms.org.

Viewpoint: When Does Aggressive Care Become Futile Care?

By Debbie Brinker, RN, MSN, CCNS, CCRN,
and Kathleen McCauley, RN, PhD, CS, FAAN

The ethical dilemma of determining when aggressive care of the critically ill has transitioned into �futile� care is of concern to nurses, physicians, patients and families. In an effort to clarify this complex issue, we talked with two experts whose practices center on helping providers, patients and families with these difficult decisions.

Mimi Mahon, RN, PhD, FAAN, clinical nurse specialist for end-of-life care and ethics at the Hospital of the University of Pennsylvania, Philadelphia, defines futility as not being able to meet the goals of care. The same disease may or may not be �futile� when experienced by different patients. Johnny Cox, RN, PhD, vice president of theology and ethics at St. Joseph�s Regional Health System, Orange, Calif., states that he avoids using the term �futility� because it has different meanings to different people.

Professional nurses and physicians share the goal of providing care and treatment to prevent disability, aid recovery and relieve suffering. Life support in critical care units is designed to restore or sustain survival that carries meaning and value for the patient. These principles guide clinicians in decisions to withhold or withdraw treatment and provide the context for many of Mahon�s and Cox�s consultations.
Conflicts often arise because we do not clearly define the goals of treatment up front and are not honest with ourselves as clinicians about the likelihood of success. Too often in healthcare, we have difficulty reaching an accurate prognosis. This is complicated by a tendency to err on the side of optimism�sometimes based on inaccurate data�in our communications with patients and families.

Mahon emphasized that care decisions are made with the best intentions, often driven by a belief that living is better than dying regardless of quality of life. In the case of a deteriorating patient, this culminates too frequently with a healthcare team asking the family, �What do you want us to do?� Cox suggested that the approach to decision making with patients and families should focus on the outcomes that the treatment might or might not produce with respect to what the patient evaluates as worth the burden he or she would have to shoulder.

To illustrate the point, Mahon said: �When your mother came to the hospital, our goal was to make her better. She had surgery for the problem with her intestine. She was on a breathing machine and received many drugs to give her body every chance to heal. When we first spoke, we thought that her body would respond within five days or so. It has now been six weeks and your mother�s body has been unable to heal. Her kidneys and liver are no longer working normally and our efforts to get them to work properly have failed. What we need to do now is change our focus from curing your mother to making sure that she is comfortable.�

When you ask family members what they want you to do, the probable answers are �Everything� or �Nothing.� A more optimal question is: �If your mother were able to participate in this conversation, what would she tell us to do?� This approach unburdens the family so that they are guided to make decisions based on what they know the patient would want.

Mahon points out that our language about care can interfere with this process. We talk about a patient �failing� therapy. As a healthcare system, we have arrived at the conclusion that to be unable to cure is to fail. She notes that in the last year of our lives, 80% of us will suffer heart failure, chronic lung disease, cancer, stroke or dementia. When faced with illnesses that cannot be cured, we must provide better symptom management. In Mahon�s clinical experience, the three major symptoms that patients face in the last days of life are pain, anxiety and dyspnea. Relieving these symptoms clearly benefits patients. However, because the death is more peaceful and less symptom ridden, it also helps with family bereavement.

Cox agrees, saying that a key is to �address the systems of treatment/care that perpetuate our struggles to shift from curative attempts to comfort only.�

�We practice in an extraordinarily vitalist field where death is considered a failure of a professional duty rather than the completion of a personal journey,� Cox said. �Until this fundamental attitude is rectified, we will only be doing damage control.�

Cox, who helped found the Hospice of Spokane (Wash.) in 1976, has committed his practice to strengthening organizational structures that support physicians, nurses, patients and families in decision making regarding end of life.

He pointed out that, when the patient is a child, we tend to provide curative treatment until it causes significant suffering for the child with little possibility of benefit. Although older people can consider dying as the final chapter in a personal autobiography, a child�s death evokes a deep sense of untimely tragedy. Whenever children can convey evaluations of the benefits and burdens of treatment options, we should listen attentively and take them seriously.

