AACN News—June 2002—Practice

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Vol. 19, No. 6, JUNE 2002

Myth Vs. Reality: Instillation of Normal Saline With Suctioning

By Frederick J. Tasota, RN, MSN
University of Pittsburgh School of Nursing

My hospital�s procedure for suctioning patients with artificial airways recommends normal saline instillation prior to inserting the suction catheter. Should this routinely be performed in conjunction with suctioning?

Myths: NSI thins secretions and lubricates the tube and catheter; increases the amount of secretions removed; and loosens and dislodges secretions.

Reality: Every day, critical care nurses and respiratory therapists suction intubated patients, attempting to maximize secretion removal and minimize complications. One purported means to enhance secretion removal involves the routine use of NSI. Although this well-established practice is firmly based on tradition and good intentions, convincing scientific support is sorely lacking.

Myth: NSI dilutes thick, tenacious secretions and promotes their removal by lubricating the tube and catheter.

Reality: Although mucus is 95% water, it becomes a semisolid, similar to gelatin when formed and incorporates further liquid poorly.1 In fact, even after vigorous shaking in vitro, mucus and saline do not mix.2,3 Furthermore, there is no evidence to support that NSI acts as a lubricant to facilitate secretion removal. NSI cannot be a substitute for adequate systemic hydration and proper heating and humidification of the airway to promote thinning of secretions and their movement on the mucociliary escalator.

Myth: More secretions are suctioned when saline is used.

Reality: This premise provides a false sense of security, as there is little evidence to support NSI increasing secretion removal. Researchers comparing the amount of secretions obtained with and without NSI have found: 1) no significant differences4; 2) statistically significant increases with NSI, but the differences were clinically insignificant and the studies failed to account for the weight of the saline5,6; and 3) significant increases with an initial NSI in a small study (n=12) that did not demonstrate significant differences with a second suction episode.7 Isea et al compared a large volume (40 ml) of normal saline instilled into the distal trachea through a double lumen tube to a conventional (10 ml) proximal bolus of saline and found significant increases in secretion removal with the larger distal instillation. However, they did no comparison to suctioning without NSI, and the study protocol required an unconventional method of saline delivery and large volume of saline.8

Myth: NSI irritates the tracheal mucosa and stimulates a cough, which helps loosen and dislodge secretions.

Reality: Saline is definitely an airway irritant and promotes coughing in those individuals who are not paralyzed or have an absent cough reflex. Anecdotal evidence supports the fact that coughing loosens and dislodges thick, dried secretions and may increase the amount of secretions obtained with suctioning.6 However, there have been no clinical trials to support this assertion or whether mere insertion of the catheter itself is sufficient to initiate productive coughing. Although coughing will help propel secretions out of the airway, forceful bagging or inspiration by the patient, combined with the potential shearing force of the saline, may move secretions lower in the airway.3 Interestingly, Hagler and Traver9 demonstrated in a small study the in vitro ability of a 5 ml saline instillation to dislodge five times the number of bacteria from the inner lumen of endotracheal tubes during simulated suctioning than with a suction catheter alone (n=10).

Myth: Although researchers have failed to support advantages to the routine use of NSI during suctioning, others have investigated its potential disadvantages.

Reality: If NSI improves secretion removal, there should be evidence of improved pulmonary function after suctioning with NSI. However, investigators have found no differences in pulmonary mechanics (peak inspiratory pressure, dynamic compliance or tidal volume) with or without NSI,6,7 nor has there been a greater improvement in gas exchange.4,6,10,11 Thus, there is no clear physiologic benefit; in fact, NSI may even be harmful for some critically ill patients.

The majority of work assessing the impact of NSI on oxygenation has focused on oxygen supply.4,6,10 Only one study provides insight into the potential influence of NSI on oxygen demand. Kinloch et al11 assessed mixed venous oxygen saturation (SvO2) in a group of postoperative cardiac bypass patients. Although the study was not randomized and had several other limitations, it clearly demonstrated the potential harm that NSI can have on critically ill patients. SvO2 nadir after suctioning decreased 17% below baseline for patients in the NSI group vs. 9% for the non-saline group. Furthermore, recovery time needed to return to baseline SvO2 was more than twice as long for the NSI group.

