AACN News—April 2003—Practice

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Vol. 20, No. 4, APRIL 2003

Wealth of Resources Targets Advanced Practice Nurses

By Debby Greenlaw, RN, MS, CCRN, NP-C
Advanced Practice Work Group

Advanced practice nurses have met educational and clinical practice requirements beyond the two to four years of basic nursing education and have acquired advanced preparation for expanded clinical practice by earning a master's or doctoral degree in nursing.

AACN is committed to supporting the practice of APNs in providing healthcare services. The AACN Strategic Plan outlines methods to meet the needs of its APN members with strategies focusing on education, publications and clinical resources, along with collaborative efforts that support public policy initiatives and issues. The
Advanced Practice Work Group, which is reviewing these resources as part of its charge for the year, is confident you will be impressed with the resources AACN offers to APNs. Check them out.
- Advanced Practice Fact Sheets provide information on APN roles, reimbursement and prescriptive authority.
- Advance Practice Links from the Advanced Practice area of the AACN Web site (www.aacn.org > Clinical Practice) connect to a variety of nursing, advanced practice and medical organizations, graduate school listings and ethics sites. For example, there is a link to the Advanced Practice Nurse Survival Guide Web site, where more than 600 medical and nursing resources for APNs are available. Other links to Medscape and NPLinx provide access to articles on legal and professional issues, APN topics and discussions, and clinical issues and updates.
- ANPACC ListServ is for Advanced Nursing Practice in Acute and Critical Care. Its purpose is to enhance communication among APNs, educators, researchers and physicians on issues of concern to advanced practice nurses.
- CCNS Certification is achieved through an exam for adult, neonatal or pediatric clinical nurse specialists in acute and critical care. AACN members receive a $100 discount on the exam fee.
- AACN News features advanced practice articles, which can also be accessed online from the Advanced Practice area of the AACN Web site. Recent topics include APN roles, PDA resources, becoming an entrepreneur, clinical practice guidelines and protocols, and demonstrating the value of APNs.
- PDA Center provides a selection of handhelds and software for use in daily clinical practice. Tutorials to assist in making those choices are available, as well as downloads that are both free and for purchase.
- Conferences of interest to APNs are featured and can be accessed from the Advanced Practice area of the AACN Web site.
- AACN Clinical Issues: Advance Practice in Acute and Critical Care article abstracts from each issue can be accessed from the Advanced Practice area of the AACN Web site. Selected articles for CE are available for download.
- Advanced Practice Institute is planned in conjunction with AACN's National Teaching Institute and Critical Care Exposition. Sessions are tailored specifically to the needs and interests of APNs, including skills development, role delineation, patient management and pharmacology. In addition, API participants are guests at a special APN reception. The 2003 API is scheduled for May 17 through 22, in San Antonio, Texas.
- American College of Nurse Practitioners provides AACN, as a national affiliate member, two publications- the American Journal for Nurse Practitioners and Nurse Practitioner World News-to distribute to its advanced practice members.
- AACN Resource Catalog and Online Bookstore offers books and other supporting products specifically aimed at APNs.
- Volunteer Opportunities provide a diversity of opportunities for networking and professional growth.

In the Circle: Annual Award Honors Excellent Nurse Practitioners

Editor's Note: The AACN Excellent Nurse Practitioner Award recognizes acute and critical care nurses who function as nurse practitioners and who demonstrate the key components of advanced practice nursing, including leadership, advanced practice clinical skills, research application, evidence-based practice, outcome-focused practice, cost containment, quality assurance, mentoring, problem solving and communication with patients, families, staff and systems. Recipients of this award for 2002 were given complimentary registration, airfare and hotel accommodations for NTI 2002 in Atlanta, Ga., which also featured the API. Following are excerpts from exemplars submitted in connection with this award.

Sophia Chu Rodgers, RN, MSN, NP-C, ACNP
Albuquerque, N.M.
Lovelace Health Systems
Selina, an 18-year-old college freshman, was driving from work to her dorm when a semi-truck struck her car. Selina sustained a serious closed head injury, pelvic rim fracture, a left tibial plateau fracture, C-spine ligamentous injury and a grade I splenic injury.