The literature on the experiences of children at end of life shows that many die in hospitals, often in critical care units after withdrawing life-sustaining technologies. In a recent study, though 76% of children were treated for pain, treatment was successful in only 26%. Similarly, 65% were treated for dyspnea, but effective management occurred in only 16% (Wolfe J, Grier HE, Klar N, Levin S, Ellenbogen JM, Salem-Shatz S, Emanuel EJ, Weeks JC. Symptoms and suffering at the end of life in children with cancer. New England Journal of Medicine. 2000;342:326-33.)

Determining whether continuing aggressive critical care is appropriate or futile requires a multidisciplinary practice knowledge base. Knowledge and skill are needed to negotiate the transition from a cure to care focus that is consistent with the patient�s wishes and values and is based on realistic prognostic outcomes.

�Families and patients feel well supported when they sense we have heard their stories, appreciate their fears and concerns, and encourage them to use their strengths in working through their decisions,� Cox said.

Our goal is to provide easily understandable information regarding their condition and treatment alternatives, comfort measures and assurance that we will not abandon them as they progress on their journey, he added.

In the Circle: Award Honors Outstanding Clinical Practice

Following are excerpts from exemplars submitted in connection with the 3M Health Care-AACN Excellence in Clinical Practice Award for 2002, sponsored by 3M Health Care. Part of the AACN Circle of Excellence recognition program, this award is presented to acute and critical care nurses who embody, exemplify and excel at the clinical skills and principles that are required in their practice. The recipients were provided complimentary registration, airfare and hotel accommodations for NTI 2002.

Capt. Erica Spillane, RNC, MHR, CCRN
Landstuhl, Germany
Landstuhl Regional Medical Center

At age 40, Theresa would not recover from severe liver disease brought on by years of alcohol and intravenous drug use. She was a challenging patient, but I consider myself lucky to have been able to work with her and her family during this difficult time. I regularly heard about Theresa�s tirades of fighting and swearing and noncompliance with her treatments. However, I was always able to provide Theresa with the nursing care that she had previously refused. At shift�s end, Theresa would smile and say that I had made her feel like a queen.

Soon, Theresa required ventilatory and vasopressor support. Despite our best efforts, her systems were shutting down, and I spoke with Theresa�s family members about her end-of-life wishes. They recalled her telling them that she did not want to be kept alive on life support if her condition was terminal. However, spiritually, they were having difficulty with this decision.

I called the chaplain, who spent time offering spiritual support. I spent the remainder of the shift talking with the family about Theresa and her life. That day, the family decided to withdraw Theresa�s life support.

Theresa was surrounded by love when she passed away. Her family later thanked me for what I had done for them and Theresa. One brother called me his sister�s angel, which made me feel extremely humble. It was then that I truly realized the power of nursing in caring for the terminally ill.

Steven Savant, RN, BSN, CCRN
Lafayette, La.
Lafayette General Medical Center

My 82-year-old patient, Genevieve, was in respiratory failure secondary to chronic CHF. She was on a ventilator, awake, cooperative and obviously concerned after being admitted to the medical ICU.
Genevieve�s prognosis was poor. Her right heart pressures were elevated, and her ejection fraction on echo was 40%. The stress of being hospitalized was taking its toll on her morale, and she seemed to be fading psychologically. The goal was to support Genevieve with inotropic therapy and diuresis in the hope of moving her to the coronary care unit and possibly to an outpatient status for control of her CHF.

I learned that Genevieve had been recently widowed after a 60-year union. She and her husband had no children, but had shared the last 15 years with Max, a mixed breed dog, and a housekeeper named Eleanor. Although I know the relationships that can evolve between pets and their owners and I have been both a pet owner and a pet enthusiast, I had never considered the relationship between the two roles.