Other potential disadvantages of NSI include infection control issues secondary to the technique used to open saline vials,12 cost considerations for the saline vials themselves13 and its impact on the patient�s psychological well-being. Although the psychological consequences are difficult to assess quantitatively, qualitative work suggests the discomfort and anxiety associated with NSI procedures.14
Long-term patient outcomes associated with or without NSI are unknown. Scientific evidence provides little to no support for any short-term benefits associated with routine NSI and suggests the potential for harm with its use. If NSI does serve a purpose in select patients, these patients need to be identified and protocols developed to promote safe and effective practice. However, for the present, practitioners need to discontinue the routine use of NSI for every patient each time they need to be suctioned.

1. Connoly MA. Mucolytics and the critically ill patient: Help or hindrance. AACN Clinical Issues. 1995; 6:307-315.
2. Demers RR, Saklad M. Minimizing the harmful effects of mechanical aspiration. Heart & Lung. 1973; 2:542-545.
3. Ackerman, MH, Ecklund MM, Abu-Jumah M. A review of normal saline instillation: Implications for practice. Dimens Crit Care Nurs. 1996;15:31-38.
4. Bostick J, Wendelgass ST. Normal saline instillation as part of the suctioning procedure: Effects on PaO2 and amount of secretions. Heart & Lung. 1987;16:532-537.
5. Ackerman MH, Gugerty BP. The effect of normal saline bolus instillation in artificial airways. Journal of the Society of Otorhinolaryngeal Head-Neck Nurse. 1990; Spring:14-17.
6. Gray JE, MacIntyre NR, Kronenberger MA. The effects of bolus normal-saline instillation in conjunction with endotracheal suctioning. Respiratory Care. 1990; 35:785-790.
7. Reynolds P, Hoffman LA, Schlichtig R, Davies PA, Zullo TG. Effects of normal saline instillation on secretion volume, dynamic compliance and oxygen saturation (Abstract). American Review of Respiratory Disease. 1990;141S:574.
8. Isea JO, Poyant D, O�Donnell C, Faling LJ, Karlinsky J, Celli BR. Controlled trial of a continuous irrigation suction catheter vs conventional intermittent suction catheter in clearing bronchial secretions from ventilated patients. Chest. 1993;103:1227-1230.
9. Hagler DA, Traver GA. Endotracheal saline and suction catheters: sources of lower airway contamination. Am J Crit Care. 1994;3:444-447.
10. Ackerman MH, Mick DJ. Instillation of normal saline before suctioning in patients with pulmonary infections: a prospective randomized trial. Am J Crit Care. 1998;7:261-266.
11. Kinloch D. Instillation of normal saline during endotracheal suctioning: Effects on mixed venous oxygen saturation. Am J Crit Care. 1999;8:231-242.
12. Rutala WA, Stiegel MM, Sarubbi FA. A potential infection hazard associated with the use of disposable saline vials. Infect Control. 1984;5:170-172.
13. Raymond SJ. Normal saline instillation before suctioning: Helpful or harmful? A review of the literature. Am J Crit Care. 1995;4:267-271.
14. Blackwood B. Normal saline instillation with endotracheal suctioning: primum non nocere (first to do no harm). J Adv Nurs. 1999;29:928-934.

NTI 2003 Abstract Deadline Is Sept. 1

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.
The designated presenters of accepted abstracts receive a $75 reduction in NTI registration fees. 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.

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

July 1 is the deadline to apply for several AACN nursing research grants.

AACN End-of-Life Grants
Two small project grants of $500 each will be awarded for studies related to end-of-life or palliative care outcomes in critical care. Eligible projects may address a range of topics, including bereavement, communication issues, caregiver needs, symptom management, advanced directives and life support withdrawal. The research may focus on any age group and may include patient education programs, staff development programs, competency-based educational programs, CQI projects, outcomes evaluation projects or small clinical research studies. Collaborative projects are encouraged.

