AACN News—December 2002—Opinions

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Vol. 19, No. 12, DECEMBER 2002

President's Note

Bold Voices
Practice Speaks Louder Than Words

By Connie Barden, RN, MSN, CCNS, CCRN
President, American Association of Critical-Care Nurses

How long does it take for research-based knowledge to make it into accepted clinical practice? Some say it�s a startling 17 years. Nearly two decades. Almost a generation. Despite this lag, we must hold ourselves accountable to the golden standard of applying research-based knowledge as a basic element of clinical practice that evolves and matures over time.

We face two essential challenges: how to bring evidence-based knowledge into practice sooner and, perhaps more to the point, how to shift evidence-based practice from optional to required. Nursing practice must be based on available evidence and research. This cannot be optional. Evidence cannot be used when convenient and ignored when taxing or unfamiliar.

The expertise gained during years of clinical practice is certainly another basic element of a mature and evolving practice. Considering that the average critical care nurse in the United States is 47 years of age and out of school for more than 20 years, there�s a lot of experience to go around. But experience alone is not a sufficient teacher. Indeed, care based solely on tradition or dated information is dangerous. It directly threatens patients and their outcomes.

In Research Strategies for Clinicians, Brady Granger and Marianne Chulay remind us that asking clinical questions and searching for the answers start the journey toward improved patient outcomes. The misconception is that many consider asking questions, looking for answers and incorporating the answers into practice as the purview of academic faculty, certainly not of nurses in clinical practice.
This is a passive and distant perspective. It diminishes our accountability and our access to solutions. Nobody is better suited to participate in clinical inquiry and drive the discovery of answers than nurses at the bedside. Clinical nurses must accept the responsibility to question, study and define the care we give. Relinquishing the task to others further reinforces the mistaken notion that ours is a passive and obedient role, where we dutifully do what we�re told.

Ultimate patient care doesn�t happen automatically when nurses ask, think, investigate and define their practice. Ultimate care happens when, driven by our purpose, research enhances the experience and judgment that come from years of nursing.

Case in point. At a recent AACN event I talked about this and used visiting policies as an example. I highlighted the solid research that confirms how, in general, less restrictive visiting hours result in better outcomes for patients and their families. I boldly called for nurses to embrace these findings and incorporate them into practice.

Just as boldly, one of our astute members offered a different perspective. Citing the rise in violence against healthcare personnel in some areas, she asked: How we can do this when open visiting hours provide no safety for staff or patients. How can AACN advocate for open visiting if it�s unsafe?

I understand this dilemma. However, the difficulty of the dilemma too often distracts us from taking the next step, from finding the best solution for each situation.

Being driven by our purpose�to provide the best outcomes for a patient�becomes the vehicle to create the solutions even in this conundrum. Liberal visiting isn�t always safe. But liberal visiting produces the best outcomes for patients. What then?

Obstacles drive easy solutions that ignore the research and conclude liberal visiting just can�t be done� at least not here, not now. Outstanding solutions invent new ways to handle a challenge. They blend the best of the evidence with the wisdom of experience. What about live visiting by video from a family lounge? Or restricting visits to individuals who are listed and identified by the patient? Ardent visitor screening by security personnel is another possibility. So is providing convenient mechanisms for recorded or written communication. These ideas may not include the right answer for your situation. But, as experienced, expert critical care nurses, I know we will find outstanding solutions when we�re committed to relentlessly seeking ones that work.

It is essential to re-engage our shared commitment to exceptional care by embracing the findings of research and incorporating them into daily practice. Anything less than this level of excellence diminishes our optimal contribution to patient care and dampens the spirit that inspires our work.

Combining decades of experience with the results of inquiry creates truly exceptional care. What is the benefit of this? Besides creating incomparable outcomes for patients, families and nurses, you�ll re-invent the standard by which you practice and re-engage the spirit of those with whom you work. An environment steeped in inquisitiveness and excitement about practice is like a magnet. Nurses clamor to work there. Embrace the opportunity to create that environment.

It is this spirit and the excellence in critical care nursing practice that truly speaks louder than words. It amplifies our bold voices in ways that will never be ignored.


Rethink the TPC Model
I am concerned about new legislation to address the nursing shortage in California. It has been proposed that this will increase satisfaction and retention among nurses, as well as improve patient outcomes. However, the organizations that fought for this legislation left out a critical element: They did not address unlicensed staff, mainly CNAs. Now, instead of having eight patients with an aide, I will have four to five patients by myself. I fail to see how this Total Patient Care model is going to help.

Consider this: I have four patients, a seemingly mild load and safe for patients. The other RNs on the floor are busy with their four patients and are unable to help me bath a large patient. Now I have a back injury.

Or this: I am assisting an elderly woman to the bedside commode. Because she has recently had a stroke and is none too steady, I have to stay at her bedside to prevent her from falling.
For 10 to 15 minutes, I help her get out of bed, on the commode and back to bed, making her comfortable. At that same time, another post-op patient has falling blood pressure (though I don't know this yet because I am unable to get into the room to take vital signs), and another has pain rated 10/10. I can�t get there to assess or to help, and I can�t get help from others because one nurse is in the middle of giving a bath, one is hanging blood and the other is at lunch.

Any acute care nurse who has seen the TPC model in action will tell you this is an absolute reality. The hospitals are cutting CNA jobs in order to hire more nurses to meet the standards. If you think this snapshot of a day in TPC is going to increase job satisfaction, patient safety, or increase nurse retention in the workplace, think again.

The hospitals are cutting CNA jobs so they can hire more RNs to meet the new staffing ratio legislation.

Summer La Salle, RN, MS
Eureka, Calif.

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