After evaluating Selina, who responded only to pain, I met with her family. I used all the pertinent films to explain Selina's injuries. I also discussed the plan of care and told them that I would be the liaison who would meet with them daily.

Selina had some small setbacks, but overall her neurological status improved. She had signs of dysphagia, cognitive impairment and expressive aphasia along with a left-sided neglect. However, she did follow some simple commands.

Every morning I met with the family to review the previous day's progress and our plan for the day. This became such a ritual that they joked about adopting me into their "familia."

Selina's neurological status continued to improve until she was ready for transfer to rehabilitation. The day of discharge was emotional. Selina had been with us for nearly four weeks.

Eight months had passed since the accident, and I thought I would never hear from or see Selina again. Then, I received a beautiful and moving letter and a picture her father took of us several months ago. She stated that she would be returning to school, and she had no neurological deficits. This type of reward makes me proud and glad to be a nurse.

Patricia Long, RN, MSN, ACNP
Long Beach, Calif.
Long Beach Memorial
Heart Institute
"See if there is anything you can do for him," the cardiologist requested on his rounds with the resident. As an acute care nurse practitioner with expertise in heart failure, the request was not unusual.

Fred was an overweight diabetic who had come to the emergency room complaining of chest pain. Intravenous Lasix and Nitroglycerin had been started, and he had been ruled out for myocardial infarction. Over the past 48 hours, the diuretic had worked its magic. Fred had lost 15 pounds of fluid; there was no pedal edema; and the echocardiogram showed his heart was contracting well. However, he was still so short of breath he could not stand to urinate. Was this really heart failure?

I immediately ordered a B-type natriuretic peptide test. When it came back at 104 peakograms, a pulmonologist was called for consultation. Arterial blood gases, pulmonary function tests and a spiral CAT scan revealed a pulmonary embolism in the right lower lobe. Anticoagulation was started.

After six days, Fred's breathing had improved, and he could easily stand to urinate. The respiratory case manager gave instructions about using the peak flow meter and his new inhalers. He was educated about Coumadin and the importance of keeping green leafy vegetables consistent in his diet. I reminded him to continue his daily weighing and maintain his diabetic and two-gram sodium diet. He was given medication instructions and advised to call me if he had any symptoms of shortness of breath. I arranged a home health nurse and physical therapist to supervise his home program.

The best contribution I can make as a nurse practitioner is to advocate for my patient, promote collaboration between all caregivers and provide an environment where patients like Fred can receive the expertise and education I have to offer.

Tamara L. Philpott, RN, MSN, CCNP-BS, CCRN
Josephine, Texas
Presbyterian Hospital of Dallas
Equipped with only a name and diagnosis, I knocked on the door of room 437 on the telemetry unit and entered. An elderly gentleman wearing only long johns and a pullover shirt harshly demanded, "Just who the hell are you?" I took a deep breath, introduced myself and told him that I was here to perform a history and physical on him.

The history revealed several concerns regarding this 71-year-old rancher, including a recent diagnosis of severe aortic stenosis, S/P CABG X 4 in 1996, stents to his RCA in 1998, hypertension, hyperlipidemia, depression, tobacco abuse and degenerative knee disease. John also revealed a history of several episodes of syncope and falls, probably from the result of his aortic valve disease. John reported that he was slowly deteriorating, limited by his physical abilities, which led to increasing dependence on others to manage the ranch. This loss of control contributed to excessive drinking, further depression and financial worries.

John underwent a battery of tests that ruled out permanent liver damage and carotid artery stenosis. The most likely cause for syncope was the aortic stenosis and alcohol indulgence. John underwent minimally invasive aortic valve replacement with a pericardial tissue valve, eliminating the long-term need for anticoagulation.
John and his family looked to me for reassurance and guidance. We had lengthy discussions regarding his future and social habits. Social work assisted in arranging for home healthcare, and all the staff played a vital role in discharge planning and teaching. He continued to make progress and was discharged home on postoperative day four, decked out in Western boots and jeans. I think of John often and feel that I got a glimpse of the Western life.