Clinical Inquiry Grant
Up to $500 will be awarded for projects that directly benefit patients or families. Interdisciplinary projects are especially invited. The principal investigator must be currently employed in a clinical setting and directly involved in patient care.

Medtronic Physio-Control-AACN Small Projects Grant
Funding of up to $1,500 will be awarded for projects focusing on aspects of acute myocardial infarction, cardiac resuscitation, sudden cardiac death, use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretive 12-lead ECG. Collaborative projects are encouraged. This grant is funded by Medtronic Physio-Control.

The grants application book can be downloaded from the AACN Web site at http://www.aacn.org or is available from Fax on Demand at (800) 2226-329 (Document #1013).

Beyond the Four Walls: Continuum of Critical Care Nursing Extends Reach

Members of the Progressive Care Task Force for 2001-03 include
(from left) Ray Quintero, Susan Helms, Randeen Cordier, Katie
Schatz (staff liaison) and LeAnn Ash (cochair). Not pictured are
Melissa Fitzpatrick (cochair), Madeleine Burke, Mary Palazzo
and Diane Salipante. M. Dave Hanson was the 2001-02 board
liaison, and Bertie Chuong is the 2002-03 board liaisons.

By Mary Palazzo, RN, MS, CCRN
Progressive Care Task Force

Critical care nursing is no longer practiced exclusively in the traditional ICU setting. Today, the practice of critical care nursing extends into other acute care areas, including progressive care, step-down and intermediate care units.

For example, because of technological advances, acute MI patients who previously were admitted to a coronary care unit on strict bed rest and hemodynamically monitored are now admitted to progressive care units. In these units, they receive primary angioplasty and a course of glycoprotein IIb-IIIa inhibitors before being discharged 24 hours later. These types of advances have influenced the way we care for patients, and future advances will further broaden the definition of critical care nursing and promote the growth of progressive care.

Recognizing that progressive care has emerged as an integral part of the critical care continuum, AACN established the Progressive Care Task Force to discuss the impact of this expanding component of patient care. At its first meeting, the task force quickly determined that, because progressive care is still evolving, it has not been completely defined. The group also recognized that the terminology used to describe progressive care has not been clearly articulated.

The task force wrestled with difficult questions, including:
� Is progressive care a separate specialty or is it a part of critical care?
� What standards of care exist for progressive care nursing?
� What type of education do nurses practicing in progressive care need?

Specialized Practice
The task force unanimously agreed that progressive care is part of the continuum of critical care nursing and that nurses working in these areas need the same level of education as nurses working in the ICU, except with respect to the invasive technologies.

Progressive care can be extremely specialized, with patient care focused on a specific system, such as cardiac, or broader based, such as in a medical intermediate care unit. With the evolution of progressive care, many hospitals have developed highly individualized practice guidelines, as well as admission and discharge criteria to define these units.

Nursing practice has expanded beyond the basic cardiac, telemetry monitoring that marked the beginning of progressive care to include many of the same technologies and therapies that were once limited to the ICU. Yet, the clinical preparation of progressive care nurses varies widely. This preparation is dependent on resource availability and whether progressive care is isolated from the critical care courses. As progressive care continues to expand, the fundamentals of critical care nursing will provide a strong foundation for the most successful patient outcomes.

Synergy Model
AACN has articulated a vision for healthcare that is driven by the needs of patients and families in which critical care nurses make their optimal contributions.1 This vision is the basis for the Synergy Model, a conceptual framework that defines contemporary nursing practice in terms of comprehensive patient and nurse characteristics that interplay to achieve optimal patient outcomes.2

By suggesting that every attempt be made to match the patient care needs to the skill level of the nursing care provider, this model affirms what charge nurses do every day when making patient care assignments. Essentially, the Synergy Model provides for a broader form of excellence in nursing care delivery that is not confined to a particular unit. Its universal applicability circumscribes each patient�s unique needs throughout the critical care continuum and allows for flexibility as the patient�s condition improves or declines.

