AACN News—February 2002—Practice

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Vol. 19, No. 2, FEBRUARY 2002


In the Circle: Award Honors Excellent Management


The following excerpts are from exemplars submitted in connection with the Excellence in Management Award for 2001, a part of AACN�s Circle of Excellence recognition program. This award recognizes nurse managers who demonstrate excellence in coordination of available resources to efficiently and effectively care for acute or critically ill patients and families. Recipients were provided complimentary registration, airfare and hotel accommodations for NTI 2001 in Anaheim, Calif.

Judy E. Davidson,
RN, MS
San Diego, Calif.
Pomerado Hospital

I look forward to Mondays with mixed pleasure and guarded anticipation. What makes this, my clinical day, different? Mondays help me not lose sight of what it means to be a nurse.

It has been years since I�ve pulled shifts. �What do you think about playing some music, Mr. Henry?� His wife hums along, brings up stories of the past�good times and memories. Making death right and good and as special as birth is a rewarding experience. His skin becomes dense and clammy, and his breathing deep and irregular. �He is leaving us now. He is having no pain. Is there anything else you wanted to tell him before he is gone? He won�t last much longer.� I pat one hand; she caresses the other. She leans forward and speaks softly in his ear. In a moment he is gone. We cry together.

I wouldn�t trade Mondays for anything. It�s what makes management doable. I realize that the new insulin syringes purchased to make us safe don�t work. You can�t see the marks on them. The doors to the storeroom are so heavy they hurt your wrists. The pressure needed to tear open the new IV bags hurts your thumb and hand. We need more footstools. The soap is too harsh. The nurses need lotion, not just soap. The back door doesn�t close smoothly. The housekeeper doesn�t know that the hopper needs to be cleaned. The DKA protocol is too cumbersome to really use; three months of committee work down the drain.

Details revealed on Mondays prioritize goals for unit management. More importantly, they feed the nursing spirit.

Karin Henderson, RN, MSN, CCRN, CS
High Point, N.C.
High Point Regional Health System

I was promoted to a management position in a critical care, step-down unit two-and-a-half years ago. I was now in a position where, instead of taking care of one patient, I could influence the care of multiple patients. With my advanced degree as a nurse practitioner, I really knew little about management. However, my hunch was that a professional caring environment with management making a personal investment in staff would bring positive results. Caring for nurses is my priority. I truly believe that this is the highest duty of management. With the help of the nurses on my unit, we turned a struggling unit into a wonderful place for nurses to practice and patients to receive care.

How? We rolled up our sleeves and changed our environment by using the following approaches:
� A new voice�I used small focus groups on every shift to gain insight and enlist staff as the authors of change in their unit.
� No more pyramids�The charge nurses and I formed a circle structure where management was accountable to each other.
� Extra training�To be truly accountable to each other, we promoted the increase in numbers of staff who can run the unit.
� Empowerment�We did not just schedule committees and interview committees, but used encouragement and accountability to help each other grow.

Today, we have a unit that is overstaffed, with nurses on a waiting list to work with us. Our unit is a different place today than when our change process began. We have formed an environment where nurses can grow, be mentored, express ideas and effect change. Heaven? No. But amazing things happen every time nurses are given the opportunity to grow.

Karen Wyble
RN, BSN, CCRN
Arnaudville, La.
Lafayette General Medical Center

Managed care did not trickle through to our area until 1997. At that time, I realized that the way we care for our patients must change if we were to compete in the healthcare market. Having recently accepted a management position and being an ICU nurse, I recognized the challenges that bedside nurses faced in caring for their patients.

Our 20-bed ICU was quickly becoming a unit of not only unstable acute patients but also of hemodynamically stable patients who could not be weaned off the ventilator. Our 10-bed medical ICU was congested with long-term care vent patients. Our immediate strategic goal was to facilitate a plan that would join the hands of the ICU, MICU and telemetry units in caring for our patients. I met with each unit team to talk about our goals and how we would accomplish them. The staff and I decided we would become a 29-bed specialty care unit.

One particular area of patient care that we viewed as an opportunity to decrease costs was angioplasties. I empowered the staff to work as a team in developing standards that would maintain the quality of care for this population. We devised orientation packets and solicited the assistance of the catheter lab and ICU staff to help with teaching the telemetry nurses to pull sheaths and hold pressure.

