AACN News—November 2002—Practice

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Vol. 19, No. 11, NOVEMBER 2002

Across the Continuum of Care: Mentoring and Partnership in Progressive Care

By Madeleine Burke, RN, BSN, CCRN
Progressive Care Task Force

Mentoring and partnership play a vital role in developing and molding future generations of nurses. Mature, expert practitioners who mentor and partner with new nurses provide meaningful clinical experiences that allow the beginning nurse to observe expert critical thinking and problem solving.

Clinical judgement, advocacy, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and learning facilitator, which are described by the Synergy Model,1 are behaviors that are integrated into clinical practice through observation and experience. Because nurses working in progressive care units require the same level of knowledge and clinical expertise as those working in critical care, newly hired nurses can acquire the knowledge base and clinical competency they need by integrating their orientation into already-established critical care internship programs.

Mentoring and partnerships not only benefit the newly hired nurse, but also provide an opportunity for experienced clinicians to share expertise with their less experienced colleagues, which satisfies an inherent professional responsibility. This helps the mentors to stay motivated to keep current. They also benefit from the sharing of knowledge and information. Their reward is in the growth and achievement of their prot�g�s and in the development of a positive, long-term relationship.

In the mentoring role, these clinicians demonstrate role expertise and promote socialization by role modeling and sharing values and customs to provide a vision for the new nurse. Mentors also provide support and structure to new nurses by listening, befriending and expressing positive expectations; setting high standards; and empowering the prot�g� to reach autonomy that comes from competency, self-confidence and responsibility.2 Although structured models for mentoring and partnerships exist in many organizations, many of the best mentoring relationships take place through informal relationships.

Following are some practical suggestions for influencing the career and professional development of new nurses:
� Get to know them as people.
� Invite them to lunch or to attend a conference or workshop with you.
� Attend an AACN meeting together and introduce them to other members.
� Offer positive feedback on a job well done.
� Remember how lonely and insecure you felt as a new nurse on the unit, as well as how nurses who took an interest in you impacted your career.

Three models can facilitate the relationship.

Combined Internships
Three large internship programs for critical care, medical-surgical and cardiovascular progressive care run concurrently at Baylor University Medical Center, Dallas, Texas, where all newly hired medical-surgical, cardiovascular and critical care nurse interns meet together for one, eight-hour class. The purpose of combining this class time is to cover core content that spans across all patient care areas, regardless of specialty. Except when content specific to the ICU is covered, the ICU and cardiovascular new hires remain together.

Newly hired nurse interns attend class two to three days a week and obtain clinical experiences the other days. Progressing at their own speed, they are matched with a primary and secondary preceptor, who offer support and clinical expertise. The preceptors themselves are supported in developing their role by attending an eight-hour class on the art of precepting.

Facilitating Care
At Baptist Hospital, Miami, Fla., a patient care facilitator model was developed for the cardiac step-down unit. In this model, leadership, patient advocacy, staff development and mentorship are combined into one role.

Patient care facilitators are senior staff members who oversee the care of between 12 and 14 patients and have 24-hour accountability. They make daily rounds and have responsibility for their patients from admission to discharge.

Because patient care facilitators do not assume a patient care assignment, they are able to assist new graduates and experienced nurses who are new to the unit. These facilitators serve as role models through their expert handling of complex and emergency situations, dealing with difficult patients and families and modeling relationships with physicians. Because they know the patient�s �story,� they are able to relate vital information to others.

This model was so successful on the cardiac step-down unit that two other nursing units are in the process of adapting the role for their patient populations. Patient and physician satisfaction has improved significantly since the implementation of this role.

Mentoring New Nurses
Also at Baptist Hospital, a mentorship program was implemented to help new employees learn about the culture and values of the organization. The mentors are chosen by their managers because they are exemplary role models and demonstrate a commitment to service excellence.

