Practice Speaks Louder Than Words
By Connie Barden, RN, MSN, CCNS, CCRN
President, American Association of Critical-Care
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
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
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