An unexpected outcome was that the telemetry nurses were becoming more confident in their ability to care for all of their patients. This translated to new respect between physicians and nurses on the unit, and we were able to decrease the cost per patient discharged by more than 50%. I was proud to lead a great team to maintain high standards and efficiently care for our patients. I truly believe that, to be an effective leader, you have to love your team of people, not your position of leadership.


Research Corner: Myth vs. Reality: Holding Intubated Infants in the NICU

By Sandra L. Smith, RN, PhD, APRN
Research Work Group

Jay is a 26-week gestation infant who now is 28 days old and weighs 985 grams. He is intubated and receiving mechanical ventilation. His ventilator settings are PIP 20, PEEP 5, SIMV 30, I-Time 0.32. His fraction of inspired oxygen requirement ranges from 0.30 to 0.45 to maintain his oxygen saturation within the neonatal ICU�s standard of care range. He is receiving and tolerating well full enteral feedings via a nasogastric tube. Jay�s mother believes that holding her premature infant will be good for him and will help him to �feel and grow better.� The nurse is aware of the literature regarding skin-to-skin holding (also known as kangaroo care) and agrees. However, the other nurses are skeptical.

Myth: Intubated infants are physiologically more stable when they are held than when they are in the incubator.

Reality: The NICU culture has been moving toward the family-centered care paradigm, which inherently demands that families be included in the care of their infants. Although holding is a seemingly benign act, it can be extremely stressful for the fragile, intubated, very low birth weight infant. There are no published studies regarding the effect of swaddled holding on the physiological responses of the intubated VLBW infant, and the research on the effects of skin-to-skin holding has been conducted primarily on the healthier, premature infant, who is no longer intubated nor mechanically ventilated. Few studies have been published describing the physiological effects of skin-to-skin holding on the intubated VLBW infant.

The belief that all infants should be held is based upon term, healthy infants. Critically ill, premature infants, including intubated VLBW infants on full enteral feedings, are a different population and appear to respond differently to external stimuli than the healthy term infant.

Skin-to-skin holding of the well, term newborn and the convalescing premature infant has been shown to be safe. In fact, term infants held skin-to-skin immediately after birth cried significantly less than infants placed in cribs. In addition, there were no differences in infant temperature between the group of infants held skin-to-skin and those placed in cribs.1-3 These findings suggest that skin-to-skin holding may be supportive and comforting to the term infant immediately after birth.

Reports on preterm infants differ because the gestational ages, birth weights, and age and weight at the time they were enrolled vary widely from study to study. Spontaneously breathing, premature infants cared for in incubators were reported to remain normothermic during one and three hours of skin-to-skin holding.4-7 Investigators have also reported that infants maintain normal heart rates, respiratory rates and oxygen saturations during skin-to-skin holding, suggesting that it is not detrimental to the convalescing premature infant.7,8

The limited data on the more critically ill premature infants are contradictory. Two groups of investigators studied a small group of infants receiving nasal prong, continuous positive airway pressure.9,10 Both studies showed no significant differences in heart rates, respiratory pattern or oxygen saturation during skin-to-skin holding or incubator care. However, the rectal temperature of one 770-gram infant did decrease to 37.2�C during skin-to-skin holding, illustrating the sensitivity and fragility of these very small infants.

Few investigations have been published on the physiological stability of intubated VLBW infants during holding, and the results of two recently published reports are inconclusive. Neu and colleagues11 studied 15 mechanically ventilated, premature infants weighing between 745 and 1876 grams. These infants had significant decreases in oxygen saturation during the transfer to and from the incubator and parent for skin-to-skin holding. These investigators also reported that the infants had normal temperatures and no differences in oxygen saturation during skin-to-skin holding compared with incubator care. Smith12 studied 14 intubated VLBW infants with a mean study entry weight of 994 grams. These infants were randomly assigned to receive incubator care for two days, followed by two hours of intermittent, skin-to-skin holding for two days, or vice versa. The infants in this study demonstrated a 14% increase in fraction of inspired oxygen requirement during skin-to-skin holding compared with incubator care to maint ain adequate oxygen saturations between 85% and 96% (the study site standard). The patterns of oxygen saturation were also more variable during skin-to-skin holding compared with incubator care in these fragile infants. Infants in this study also became hyperthermic during skin-to-skin holding, most likely because of the transfer of heat from the mother�s chest to the infant. Although not statistically significant, infants during the skin-to-skin holding phase of the study gained less weight (6.8 grams/kg/day) than during the incubator phase (12.6 grams/kg/day).13

In summary, the data regarding the safety and efficacy of skin-to-skin holding on intubated VLBW infants are conflicting. Current research suggests that the intubated VLBW infant may be physiologically stressed during skin-to-skin holding, a situation that may have uncertain, long-term effects. Nurses must weigh the perceived benefit to the mother of holding her baby during this critical phase of the infant�s illness against the physiological stress that will be placed upon the infant�s immature systems. Studies of physiological responses during traditional, swaddled holding are needed to determine if this method of holding may be less stressful and more supportive of the intubated VLBW infant.