Genevieve was mourning her husband and worrying about her dog. A special visit by Max was the obvious solution to motivating her. Within 48 hours of Max�s visit, Genevieve was extubated and moved to the coronary care unit. Two days later, she went home. Because of the positive outcomes that resulted from Max�s visit, our hospital has started a pet therapy program. Although it is still in its infancy, the program is being supported by enthusiastic staff and the administration.

Debra Pronitis-Ruotolo, RN, BSN, CCRN
Dallas, Texas
Presbyterian Hospital Dallas

�You�re getting this patient from Spain at about 10 p.m,� was the assignment I received when I came on shift. Upon B.�s arrival, I took report from the French transport team. Except for the fact that she had no discernable neurological response, the patient was stable. The disconcerting findings were a decreased level of consciousness and the lack of reflexes in the absence of sedation or paralytic agents. What she needed now was close observation.

Turning my attention to her family, I described what they would see in the room and encouraged them to hold B.�s hand and speak to her. Although our ICU visiting times are open, we encourage family members to get some rest after 10 p.m. However, because this family could not bear to be away from the patient�s side, I agreed to let one family member at a time sit quietly at her bedside the first night.

B.�s brother called me to the room and said, �She squeezed my hand! B., do it again for the nurse!� Soon, a crowd had gathered around B.�s bed. Although I finished my shift without experiencing a hand squeeze from B., her family did not give up hope.

Ten months after the crash, B. and her husband hosted a thank-you party for everyone who had cared for B. We all rejoiced! Recently, B. and her husband visited my unit. As I hugged both of them, I remembered what I had thought when I first saw B. I had recoiled at the prospect of guiding yet another family through the grieving process. Instead, I had been given this incredible gift, a reminder that sometimes miracles do happen.

Kate McCarthy, RN, BSN, CCRN
Tallahassee, Fla.
Tallahassee Memorial Hospital

In 1987, I entered the world of critical care nursing. I had spent more than 10 years in nursing practice, working in the emergency department, surgery and obstetrics. However, after a move from Ohio to Florida, I entered the highly technical and stressful arena of acute, critical care.

As I familiarized myself with the equipment, I comforted myself with the thought, �If I really care and pay close attention, things will be OK until I learn everything I need to know.� As I tried to keep a balance between seeking knowledge and giving care, I found solace in caring for my patients and focusing on their perception of what was happening to them. The privilege of my role was apparent. What some saw as sadness or stress presented itself to me as an invitation into an intimate human exchange. Hearts were laid bare, relationships were illuminated, and basic human needs were the true patient call bells.

One evening, an older woman with a ruptured septal wall was heading to surgery. Prior to her transport, I asked if there was family to be called. This frail woman simply smiled and said, �Yes, there�s Albert. He�s my nephew. I never married, never had children. My sister�s boy always took an interest in me. He�s the only one here tonight with his wife. I wonder if you would do me a favor, dear. I don�t suspect I�ll be coming back here tonight. If that should happen, I want you to tell Albert �thanks� for me. Tell him I went to surgery for him. He insisted I couldn�t just lay here. I had to try to lick this. Tell Albert it was a nice way for him to say goodbye after all these years. Give him my love.�

Dea Ann Martin, RN, BSN, CCRN
Allen, Texas
Presbyterian Hospital of Dallas

As I entered Amy�s room, I noticed her husband Scott was still in the same �labor coach� scrubs from the previous night. He appeared lost, distraught and alone. Amy was admitted to our unit after a difficult delivery followed by an emergency hysterectomy. This was her first and last baby.

Amy arrived ventilated, with severe hypotension and on multiple intravenous medications. She had an amniotic emboli to the lung, which resulted in disseminated intravascular coagulation. She was also in acute renal failure and continued to hemorrhage. The only option was to return to the operating room to find the source.

Although the bleeding had stopped, her condition worsened, and, after surgery, she was severely edematous because she had received 30 liters of fluid and blood. Scott would not leave her side. Because the airports were still closed because of the Sept. 11 tragedy, Amy�s mother, who lived out of state, could not get a flight in. My goal was to keep Amy hemodynamically stable while providing emotional support to Scott and her distraught mother.