The Power of One: Physician-Nurse Collaboration Was Key to Outcome

By Kate Sullivan Collopy, RN, PhD, CCNS
Ethics Work Group

At age 57, Mr. R. had experienced a nagging chest cold for several weeks. Although he received treatment, his condition worsened into pneumonia that resisted treatment with antibiotics. After six weeks, he was admitted to the medical unit of a community hospital for oxygenation, chest physiotherapy, IV antibiotics and a diagnostic workup.
The first night, he experienced a progressive decline culminating in a respiratory arrest. He was immediately intubated and transferred to the ICU.

Over the next six weeks, Mr. R.'s stay in the ICU was characterized by extremes. Although he was given comprehensive care led by an experienced weaning team, several days of improvement were followed by declines that impeded his progress. He found the frequent suctioning, necessitated by copious secretions, demeaning and agonizing. Sobbing uncontrollably and complaining that he was "tired of living this way," he begged the nurses and respiratory therapists to leave him alone.

In contrast, his wife and his longtime primary care physician, Dr. C., were indefatigable in their view that each decline was a temporary setback and that a permanent improvement was "just around the corner." When the nurses gently brought up the possibility that Mr. R. might not recover, the reply was, "You don't know Jim like we do." Mrs. R. shared that her husband had worked full time in the Air Force while going to school full time and being an active father. Dr. C. described how Mr. R. had recovered from a horrific injury to his knee, working tirelessly in therapy until he could walk unassisted and without a limp.

The nursing staff became increasingly frustrated, because they perceived that Mr. R. was able to view his situation realistically, but that his wife and physician were holding on for a miraculous recovery that was not likely to occur.

At the same time, Mrs. R. and Dr. C. were becoming increasingly frustrated with the nursing staff and most members of the weaning team. Insisting that, "apart from his respiratory status," he was a "relatively young, healthy man," they were furious that anyone would consider anything less than aggressive care.

Ms. T., Mr. R.'s primary nurse, felt torn. On one side, she had a somewhat resilient, highly vulnerable patient who, though able to repeatedly draw on his reserves, was unable to sustain a rally. He was despondent and irritable with both his family and his caregivers. On the other side, she was feeling pressure from her peers, who expected her to "persuade the family and Dr. C. to see reason."

Ms. T. scheduled a meeting with Dr. C. to review the case. However, she asked him to first spend an hour with her at Mr. R.'s bedside to get an idea of what it was like to care for him an extended period of time. Dr. C. gladly accepted. He had an opportunity to assist in suctioning, turning, cleaning and feeding Mr. R. He was distressed to see how painful performing basic activities of living were for Mr. R. and was clearly distressed to see his patient beg "to be left alone to die." At the same time, Ms. T. was struck by the tender care that Dr. C. provided as he engaged Mr. R. in conversations about his friends, family and hobbies. It was apparent that he knew Mr. R. well.

During their meeting, both Dr. C. and Ms. T. had an opportunity to discuss their concerns and experiences with Mr. R. in detail. Ms. T. began to understand that her physician colleague saw the patient as an acutely ill man who was in a reversible condition. She understood his frustration that anyone would consider "giving up on him."
Dr. C. began to see that the nurses were advocating for what the patient stated that he wanted. They agreed to call a "timeout" where no weaning would be attempted for a period of 10 days. In the interim, psychiatric and pain services consults were called to ensure that Mr. R.'s desire to stop treatment was not due to pain or despair. As a result of the meeting and the increased understanding that resulted, communication among the nurses, physicians, family and patient improved greatly.

During the 10-day period, several different medications were tried, which significantly decreased but never completely alleviated, his pain. Mr. R. had more uninterrupted sleep and his mood improved. Although suctioning was still difficult, he was able to tolerate it better. As a result of the psychiatric consult, antidepressants were ordered. Soon after, weaning was reattempted.