References
1. Christensson K, Siles C, Moreno L, et al. Temperature, metabolic adaptation, and crying in healthy full-term newborns cared for skin to skin or in a cot. Acta Paediatr. 1992;81:488-493.
2. Christensson K. Fathers can effectively achieve heat conservation in healthy newborn infants. Acta Paediatr. 1996;85:1354-1360.
3. Michelsson K, Christensson K, Rothg�nger H, Winberg J. Crying in separated and nonseparated newborns: sound spectrographic analysis. Acta Paediatr. 1996;85:471-475.
4. Bauer J, Sontheimer D, Fischer C, Linderkamp O. Metabolic rate and energy balance in very-low-birthweight infants during kangaroo holding by their mothers and fathers. J Pediatr. 1996;129:608-611.
5. Bauer K, Uhrig C, Sperling P, & Versmold HT. One hour of skin-to-skin care was no cold stress for VLBW infants, as oxygen consumption and central-peripheral temperature gradient did not increase. Pediatr Res. 1995;37(4):196A.
6. Bauer K, Uhrig C, Sperling P, Pasel K, Wieland C, Versmold HT. Body temperatures and oxygen consumption during skin-to-skin (kangaroo) care in stable preterm infants weighing less than 1500 grams. J Pediatr. 1997;130:240-244.
7. Ludington-Hoe SM, Hadeed AJ, Anderson GC. Physiologic responses to skin-to-skin contact in hospitalized premature infants. J Perinatol. 1991;11:19-24.
8. Messmer PR, Rodriquez S, Adams J, Wells-Gentry J, Washburn K, Zabaleta I, & Abreu S. Effect of kangaroo care on sleep time for neonates. Pediatric Nursing. 1997;23(4):408-414.
9. Leeuw R, Colin EM, Dunnebier EA, Mirmiran M. Physiological effects of kangaroo care in very small preterm infants. Biol Neonate. 1991;59:149-155.
10. Hurst NM, Valentine CJ, Renfro L, Burns P, Ferlic L. Skin-to-skin holding in the neonatal intensive care unit influences maternal milk volume. J Perinatology. 1997;17:213-217.
11. Neu M, Browne JV, Vojir C. The impact of two transfer techniques used during skin-to-skin care on the physiologic and behavioral responses of preterm infants. Nurs Res. 2000;49:215-223.
12. Smith SL. Physiologic stability of intubated VLBW infants during skin-to-skin care and incubator care. Advances in Neonatal Care. 2001;1:28-40.
13 Smith SL. Physiological responses of intubated very-low-birthweight infants during skin-to-skin care. Dissertation Abstracts International. 2000;61(02):784. (University Mircrofilms No. AAT9961431.)


The Power of One: Proper Translation Key in Family-Centered Decision Making

By Christine Westphal, RN, MSN, CCRN
Ethics Work Group

Mr. and Mrs. Ang had immigrated from Korea seven years ago with their son, grandson and their families. After struggling initially, the family had become successful owners of a local market, with all three generations living and working together.

Late last year, Mr. Ang died suddenly. The eldest son Chin made certain his now 80-year-old mother was well cared for and protected. Protection of the elderly, widowed and infirm is an expectation in Korea, as well as many other Asian and Middle Eastern cultures.

A resilient woman, Mrs. Ang continued to be active in the family business after Mr. Ang�s death, putting in long hours. Over time, her family began to notice that she seemed to tire more easily and was often short of breath. At closing time one evening, Chin found his mother seated on a crate in the back room of the store, short of breath and diaphoretic. He called 911.

At the emergency department, Chin served as the interpreter as the healthcare team assessed Mrs. Ang, who had suffered a myocardial infarction and was in pulmonary edema. With aggressive treatment, she was stabilized, without the need for emergent intubation, and transferred to the ICU.