Slowly, Amy�s condition improved. We needed to arrange for Amy to see her baby, Emma Grace, who was in the neonatal ICU. Emma was crying when she arrived, but stopped when the NICU nurse placed her in her mother�s arms. As the family was reunited, our tears of sadness turned to joy.

I saw Amy often during her two weeks in the hospital. I knew she would not remember the week�s events, but I would never forget. I was elated that everything had turned out so well. It was the most precious success story of my career.

Practice Resource Network: Withdrawing Blood From Central Lines

Q: When drawing blood off central lines, is it OK to re-inject the initial discard blood into the patient instead of throwing it away? In our adult critical care unit, many labs are drawn from a single patient during a 24-hour period. Each discard usually involves approximately 10cc of blood, which can amount to a significant blood loss over time. We would like to conserve blood but are concerned about exposing the patient to an increased risk of infection. What does the literature suggest?

A: The purpose of withdrawing blood from the central line before obtaining a blood sample is to clear the catheter and tubing of material that could contaminate the sample and affect the test results. Studies have shown that between 62.6 and 73.9 mL is the mean range of blood withdrawn per day from indwelling catheters in adult ICU patients. One study of cardiothoracic ICU patients demonstrated a mean daily blood loss of 377 mL, 30% of which was due to blood discard.1

This data illustrate that frequent blood samplings and their accompanying discards can present a significant blood loss over time, potentially resulting in anemia. This nosocomial-induced anemia introduces an additional and unnecessary risk for the ICU patient, especially in highly vulnerable populations, such as postoperative, posthemorrhage and volume-depleted patients.

This is a particularly significant problem in pediatric populations. If strict conservation efforts are not followed, routine blood draws and discard from the neonate often exceed 10% of the child�s circulating blood volume.2 Unfortunately, the practice of re-instilling the discard blood via a conventional central line setup poses a significant risk for contamination and infection. The use of a well-designed, inline, closed-loop system will help to avoid this problem, while conserving much-needed blood.

A closed-loop system with a built-in blood conservation device provides a practical and relatively low-cost solution to excessive blood loss due to blood discard.

Dech and Szaflarski3 define a blood conservatory system as a device that allows for sampling of undiluted, heparin-free blood, while storing the discard volume in a reservoir placed in the line�s circuit. This allows the full volume of discard blood to be maintained in a closed system and then returned to the patient without risk of contamination. A variety of commercial products are available and are illustrated and discussed at length by Dech and Szaflarski.

1. Henry M, Gamer W, Fabri P. Iatrogenic anemia. Am J Surg. 1986;151:362-363
2. Wilson JR, Gaedeke MK. Blood conservation in neonatal and pediatric populations. AACN Clin Issues. 1996;7:229-237.
3. Dech ZF, Szaflarski NL. Nursing strategies to minimize blood loss associated with phlebotomy. AACN Clin Issues. 1996;7:277-287.

Critical Thinking Spans the Continuum

By Diane Salipante, RN, MSN, MS, CCRN, NP
Progressive Care Task Force

After being admitted to the progressive care unit with pneumonia, Mr. J., a 50-year-old diabetic with hypertension and COPD, tells the nurse he can�t breathe. He is diaphoretic and using accessory muscles to breathe. His vital signs are: RR 40, P 120, BP 88/50, and oxygen saturation 85%.

While completing the physical assessment, the nurse draws upon basic knowledge and past experience to assess that the problem might be an MI, a pulmonary embolus, a pneumothorax or CHF. The nurse starts oxygen, summons help, calls the medical care provider and prepares the emergency cart. Next, the nurse draws labs, including a blood gas, does an ECG and calls for an x-ray. By using critical-thinking skills to anticipate what interventions are needed, this nurse can prevent delay in diagnosing and treating Mr. J.�s problem and possibly avert a more serious situation.