Mr. R. appeared to be responding well until he experienced a massive myocardial infarction and cardiopulmonary arrest. Although he was resuscitated, it was soon apparent that he had sustained a significant cerebral insult. Ms. T. and Dr. C. jointly called for a patient care conference to discuss his prognosis with the staff and family. During the conference, Mrs. R. and her children agreed to withdraw life support. Mr. R. died 20 minutes after removal of the ventilator. The family told the staff that they were at peace, as the last few weeks had given them an opportunity to work together to try to give Mr. R. the best possible result.

The key to this outcome was the collaboration between Ms. T. and Dr. C. By spending time together in direct patient care, they each saw a new side of one another. Dr. C. was moved by how difficult it was to suction Mr. R. and how hard it was to hear him beg them to let him die. Ms. T. was surprised to see the deep, mutual caring between Dr. C. and Mr. R. that had not been obvious during brief, daily rounds. Working together, they were able to share their clinical judgments, to synthesize conflicting data to come to consensus and to present a united front to the family and the rest of the healthcare team.


Apply for Medtronic Physio-Control Small Projects Grant

AACN offers a variety of small and large research grants. July 1 is the deadline to apply for the Medtronic Physio-Control AACN Small Projects Grant. This grant awards up to $1,500 for a project that focuses on aspects of acute myocardial infarction, resuscitation or sudden cardiac death, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing or interpretive 12-lead ECG.

To find out more about AACN's research priorities and grant opportunities, visit the AACN Web site. The grants handbook is also available from AACN Fax on Demand at (800) 222-6329, Request Document #1013.

Viewpoint: Oh, My Aching Back! Become Ergonomically Healthy

By Susan Yeager, RN, MS, CCRN, ACNP, EMT
AACN Board of Directors

When someone mentions healthy work environment, do you automatically think of Ben Gay, support hose and orthopedic shoes? Is a therapeutic back massage more appealing than jewels as a special gift? Although the jewel replacement question may be a bit over the top, supportive ergonomics to promote a positive work environment should not be.

Achievement of a positive, work environment is multifactorial. A healthy unit is often equated with communication and conflict management expertise, such as collaborative nurse-to-nurse and physician-to-nurse relationships or supportive management. However, healthy environments encompass more, including the actual physical space and technologic support available to a caregiver. And, it's not just the aging, "seasoned" nurse who has to worry about ergonomic health.

According to 1998 statistics from the Bureau of Labor, nursing tops the list of occupations most associated with work-related, musculoskeletal disorders. In fact, 12 out of 100 nurses in hospitals report work-related musculoskeletal injuries-approximately double the rate for all other industries combined.

To create an improved ergonomic reality, our nursing colleagues in the United Kingdom, Canada and Australia have adopted a national approach to their ergonomic health. In these areas, legislation has even been passed to prohibit nurses from lifting. Several nurses in the US are working to collect the necessary data to promote this best practice in our nation's hospitals.

As a part of a recently completed study headed by Audrey Nelson, RN, PhD, FAAN, director of the VHA Patient Safety Center, spinal cord and nursing home units at VA hospitals in Florida and Puerto Rico participated in a multisite trial.

The study began with an individual assessment highlighting ergonomic opportunities in each area. Based on these recommendations, technology that resulted in a "no-lift" environment was purchased in these areas. Although the results of this study have not yet been published, Nelson says that the decrease in her endpoints was positive enough to promote a second phase of study, with expansion into critical care units.

Building on Nelson's work, a spinal cord unit in a VA hospital in San Diego, Calif., implemented a "no lift" policy. Headed by Kathleen Dunn, RN, MS, CRRN, the clinical nurse specialist and rehabilitation case manager, the policy was presented to and gained the support of the unit administrators. Dunn and unit staff then collaborated with a variety of vendors to select the product that would provide the technology necessary to create a more ergonomic unit.

The technology installed used ceiling tracks and Hoyer-like devices that enabled nurses to move patients from the bed to the toilet or the chair without lifting. As a result, Dunn says, no injuries have occurred in the past six months, indirectly saving $100,000.