According to the Synergy Model, stability, complexity, vulnerability, resiliency, predictability, resource availability, participation in care and participation in decision making are the patient characteristics that describe patient function. The nurse characteristics that typically represent comprehensive nursing practice include clinical judgment, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and learning facilitator.2 The framework is thus a fluid one that takes into account the unpredictability of illness, as well as the growth of the nurse.

Using the Synergy Model in progressive care helps us to better identify the patient population, the process of care and the location where care should be given. Patients who are highly unstable or unpredictable, with multisystem complexity and high resource use, require continuous nursing vigilance and therefore should be in an ICU. Moderately stable patients who are less complex and require intermittent nursing vigilance and moderate technological resources can be cared for in a progressive care unit. This conceptual model is a useful tool that can be used to better articulate nursing care guidelines and provide a much-needed, more clearly defined structure in the broader continuum of critical care.

Embrace Changes
As we face the daily challenges of nursing care, it is important to embrace changes in our practice as they evolve. Progressive care nurses will need to take the initiative to attend critical care courses to advance their assessment skills and expand their knowledge base. However, it is easy for nurses to simply say, �we have always done it this way,� instead of reaching out to explore new research that points to a better path or to perhaps admit that what we have been doing is not the best way to practice anymore.

1. American Association of Critical Care Nurses. Standards for Acute and Critical Care Nursing Practice. Aliso Viejo, CA: American Association of Critical-Care Nurses. 2000.
2. Edwards DF. The Synergy Model: linking patient needs to nurse competencies. Crit Care Nurse, 1999;19:88-97.

Philips Announces Support of $100,000 Outcomes Grant

On hand for the announcement by Philips Medical Systems of a new
$100,000 nursing research grant were (from left)  AACN board member
Mary Fran Tracy, Research Work Group Chair Paula Lusardi, 2002
Distinguished Research Lecturer Barbara Drew and Philips
representatives Joan Hodges and Marianne Messina.

Philips Medical Systems has contributed $100,000 to support a new Philips Medical Systems-AACN Outcomes for Clinical Excellence Research Grant, which will replace the Critical Care Nursing Research Grant it has funded since 1991.

The announcement was made by Joan Hodges, learning products manager at Philips in conjunction with the Distinguished Research Lecture at NTI 2002 in May in Atlanta, Ga.

Hodges noted that this year marks the second decade of research collaboration with AACN by Philips, which formerly was Hewlett Packard and then Agilent Technologies.

The new grant will support studies that center on improved outcomes or system efficiencies in the care of acute or critically ill individuals of any age in any clinical environment and relate directly to at least one of AACN�s research priorities. The grant, which will be awarded every three years, will be awarded for the first time at the 2003 NTI in San Antonio, Texas.

�Our company has a long history as a champion of critical care nursing research through AACN,� Hodges said. �Throughout the years, our commitment to research has always been founded on a vision that is entirely complementary with AACN in its support of nurses� optimal contributions to the care of critically ill patients and families.�

Barbara Drew, RN, PhD, FAAN, the 2002 distinguished research lecturer, was the recipient of Philips� first collaborative research grant with AACN in 1991.

Congratulations to Research Grant Recipients

Evidence-Based Clinical Practice Grant

This program provides six $1,000 awards 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.

The recipients of this grant for 2001 are:

Serna Esperanza, RN, CCRN
Puyallup, Wash.
A Continuous Quality Improvement Project to Examine and Enhance Nurses� Management of Tube Feeding Therapy

Roxanne Sabatini, RN, CCRN
Andover, N.J.
The Effects of Music Therapy Twice Daily on Ventilated Patients in the ICU Setting

Elaine Yellen, RN, PhD, CCRN
Corpus Christi, Texas
Nurse-Sensitive Outcomes in Ambulatory Surgical Patients

Sarah Perry, RN, MA, CCRN
Las Cruces, N.M.
Femoral Sheath Performance Improvement Project

Grant proposals are accepted twice a year and must be received by either March 1 or Oct. 1.