The mentor is responsible for regularly communicating with the new employee and providing information about the organization, as well as for discussing and exhibiting core values and service excellence essentials. Being a mentor has a positive impact on performance evaluations and is a step in climbing the clinical ladder.

Because of our changing healthcare environment and the nursing crisis evidenced by an aging workforce and the ongoing nursing shortage, sharing expertise becomes more important. Efforts to uphold AACN�s vision for creating a healthcare system driven by the needs of patients and families, in which critical care nurses make optimal contributions, require us, individually and collectively, to commit to seeking out opportunities for sharing our knowledge and experience.

1. Medina J (ed.) Standards for Acute and Critical Care Nursing Practice. 2000. Aliso Viejo, Calif. American Association of Critical-Care Nurses.
2. Busen N, Engebretson J. Mentoring in advanced practice nursing: the use of metaphor in concept exploration. Internet Journal of Advanced Nursing Practice. 1999. Volume 2, No. 2.


AACN offers a variety of small and large research grants. Jan. 15 is the deadline for two of these grants:

Philips Medical Systems-AACN Outcomes for Clinical Excellence Research Grant
This new grant, funded by Philips Medical Systems, will award $100,000 every three years to support studies that center on improved outcomes or system efficiencies in the care of acutely or critically ill patients. Research conducted with this grant may apply to any age patient in any clinical environment, but must relate directly to at least one of AACN�s research priorities.

The grant will be awarded for the first time at AACN�s 2003 National Teaching Institute and Critical Care Exposition, May 17 through 22 in San Antonio, Texas.

Clinical Inquiry Grant
This grant supports multiple awards of $500 each, up to $5,000 annually, for clinical research projects that directly benefit patients or families. Interdisciplinary projects are especially invited.

AACN End-of-Life/Palliative Care Small Projects Grant
This grant awards $500 each to two projects focusing on end-of-life or palliative care outcomes in critical care.

Due Feb. 1
Feb. 1 is the deadline for the following grants:

Datex-Ohmeda-AACN Research Grant
Sponsored by Datex-Ohmeda, this grant provides up to $5,000 to support research by a critical care nurse addressing the issue of nutritional assessment in the critically ill patient.

AACN Critical Care Grant
This grant awards up to $15,000 to support research focused on one or more of AACN research priorities. The proposed research may not be used to meet the requirements of an academic degree.

AACN Mentorship Grant
This grant awards up to $10,000 to support research done by a novice researcher working under the direction of a mentor with expertise in the area of proposed investigation. The novice researcher will be the principal investigator and will receive the award. The novice researcher may be conducting the research to meet requirements for an academic degree, but the mentor may not. The mentor may not be a mentor on an AACN Mentorship Grant in two consecutive years.

AACN Certification Corporation Research Grant
Sponsored by AACN Certification Corporation, this grant awards up to four awards of $10,000 each for studies related to certified practice.

Due March 1
March 1 is the deadline for the following grants:

Evidence-Based Clinical Practice Grant
This grant awards $1,000 to cover direct project expenses, such as printed materials, small equipment and supplies. Eligible projects can include research utilization studies, CQI projects and outcome evaluation studies. Collaborative projects 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 (Canada call 949-448-7315), Request Document #1013.

The Power of One: Ethics Work Group Examines Practice Dilemmas

Members of the Ethics Work Group for 2002-03 are (from left,
seated) Cynthia Janacek, Natalie Correll-Yoder and Suzanne
Burns and (from left, standing) Kate Sullivan-Collopy,
Elizabeth Rogan, Mary Hardy, Benny Bolin, Jacqueline Fowler
Byers, Katie Schatz and Kimberly Brown.

By Natalie Correll-Yoder, RN, CNS, MN, CCRN
Chair, Ethics Work Group

Informed consent, a patient�s decision-making capacity, family decision making and suffering at the end of life are just some of the issues that cause distress for critical care nurses as they try to advocate for patients. Working with a shortage of staff or with colleagues who are still learning critical care can aggravate this distress, as do the ever-increasing workplace issues that result from stricter regulatory guidelines and financial limitations.