The San Diego VA spinal cord unit staff was able to collectively use their research utilization voice to create changes that promote ergonomic health for nurses. Additional examples of ways nurses can use their voices in this fashion can be as informal as a conversation with an industry partner to provide input into product development, or as formal as collecting data. As was the case with the San Diego VA, vendors want to hear feedback on prototypes or designs for support devices from the people who will be using them-the nurses.

To determine whether your unit supports ergonomic health, answer several of the following questions:
- Are the computer terminals and monitor levels ergonomically correct?
- What is the average patient weight on a given day/week?
- What is the location, and weight of commonly used supplies?
- Do the chairs at the nurse's station have lumbar support?
- Are step stools available?

Going a step further, collaborate with your Quality Assurance or Human Resource department to compile answers to the following questions:
- How many nurses sustain work-related musculoskeletal injuries annually?
- Is your area a "high-risk" area. For example, are spinal cord injured or large, unconscious individuals cared for on your unit?
- What is the estimated cost of workman's compensation and sick leave pay, and the annual cost of replacement staff for musculoskeletal-related injuries?

By using data in this fashion, the economic impact of not having protective devices can be equated to eventual cost savings. Support for obtaining ergonomic technology will be perceived not as another direct cost to the institution but as a solution that makes economic sense. It is a language that decision-makers will more likely listen to when we exercise our bold voice.
Public Policy Update

$20 Million Approved for Nurse Reinvestment Act
AACN commends Congress and the efforts of Sens. Barbara Mikulski (D-Md.) and Ted Stevens (R-Ark.) in approving $20 million in new federal funds for nurse education programs. The funds are included in the Nurse Reinvestment Act as part of the omnibus appropriations bill for FY2003.

The Nurse Reinvestment Act (PL 107-205), which was signed into law in August 2002, not only expands authority for existing nursing programs, but also creates new ones. For example, the new law authorizes scholarships and loan repayments for nursing students who agree to work in areas where there is a shortage of staff after they graduate. In addition, the act authorizes public service announcements to promote nursing as a career, loan cancellations for nursing faculty, grants for geriatric nurse education and grants to encourage nursing best-practices.

Although these funds will assist in implementing the programs included IN the act, AACN will continue to collaborate with other nursing organizations to obtain additional funding for the programs in fiscal year 2004.

Bills Would Limit Unscheduled Overtime
Companion bills introduced by Sen. Edward Kennedy (D-Mass.) and others in the Senate and by Rep. Pete Stark (D-Calif.) and others in the House would restrict the use of unscheduled overtime for nurses to an official state of emergency declared by federal, state or local government. H.R. 745 has been referred to the House committees on Energy and Commerce and on Ways and Means, and S. 373, has been referred to the Senate Committee on Finance.

AACN's Position: AACN believes that mandatory overtime is not an acceptable means of staffing a hospital, because it may place nurses and their patients at increased risk of being involved in medical errors. Instead, nurses should be able to decide whether working overtime will affect their ability to care safely and effectively for patients. They should have the option of refusing overtime assignments and not be forced into working beyond their capacity to provide optimal care. AACN supports this legislation and will continue to work to educate the public on the negative impact that mandatory overtime can have on patient safety.

Nursing Education Bills Introduced
AACN has endorsed two recently introduced bills that will increase education loan opportunities and loan forgiveness for nursing students. The Teacher and Nurse Support Act of 2003, introduced by Sens. Tom Harkin (D-Iowa) and Ted Stevens (R-Ark.), would amend the Higher Education Act of 1965 to increase nursing education loan opportunities within the Department of Education. H.R. 501, the Nurse Loan Forgiveness Act of 2003, introduced by Rep. Tom Tancredo (R-Colo.), would establish a student loan forgiveness program for nurses.

AACN encourages members to contact their legislators to voice support for these pieces of legislation. Visit AACN's Legislative Action Center to send your messages. Full text of the bills can also be viewed from this area.

Bills Offer Smallpox Safeguards, Border Funds
In a move that could give President Bush's lagging smallpox vaccination campaign a push, Rep. Henry Waxman (D-Calif.) introduced legislation to establish "no fault" compensation for those injured by the vaccine and help states offer education and testing for risk factors. The legislation would give states full funding for the immediate medical care of healthcare workers or first responders injured by the vaccine or anyone injured by coming into contact with someone recently vaccinated. It would prohibit discrimination against workers who refuse the vaccine and authorize up to four days' paid leave following reactions.