Upon admission to the ICU, the nurse, Jon, assessed both Mrs. Ang and the family dynamics. Although Mrs. Ang was responding to diuretics, oxygen and inotropes, Jon knew that she would require a cardiac catheterization. Because she was physiologically vulnerable and at risk for a respiratory or cardiac emergency, Jon wanted to clarify her wishes for resuscitation in the event that she became further compromised. He also recognized that the Ang family was close and interdependent, and would likely need additional support.

Chin was willing to participate in his mother�s care. However, Jon was concerned that Chin might not be able to accurately translate some of the complex medical terms. He was also concerned that Chin might be reluctant to communicate information to his mother that might upset her. At the same time, Jon recognized that Mrs. Ang might be reluctant to answer personal health questions in the presence of her son. Thus, as an advocate for Mrs. Ang and her family, Jon sought out a medically competent translator to assist with the communication.

Jon recalled that the hospital had contracted for a language translation service, which provided the hospital with interpreters via telephone, as well as translation of documents in more than 140 languages. The service guaranteed that a translator would be available within minutes.

However, Jon also knew that the service could not always provide interpreters fluent in �medical language� and that, because the message is more than simply words, having the translation in person would be more effective. He remembered that a nurse in the ambulatory clinic spoke Korean.

As Jon waited for the bilingual nurse to arrive, Chin expressed concern about alarming his mother with information about her condition and possible treatments. He explained that, because he could give consent for anything his mother needed, it was not necessary to involve her. Jon explained to Chin that, because Mrs. Ang was alert and able to participate in decision making, she had a right to make her own decisions and not disclose information to anyone, if she so chose. This position upset Chin greatly. Afraid that the stress of the medical information and decision making could make his mother sicker, he begged Jon to let him talk to his mother in his own way. Jon was torn. Although he understood the need to be sensitive to the unique cultural and spiritual needs of patients and their families, he felt obligated to protect the patient�s rights.

Jon sought advice from his manager, who consulted Carolyn, the on-call resource from the hospital Ethics Committee. Carolyn explained that a patient�s right to truth-telling, confidentiality and self-determination is based upon western values and beliefs that may not be espoused by all patients. She further explained that a patient, based upon his or her own values and beliefs, can defer these rights and give permission to another to act on his or her behalf. The team met with Chin and explained that his request to protect his mother and make decisions on her behalf could only be honored if Mrs. Ang agreed.

The team, along with the bilingual nurse, went to Mrs. Ang�s bedside. To avoid influencing his mother�s decision, Chin was asked to remain outside. The nurse explained Mrs. Ang�s rights as a patient to her, but also told her that she could allow her family to receive information and make decisions on her behalf if she wanted. Mrs. Ang expressed that Chin had always taken care of her and that she trusted him to decide what was best for her. She expressed that she trusted him to tell her what she would need to know.

Jon�s clinical judgment, advocacy, caring, collaboration and system thinking helped him to effectively meet the needs of Mrs. Ang and her family. The �power of one� did, indeed, make a difference!


Sharing the Experience: Program Experience Exceeded Expectations

Editor�s Note: In celebration of the 10th anniversary of the AACN Wyeth-Ayerst Nursing Fellows Program, AACN invited alumni mentors and fellows to share their thoughts about and experiences with the program. These accounts will be published in AACN News throughout this anniversary year.

By Judy Graham-Garcia, RN, MS, CCRN, FNP, ACNP, Wyeth-Ayerst Fellow
and Janie Heath, RN, MS, CCRN, ANP, ACNP, Wyeth-Ayerst Mentor

Participating in the 2000 AACN Wyeth-Ayerst Nursing Fellows Program exceeded all of our expectations. Although we knew that being recognized by such a prestigious program was an honor and that being associated with such renowned nursing colleagues was a privilege, we did not know that we would receive �the royal treatment� at the NTI. From the fruit and cheese basket that arrived at our hotel to welcome us to the special treatment we received at the opening and closing sessions and in the exhibit hall, the experience was truly first class.

We will always appreciate the opportunity AACN, Wyeth-Ayerst and the American Journal of Nursing provided us to have our study, �The Value of Urgent Smoking Cessation in the Veteran Population,� published in the AJN supplement.