AACN Certification Corporation Research Grants
This program, which is supported by AACN Certification Corporation, awards up to four grants of up to $10,000 each to fund research related to certified practice. Examples of eligible projects include studies that focus on continued clinical competency, the Synergy Model, the value of certification as it relates to patient care or nursing practice, certification concepts and educational preparation of certificants.

The recipient of this grant for 2001 is:

Martha Curley, RN, PhD, CCNS, FAAN
Newton Centre, Mass.
Patients and Families� Perceptions of Being Cared for Well

The annual application deadline for this grant is Feb. 1.

AACN Datex-Ohmeda Grant
Funded by Datex-Ohmeda, this $5,000 grant supports research related to nutritional assessment in the critically ill patient.

The recipient of this grant for 2001 is:

Mary McCarthy, RN, MN
Steilacoom, Wash.
The Use of Body Fat Analysis and Severity of Illness to Determine Energy Expenditure in the Obese, Critically Ill Patient

The annual application deadline for this grant is Feb. 1.

AACN Critical Care Grant
This grant awards up to $15,000 to support research focused on one or more of AACN�s research priorities.

The recipient of the AACN Critical Care Grant for 2001 is:

Cynthia Peden-McAlpine, RN, PhD, RN, CS
Stillwater, Minn.
Extending Pediatric Critical Care Nurses� Expertise in Family Sensitive Care Giving

The recipient of the AACN Critical Care Grant for 2002 is:

Linda L. Chlan, RN, PhD
Lakeville, Minn.
Effects of Three Groin Compression Methods on Patient Comfort and Complications After a Precutaneous Coronary

The annual application deadline for this grant is Feb. 1.

AACN Clinical Practice Grant
This $6,000 grant supports research that is focused on one or more of AACN�s clinical research priorities.

Receiving this grant for 2002 is:

Margaret Campbell, RN, MSN, CS, FAAN
Detroit, Mich.
Psychometric Testing of a Respiratory Distress Observation Scale

Oct. 1 is the annual application deadline for this grant.

AACN Mentorship Grant
This $10,000 grant provides research support for a novice researcher with limited or no research experience to work under the direction of a mentor with expertise in the area of proposed investigation.

The recipient of this grant for 2001 is:

Michelle Kirschner, RN, BSN, CCRN
Cincinnati, Ohio
The Use of Sensory Preparatory Training in Decompensated Heart Failure Patients

The recipient of this grant for 2002 is:

Maher M. El-Masri, RN, MS
Baltimore, Md.
Predictors of Noscomial Bloodstream Infections Among Critically Ill Adult Trauma Population: A Model Testing Approach

The annual application deadline for this grant is Feb. 1.

AACN Clinical Inquiry Grant
This grant provides awards of up to $500 for clinical research projects that directly benefit patients or families. Interdisciplinary projects are especially invited.

The recipients of this grant for 2001 are:

Jennifer Wagner, RN, BSN
Louisville, Ohio
The Lived Experience of Critically Ill Patients� Family Members During Cardiopulmonary Resuscitation

Melissa Hutchinson, RN, CCRN
Bothell, Wash.
Does the Addition of Glutamine and/or Polyunsaturated Fatty Acids to Enternal Feeding Reduce the LOS Infection and Ventilator Day in Critically Ill Patients With or Without ARDS

Teresa Simpson, RN, CCRN
BonAqua, Tenn.
Family Needs Visitation Study

Janice Frederick, RN, MSN, RRT
Charlottesville, Va.
Colonization Patterns of Bedside Tonsil Suction Devices

The recipient of this grant for 2002 is:

Cynthia Kociszewski, RN, MS, CCRN, ACNNP-CS
Thomaston, Conn.
The Experience of Providing Spiritual Care to the Critically Ill Patient/Family

The annual application deadlines for this grant are Jan. 15 and July 1.

AACN-Sigma Theta Tau Critical Care Grant
This $10,000 grant is cosponsored by AACN and Sigma Theta Tau International. The grant may be used to fund research for an academic degree.

Receiving the grant for 2002 is:

Kimberly Howe, RN, MSN, CS, CCNS, CCRN
Youngstown, Ohio
Mechanical Ventilation Antioxidant Trial

Oct. 1 is the annual application deadline for this grant.