In related news, border-state hospitals would be reimbursed for treating illegal immigrants under bills introduced in the Senate by Sens. Jon Kyl and John McCain, both Arizona Republicans, and in the House by a fellow Arizona Republican, Rep. Jim Kolbe. The lawmakers seek $1.45 billion per year for four years. And, the House Energy and Commerce and Ways and Means committees passed a bill to expedite Medicare beneficiaries' appeals of claim denials, establish a beneficiary ombudsman and create a central, toll-free help center to answer beneficiaries' questions.

A comprehensive guide to smallpox vaccination resources for clinicians is available on the Centers for Disese Control and Prevention Web site. In addition, the CDC has established a Clinician Information Line for Smallpox and Smallpox Vaccination at (877) 554-4625.

New Patients' Bill of Rights Introduced
Rep. Charlie Norwood (R-Ga.) attempted to revive the patients' rights issue by introducing two bills-one to establish a Patient Protection Act ensuring access to certain kinds of care and a second, the ERISA Clarification Act, to guarantee that state law on medical necessity supersedes the federal Employee Retirement Income Security Act. Although Norwood acknowledged that such issues may lack momentum, given the sour economy and a possible war with Iraq, he said insurers' and employers' increasing concern about the cost of healthcare potentially threatens the quality of care patients receive. The Patient Protection Act is similar to a bill passed by the House last year, but allows states to set more stringent standards than federal law. The Health Insurance Association of America said the bills would impose "hundreds of new, duplicative federal regulations, throw out the insurers' right to contract and require insurers to rewrite millions of existing insurance policies, all of which will require higher health insurance premiums."

Register for Terrorism Updates and Training
The Centers for Disease Control and Prevention has set up a registry to provide clinicians with real-time information to help prepare for or possibly respond to terrorism events. Participants receive regular e-mail updates on terrorism issues and training opportunities relevant to clinicians.

For more information about these and other issues, visit the AACN Web site.

Bush Outlines Funds for Nursing Education

The president's budget provides $98 million for nursing programs. Included is $7 million to implement the newly authorized scholarship programs contained in the Nurse Reinvestment Act. Scholarship recipients must provide nursing care for a minimum of two years in a facility with a critical shortage of nurses to fulfill their service commitment.

In addition, the budget reflects a redistribution of monies between basic and advanced nursing education. The redistribution places the funding priority on basic education and reflects the recommendations of an independent expert panel. The panel's recommendations are designed to help attract people into the profession while maintaining support for advanced practice nurses. For FY2004, the budget allocates $72 million to support basic nurse workforce development and $26 million for advanced nursing education. The budget also includes $10 million for scholarships focused on increasing diversity in the health professions through the Scholarships for Disadvantaged Students program.


Health Resources & Services Administration
Advanced Nursing Education
Nursing Workforce Diversity
Basic Nurse Education and Practice
President's FY2003
Appropriations Request
$ 6.08B

$ 61.04M
$ 6.17M
$ 16.29M
President's FY2004
Appropriations Request

$ 26.00M

$ 72.00M
+/- 2003

-$ 6.17M
Subtotal: Nursing Workforce
Nursing Education Loan Repayment
Health Professions Education
$ 83.50M
$ 15.00M
$ 11.00M
$ 98.00M

$ 11.00M
Total: Health Professions
Scholarships for Disadvantaged Students
National Health Service Corps
Bioterrorism Hospital Preparedness
Bioterrorism Medical School Curriculum
$ 109.50M
$ 10.00M
$ 518.00M
$ 60.00M
$ 10.00M
$ 60.00M
-$ 0.5 M

$ 21.49M
Agency for Healthcare Research & Quality
National Institutes of Health
National Institute of Nursing Research
$251.00 M
$ 27.30B
$279.00 M
$ 27.90B
$135.00 Ml
+$28.00 M
+$ 0.60B
+$ 4.00M
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