How do we cope with situations where sick patients outnumber the nurses available to provide them care? How do we support colleagues who are new to critical care and still learning how to manage that sick patient? What is it that we can do as critical care nurses?

Ethical dilemmas such as these that continue to occur in the critical care environment were discussed by members of the AACN Ethics Work Group when they met in August in Costa Mesa, Calif. As part of the discussion, members were asked to identify not only the current clinical ethics issues in critical care, but also what is needed related to end-of-life care.

Feedback from participants at the Ethics Roundtable at AACN�s National Teaching Institute and Critical Care Exposition in May provided some clarity to the issues faced by critical care nurses. The goal of the Ethics Work Group is to identify and help develop resources to assist critical care nurses in dealing with ethical issues or providing end-of-life care.

Joining me as members of the Ethics Work Group for 2002-03 are Benny Bolin RN, ADN, MS, Kimberly Brown, RN, MSN, FNP, CS, CEN, Jacqueline Fowler Byers RN, PhD, Mary Hardy, RN, BSN, Cynthia Janacek, RN, BSN, AA, CCRN, Elizabeth Rogan, RN, BSN, MA, and Kate Sullivan-Collopy, RN, PhD, CCRN, CCNS. Suzanne Burns, RN, MSN, CCRN, NP, is AACN board liaison, and Katie Schatz, RN, MSN, NP, was staff liaison.

It is not always easy to speak out and advocate for patients and their families. Having an understanding of ethical principles and guidelines can assist the critical care nurse in this role.

Over the course of the next several months, these members will provide support for AACN members by identifying helpful resources and by writing articles on ethics and end-of-life cases for AACN News. Each case study is designed to reflect common problems encountered in most critical care areas and to provide the ethical principles and guidelines that apply.

The �Power of One� will continue to be the theme for this year�s Ethics Work Group. This story of �The Starfish� reminds us that each critical care nurse can make a difference, one patient at a time. The Ethics Work Group members hope the case studies provide tools that can help critical care nurses make a difference with their patients.

The Star Thrower
As the old man walked the beach at dawn, he noticed a young man picking up starfish and flinging them into the sea. Catching up to the youth, he asked why he was doing this. The answer was that the stranded starfish would die if left until the morning sun. �But the beach goes on for miles and there are millions of starfish,� countered the other. �How can your effort make any difference?� The young man looked at the starfish in his hand and threw it to safety in the waves. �It makes a difference to this one,� he said.
� Loren C. Eiseley

Nominations Are Due Dec. 1 for 2004 AACN Distinguished Research Lecture Award

Dec. 1 is the deadline to apply for the 2004 AACN Distinguished Research Lecture Award. The recipient of this prestigious award will present the Distinguished Research Lecture at AACN�s National Teaching Institute and Critical Care Exposition, May 15 through 20, 2004, in Orlando, Fla.

In addition, the distinguished research lecturer receives a $1,000 honorarium and $1,000 toward NTI expenses.

The 2003 Distinguished Research Lecture will be delivered by Kathleen Puntillo, RN, MS, DNSc, FAAN, a professor at the University of California, San Francisco, on May 19, during AACN�s National Teaching Institute and Critical Care Exposition in San Antonio, Texas. Her topic will be �Pain Assessment and Management in the Critically Ill: Wizardry or Science?�

The lecture will again be sponsored by Philips Medical Systems.

For more information, contact Research Associate Dolores Curry at (800) 394-5995, ext. 377; e-mail, dolores.curry@aacn.org.

Sepsis Education Program Is Now Available in CD-ROM Format

Eli Lilly Grant Underwrites Purchase Fee

Identification and Management of the Patient With Severe Sepsis,� AACN�s national sepsis education program for nurses, is now available in a self-paced CD-ROM format. Funded by an unrestricted educational grant from Eli Lilly and Company, this program is sponsored by AACN and is accredited for 5.0 contact hours of CE credit for single users.