Critical thinking is a reasoning process in which individuals analyze their own thoughts, actions and decisions, as well as those of others. A critical thinker takes nothing for granted, considers alternatives and makes an informed decision by applying reasoning and logic. A critical thinker then evaluates and reflects on the decision to determine if it was the best possible one.1

Unlike the five-step nursing process, critical thinking cannot be taught as a competency in a basic educational program. Critical thinking is a problem-solving approach that becomes part of each nurse�s character through the acquisition of knowledge and experience.2 Although principles of critical thinking are often introduced in basic nursing education, they must be nurtured in the individual by example and fostered in an environment where they can develop further.

Critical thinking parallels professional development, evolving through three levels: basic, complex and committed. As nurses gain experience and knowledge, attitudes and standards that are basic to decision making develop. At the basic level, nurses rely on experts for answers and see each situation as having a right or wrong solution. As nurses progress to the complex level, they analyze and examine situations more independently, explore alternatives, and weigh the risks and benefits of each alternative before making a final decision. When nurses advance to the commitment level, they assume accountability for decisions and choose actions or beliefs based on previous knowledge and experience.3

To ensure that safe, efficient and expert care is delivered across the continuum of critical care nursing, the development of critical-thinking skills must be fostered. An environment in which nurses can develop a sense of confidence, independence, fairness, responsibility, risk taking, discipline, perseverance, creativity, curiosity, integrity and humility is key to nurturing critical-thinking skills. In addition, the environment must support adherence to professional standards and intellectual standards, such as logic, accuracy and clear thinking.3

Although critical-thinking skills are valuable in all nursing situations, they are essential for nurses who function autonomously without the availability of a large number of support systems, such as in a progressive care unit. When critically ill patients are moved from ICUs to progressive care units, their characteristics, as defined by the Synergy Model, have changed from unstable and vulnerable to more stable and less vulnerable.4 However, these patients are at risk of relapsing to the unstable and vulnerable state at any time.

If safe, effective, and expert care is to be delivered in the progressive care setting, progressive care nurses must have the same knowledge base, assessment skills and critical-thinking skills as ICU nurses. Leadership must acknowledge the importance of critical-thinking skills for progressive care nurses and mobilize support systems and educational resources to support them. They must promote an environment where progressive care nurses can acquire the clinical and critical-thinking skills that are essential to meeting the needs of their patients.

1. Paul RW, Heaslip P. Critical thinking and intuition in the nursing process. J Adv Nurs. 1995;22:40-47.
2. Facione NC, Facione PA. Externalizing critical thinking in knowledge development and clinical judgment. Nurs Outlook. 1996;129-136.
3. Katako-Yahiro M, Saylor C. A critical thinking model for nursing judgment. J Nurse Ed. 1994;33: 351-356.
4. Edward DF. The Synergy Model: linking patient needs to nurse competence. Crit Care Nurse. 1999;19:88-97.

NTI 2003 Abstracts Due Sept. 1: Share Your Research or Creative Solutions

Sept. 1 is the deadline to submit research and creative solutions abstracts for AACN�s 2003 National Teaching Institute and Critical Care Exposition, scheduled for May 17 through 22 in San Antonio, Texas.

Abstracts must be relevant to the care of the acute and critically ill or critical care nursing and must be noncommercial in nature. The first author must be a nurse holding current AACN membership. Only completed research and finished projects are eligible, and abstracts must not have been previously published or presented nationally.

The designated presenters of accepted 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.

In addition, four awards will be presented for oral research abstracts reflecting outstanding original research, replication research or research utilization. Each of these awards provides an additional $1,000 toward NTI expenses.

Following is information about the abstracts:

Abstracts can focus on any aspect of critical care nursing research, including reports of research studies or reports of research utilization. Only abstracts of completed projects will be accepted. Abstracts reporting research studies must address the purpose; background and significance; methods; results; and conclusions.

Creative Solutions
Abstracts should focus on specific strategies and practice innovations that are used by nurses to solve difficult, unique or interesting problems in patient care, nursing practice, nursing management or nursing education. The creative solution must have been implemented, with outcomes evaluated. Abstracts must address the purpose of the project and include a description of the creative solution, as well as evaluation and outcomes.

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