This program has been a significant stepping stone for our professional and personal relationship on many levels. From a scholarly perspective, we completed another study on the �Assessment of Professional Development in Critical Care Nurses,� which was published in the American Journal of Critical Care. From a professional perspective, we continue to stay passionate about AACN and encourage nurses to become active in their local chapters. From a personal perspective, our mentoring relationship continues today, despite the fact that we are several hundred miles apart.

AACN has so many resources and opportunities available to all of its members, and we are now dedicated to spreading the excitement and encouraging others to apply to this wonderful nursing fellows program.

Advanced Practice Roles: CNS or NP? What�s in a Name?

By Julie Stanik-Hutt, RN, PhD, CCRN, ACNP
and Sandra J. Cagle, RN, MSN, CCRN, ACNP
Advanced Practice Work Group

Does a clinical nurse specialist or nurse practitioner work at your hospital? Is there really a difference between these two advanced practice roles? Are credentials, such as CCNS and ACNP, just more �alphabet soup�?

Advanced practice nurse is a generic, umbrella term that encompasses NPs, CNSs, nurse anesthetists and nurse midwives. The NP and CNS roles were created in the early 1970s, whereas nurse anesthetists and nurse midwives have been advanced nursing roles for more than 50 years.

Advanced practice nurses are RNs who have acquired advanced preparation for expanded clinical practice by earning a master�s degree in nursing. Their distinct training and skills differentiate them from other RNs.

What Is a CNS?
A CNS is an expert in clinical nursing who is familiar with the theory and research related to a nursing specialty area, such as critical care nursing. Traditionally, CNSs influence patient outcomes through direct clinical practice, as well as education, research, consultation and management. They are uniquely prepared, by experience and education, to manage the complexities of negotiating our complex healthcare delivery systems. CNSs may fill positions with job titles such as case manager, nurse educator (hospital or university based), quality improvement manager or community education specialist.
Nurses preparing for CNS positions take courses in specialized areas, such as pathophysiology, advanced health assessment, critique and application of research. They also complete courses related to management of the clinical care system, including systems management, teaching and learning theories, performance and quality improvement, and management of change. Those aspiring to become CNSs may also complete clinical practicums to gain experience in subroles, such as educator, researcher or consultant.

CNSs practicing in critical care can become certified by successfully passing the CCNS exam offered by AACN Certification Corporation. Most states do not require national certification or special licensure for practice as a clinical nurse specialist. However, several states now recognize CCNS certification as meeting the criteria for advanced practice nursing designation or licensure.

What Is an NP?
An NP provides direct care to a specific population of patients, such as adult, children, women, acutely ill adults and neonates. They diagnose and manage common acute and stable chronic health problems, responsibilities traditionally reserved only for physicians. In addition to the traditional RN skills, NPs can perform comprehensive physical examinations, order and interpret diagnostic tests, obtain specialty consults, and perform and prescribe therapeutic measures, including most classes of medications. They also incorporate health promotion and disease prevention, as well as patient and family education, into their practice. NPs, who are individually accountable for their practice and decisions, collaborate closely with physicians.

A nurse preparing to be an NP completes courses related to the direct care of individuals, including differential diagnosis, clinical decision making, medical therapeutics and pharmacology. NP students must also complete more than 500 hours of clinical practice that is closely supervised by experienced NPs and physicians. Following graduation, NPs take national certification exams and are usually specially licensed by their states to practice. The educational preparation, certification and scope of practice of an NP focuses on a specific patient population, such as adults, children, women or acute care.
An acute care nurse practitioner is an NP who has completed the ACNP examination administered by the American Nurses Credentialing Center and whose practice focuses on acutely and critically ill individuals. These NPs are employed in hospitals and ICUs, as well as in specialty medical practices. They manage hospitalized patients with complex, but often stable, medical problems, such as uncomplicated myocardial infarction, pneumonia, exacerbation of chronic obstructive pulmonary disease, diabetic ketoacidosis, postpercutaneous transluminal coronary angioplasty, postcoronary artery bypass graft or common complications of organ transplantation. They may be credentialed to perform bedside procedures, such as insertion of central venous and pulmonary artery catheters and arterial lines; lumbar punctures, thoracentecis or paracentecis; insertion and removal of chest tubes; or wound debridement.

NP or PA?
When explaining to someone what an NP does, the inevitable response seems to be, �Oh, like a physician�s assistant.� Although NPs and PAs may fill similar roles in community and hospital settings and the functions of their roles may appear similar, there are clear differences.