Narrated by clinical expert Barbara McLean, RN, MN, CCRN, CCNS-NP, FCCM, the new program offers clinicians a comprehensive view of the latest information on the diagnosis and care of patients with severe sepsis.

The 170-page, audio/slide CD-ROM study guide includes: pathophysiology of severe sepsis; identification of acute organ system dysfunction; antibiotics, source control and monitoring in severe sepsis, including investigational and new approved therapies; hemodynamic, ventilatory, renal and other aspects of care; and nursing care of patients with severe sepsis. Case studies are also included in the presentation.

To order this cutting-edge learning program for only the $7.50 shipping and handling fee, call (800) 899-2226 and request Item #004060. Quantities are limited.

Practice Resource Network

Q: My fellow nurses and I have been frustrated because of what we consider to be unsafe staffing ratios and patient assignments in our critical care unit. Does AACN have written guidelines or recommendations for staffing ratios and requirements for critical care units?

A: Because of the nurse�s critical role as a patient advocate, the responsibility for ensuring safe, quality care for the patient is a valid concern. AACN strongly advocates that the delivery of care be driven by the patient�s needs.

AACN does not advocate mandated nurse-to-patient ratios. Instead, AACN believes that appropriate staffing of a patient care area is dependent on the ability of the nurse to meet the needs of the patient. According to the AACN Position Statement titled �Maintaining Patient-Focused Care in an Environment of Nursing Staff Shortages and Financial Constraints,� resolving staffing dilemmas requires a thorough understanding of the inter-

related factors that impact the quality of care delivered, such as acuity, skill mix and available resources. (This position statement can be accessed online at http://www.aacn.org via AACN Fax on Demand at [800] 222-6329. Request Document #2001.)

When evaluating staffing issues, nurses should be knowledgeable about federal and state regulations and their state�s Nurse Practice Act, which defines the legal scope of nursing practice. In addition, acute care hospitals that receive government funding for Medicare and Medicaid patients are bound to conditions of participation, which include staffing and quality-of-care guidelines. If you believe a violation has occurred, you are responsible for notifying first your nursing supervisor, then the State Board of Nursing.

To provide safe nursing care, the following activities must be carried out:
� Accurate administration of medications and implementation of critical medical treatment regimens
� Protection of patients at risk of harming themselves
� Monitoring patients� responses to medical and nursing interventions, consistent with each patient�s healthcare problem
� Notification of the physician of deteriorating or unexpected change in a patient�s status
� Accurate documentation of the care delivered to the patients

In today�s healthcare environment, the frequent lack of nursing staff, as well as the fact that many units are being staffed by mostly novice nurses is, unfortunately, common. If you feel that you have been placed in an unsafe situation, you are ethically and legally obligated to protect the patients. You are responsible for identifying the unsafe situation. If you have concerns that a patient assignment or procedure that you have been asked to do is unsafe or that you are not fully trained to accept, you should report the situation immediately, preferably before you accept the assignment.

Begin by reporting your concerns to the charge nurse, nursing supervisor or nurse manager. Document your concerns on a separate sheet of paper, in an objective way, providing specifics to back up your concerns. To protect yourself from legal liability, always keep copies of this documentation. Some state nurses associations have �assignment despite objection� forms that you may want to obtain. If the problem is a recurring one, it is important for you to know if your state has a �whistle blower� protection law, what it states and how you are protected if you decide to pursue the issue.

A useful tool for evaluating and strategizing staffing needs is AACN�s Staffing Blueprint: Constructing Your Staffing Solutions. Included in this comprehensive resource are references to sources where you can find additional information. To order, call (800) 899-2226 and request Item #300117 or visit the AACN Web site at http://www.aacn.org.

Do you have a practice-related question? Call the Practice Resource Network at (800) 394-5995, ext. 217, or visit the AACN Web site at http://www.aacn.org.

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