Medtronic Physio-Control AACN Small Grants Program
This program awards up to $1,500 to carrying out projects that focus on aspects of acute myocardial infarction resuscitation, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretative 12-lead electrocardiogram.

The recipient of this grant for 2001 is:

Diane Oppeneer, RN, BSN, CCRN
Sheboygan Falls, Wisc.
Experiential Learning and the AED

The annual application deadline for this grant is July 1.

Viewpoint: Apply Your Expertise as a Tour Guide for Novice Nurses

Critical care has typically attracted young nurses in the past. However, with only 10% of all nurses today younger than 30, the specialty is being disproportionately affected. How novice nurses are nurtured can make a difference.

AACN is committed to creating environments where novice ICU nurses feel safe, can learn and still make their optimal contributions. Partnering with educational institutions to produce more qualified new graduates is an important collaboration that must take place. As AACN members and experienced critical care nurses, we individually and collectively have great potential. Together, we can help to change the stereotype where critical care nurses �eat their young� into one in which critical care nurses nurture and support their newest colleagues.

We asked board members M. Dave Hanson, RN, BSN, CCRN, EMT-P, and Dorrie Fontaine, RN, DNSc, FAAN, to discuss this issue from their unique perspectives. Hanson is a nurse educator for the Surgical, Trauma, Neurology & Transplant Services at Baylor University Medical Center, Dallas, Texas, and Fontaine is associate dean of the School of Nursing at the University of California-San Francisco.

Patti�s story
While attending nursing school, Patti worked part time as a nurse technician in the 12-bed medical-surgical ICU. After graduating with a bachelor of science in nursing, she knew she wanted to be a critical care nurse. However, she lacked the formal education and training required by many of the ICUs. So, she found a hospital that provided an internship program for critical care nurses, which would help to prepare her for this new and challenging role. During the internship program, Patti was matched with a unit-based clinical preceptor who helped to teach, nurture and support what was being taught in the classroom. Patti successfully completed the 10-week internship program and was assigned to the night shift, where she connected with a special person who would continue the coaching and mentoring process. Now, 12 years later, Patti still enjoys her work as a staff nurse in the ICU.

Patti�s story represents the successful journey of an ICU nurse from novice to experienced practitioner. It is an example of what can happen when experienced nurses create opportunities for novice nurses to succeed in the critical care setting. However, it is equally important to remember that, without the appropriate support systems, being a novice ICU nurse can potentially lead to feelings of inadequacy, helplessness and frustration.

Clinical perspective
Hanson: As a nurse educator at Baylor University Medical Center, Dallas, Texas, I help to educate novice ICU nurses and provide them with the tools they will need to move along the continuum to expert status. I�ve seen the results when experienced nurses commit to helping novice nurses transition into the critical care setting. Unfortunately, I�ve also witnessed as novice nurses with excellent ICU potential have simply left because there was no support system. Following are just a few of the ways that experienced ICU practitioners can help novice nurses to succeed.
� ICU nurse internship programs are valuable because they provide the educational experience to help link clinical and classroom instruction. Clinical experts who support the development of competent and proficient practitioners generally guide the internship content. It is important to recognize that �on-the-job training� is not considered an internship program.
� Preceptors should possess sound clinical experience and a strong desire to share their knowledge. The preceptor plays a vital role because he or she helps the novice nurse to integrate the acquired knowledge and skills. The relationship between novice nurse and preceptor should ideally be a one-to-one arrangement. The preceptor can have a positive influence by being a teacher, resource person and role model.
� The mentor�a different role from the preceptor�challenges and supports the novice ICU nurse to achieve higher levels of performance. The focus of the mentoring process is to promote professional and personal growth of the novice nurse. However, it is important to acknowledge that there are only three letters between mentor and tormentor. Patti described her mentor as that �person who helped in the process of professional socialization and who first encouraged her to network in the local AACN chapter.�
� An emotionally intelligent critical care setting allows the novice nurse to feel proud of his or her accomplishments. It is also a place where novice nurses do not feel inadequate, frustrated and unappreciated. Whether novice or expert, each of us has something of value to bring to patient care. The next time you begin to hear your peers talk about perceived deficiencies of a novice nurse, we encourage you to �to take the high road,� use your bold voices and begin helping to build realistic expectations among the staff.