A PA has completed a formal educational program and usually completes a national certification exam. PA programs are usually for two years and offered by a community college. However, some are in four-year colleges and even graduate programs. Prior experience in healthcare is not a prerequisite. A PA may obtain a patient�s medical history, perform physical exams, assist the physician in developing and implementing patient management plans, record progress notes and perform common routine diagnostic procedures. Although the scope and regulation of PA practice varies by state, it always requires supervision by a physician.

Although an associate�s degree is all that is required to become a PA, an NP must have a master�s degree in nursing. NPs are independently licensed; a PA is not. A physician must supervise the practice of a PA. NPs already have a background in professional nursing practice and approach patient problems from that perspective. A background in healthcare is not a prerequisite to practice as a PA, who is educated in the medical model of care. In addition, some PAs are trained by their supervising physicians to perform routine procedures, such as suturing and wound care, or to assist in surgery. Both NPs and PAs may write medical orders. However, the PAs� orders must be cosigned by the physician (sometimes before they are carried out).

Summary
As you can see, both NPs and CNSs are advanced practice nurses. They fill different but complementary roles. Depending on the individual practice, the roles of the CNS and NP may even overlap. Both NPs and CNSs approach problems from a shared nursing as well as distinct subspecialty background. They both make important contributions to patient care.

Now, the next time you encounter a clinical problem, you�ll know which advanced practice nurse to call for help. When you run into a CNS or an NP, ask him or her to tell you about the job. You may discover that being an NP or a CNS means doing something you�d like to do.


Grants

March 1 is the deadline to apply for the AACN Evidence-Based Clinical Practice Grant. This grant funds multiple $1,000 awards, up to a total of $6,000 per year, 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.

New projects, projects in progress and projects required for an academic degree are eligible for funding. Projects may include research utilization studies, CQI projects or outcomes evaluation projects. Interdisciplinary and collaborative projects are encouraged and may involve interdisciplinary teams, multiple nursing units, home health, subacute and transitional care, other institutions or community agencies.

Funds may be used to cover direct project expenses, such as printed materials, small equipment or supplies, including computer software. Funds may not be used for salaries or institutional overhead.

To obtain an application, call (800) 899-2226 and request Item #1013, or visit the AACN Web site at www.aacn.org > Clinical Practice > Research.
 

Compassionate Care Videos Available in Both Family and Professional Versions

Two videos titled �Compassionate Care in the ICU: Creating a Humane Environment� are now available through AACN. Funded by an educational grant from the critical care/surgery division of Ortho Biotech, each version of the videos was produced in cooperation with the Society of Critical Care Medicine.

One version is geared to families and the other to professionals. Both are hosted by Mitchell Levy, MD, associate professor of medicine at the Brown University School of Medicine, Providence, R.I., and chair of the Robert Wood Johnson Critical Care End of Life Work Group.

The professional version, which features a candid discussion of the complex psychological, emotional and legal issues surrounding end-of-life care, is intended to help ICU practitioners begin cultivating the compassionate skills needed to assist patients and loved ones.

The family version focuses on the complex decisions faced in the ICU and the importance of advance planning and communication. It also answers questions about the withdrawal of life support and addresses the issues of pain and symptom management.

To order either of these videos, call (800) 504-9334.


Evidence-Based Practice Issue Available at Discounted Price

Because of the popularity of the November 2001 issue of AACN Clinical Issues (Vol. 12, No. 4), Lippincott Williams & Wilkins has made back issues available for the special price of $29.95. This issue focused on the role of experienced and advanced practice nurses in evidence-based practice and how they can incorporate research findings into their practice.

The issue included articles on the following topics:
� Integrating Clinical Reasoning and Evidence-Based Practice
� Champions for Evidence-Based Practice: A Critical Role for Advanced Practice Nurses
� Quality Care Outcomes in Cardiac Surgery: the Role of Evidence-Based Practice

To order, call (800) 638-3030. Use code D1K140ZZ.

AACN Clinical Issues is available to advanced practice AACN members at a 30% discount. To subscribe to this journal at the reduced, member rate of $53.90, call (800) 638-3030 and ask for membership services.


AACN Online Quick Poll

Does your hospital have a policy and procedure for doing �non-heart beating� or asystolic donation ?

Yes 36%
No 64%

Number of Responses: 363

The AACN Online Quick Poll is a voluntary survey on a variety of topics and is not scientifically 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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