There are many obstacles today that novice nurses must face. Whether we started out in the ICU as a new graduate or first sought some medical-surgical experience prior to coming to the critical care unit, we succeeded because there was something or someone (internship, preceptor or mentor) helping to make the journey easier. I�m sure that each of us can remember what it was like, as a novice ICU nurse, to feel overwhelmed and inadequate. However, just because some of us had to �learn the hard way� does not mean that the novice nurse of today must face that same difficult experience.

Our challenge as experienced critical care nurses is to identify the best in ourselves and commit to sharing it with novice nurses. While some of us might be better teachers, educators or preceptors, others are better suited for the informal yet highly important mentoring relationship. In the words of Leo Buscaglia in his book Born for Love:

The majority of us lead quiet, unheralded lives as we pass through this world. There will most likely be no ticker-tape parades for us, no monuments created in our honor. But that does not lessen our impact upon the world, for there are scores of people waiting for someone just like us to come along; people who will appreciate our compassion, our encouragement, who will need our unique talents. Someone who will live a happier life merely because we took the time to share what we had to give. Too often we underestimate the power of a touch, a smile, a kind word, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.

Academic perspective
Fontaine: As a nursing educator in a baccalaureate program, I have watched with pride as an increasing number of new graduates choose critical care as their first position after graduation. Although some may be influenced by growing up with the television show �ER,� I believe their choice also comes from the 15-week clinical practicum experience in their senior year, when they spend 16 hours per week in a precepted clinical of their choice at schools like Georgetown University in Washington, D.C. The students receive both classroom and clinical instruction, with a focus on critical care knowledge and skills. Students are expected to join AACN during their senior year, when the curriculum content is patients with complex problems. The journals they receive with their membership�Critical Care Nurse and the American Journal of Critical Care�assist them in writing papers and care plans, as well as passing exams and studying for NCLEX.

The critical care units of today need our new graduates, and we owe it to the hospitals to produce students who are ready, willing and able to hit the ground running. Increasing numbers of BSN programs are adding critical care electives for this reason. The future will include ideas like pre-CCRN certification courses for undergraduates so that, once the new nurse has the requisite year of experience, the journey of studying and passing the CCRN exam is a reality. AACN has the resources and tools to assist faculty and students with teaching and learning critical care content.

Put PDA Technology to Use in Your Practice

Put powerful nursing education at your fingertips with personal digital assistant technology. Visit AACN�s new PDA Center online to discover the types of PDA devices and clinical nursing software that will enhance your bedside nursing practice. To introduce these new resources, AACN is offering free shipping on any hand-held device purchased from the AACN PDA Center through July 15, 2002. To take advantage of this offer, you must enter coupon code AACNJUNE at time of checkout.

In addition, save on AACN Grand Opening specials, which include clinical nursing PDA software bundles specifically for critical care. In particular, the Critical Care Nurse Kit 1 provides bedside critical care and advanced practice nurses with comprehensive patient/disease management information, as well as drug compatibilities, nursing implementation and assessment characteristics for hundreds of drug and disease states.

To learn more about these AACN PDA resources, visit http://www.aacn.org. Be sure to visit soon, as both offers expire July 15, 2002!

CNS Practice Standards Publication Now Available

The recently completed Scope of Practice and Standards of Professional Performance for the Acute and Critical Care Clinical Nurse Specialist is now available.

This publication describes the role of CNSs who care for acutely and critically ill patients within the framework of the Synergy Model and expands on the foundation of the �Statement on Clinical Nurse Specialist Practice and Education.�

To order, call (800) 899-2226 and request Item #128101. The price is $20 ($25 for nonmembers). The publication will be available through AACN�s online Bookstore (hrrp://www.aacn.org) after June 15.
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