Viewpoint: Collaboration With Respiratory
Therapists Is Best for Patients
By Suzanne M. Burns,
RN, MSN, RRT, ACNP, CCRN, FAAN, FCCM
AACN Board of Directors
Don�t touch the knobs" is a common �request" in
critical care units. The understanding of this statement is so integrated into
the practice arena that little explanation is required. When I jokingly refer to
this statement in my talks on mechanical ventilation and weaning, everyone
laughs and shakes their heads in knowing assent. They understand that the
statement is a reference to a boundary delineated by our colleagues in
Mechanical ventilators are complex machines, and the
respiratory therapists are specialists in managing them. I believe that the
reason respiratory care practitioners promote the �don�t touch the
knobs"perspective is because, like nurses, they want ventilated patients to be
cared for safely and effectively, and they want to ensure that no untrained
individuals adjust a ventilator. Unfortunately, this thinking can be carried to
the extreme. For example, a nurse attending one of my talks shared this example:
In my hospital, the nurses are forbidden to �touch
the ventilator.� When my patient had a sudden and profound drop in oxygen
saturation, I began bagging the patient on 100% oxygen. The respiratory
therapist and doctor were called, but the therapist was busy and the doctor took
the better part of an hour to arrive. Because I was not allowed to turn the Fio2
on the ventilator to 100%, I had to bag the patient the whole time.
This nurse related her frustration with the �don�t
touch the knobs" directive, because her ability to further assess the patient
was severely impeded by being tethered to the side of the bed as she manually
ventilated the patient and because she knew that the repercussions of not
following this directive would result in being �written up"if she turned up the
Fio2. Her frustration was heightened because the appropriateness of the
intervention, the competency of the individual and the patient needs are not
addressed by this directive.
Another example comes from South Carolina, where an
advanced practice nurse with educational and skill-based expertise in ventilator
management was caring for a ventilated patient who began to decompensate. The
patient was bagged. The respiratory therapist who was called was unavailable.
After a prolonged period of bagging the patient, the nurse adjusted the
ventilator settings, put the patient back on the ventilator and continued his
assessment. When the therapist arrived, the nurse informed her of his
interventions. Because the �rules"dictated that only a therapist should manage
the ventilator, this nurse was �written up.�
These are only two examples of a practice that is
prevalent in this country. Although the intent of the �don�t touch the
knobs"statement is to protect the patient, these extreme interpretations instead
put the patient at extremely high risk, do not reflect the competency and
education of all professionals who may care for that patient, and do not reflect
collaborative relationships of trust and respect.
Standards of practice and the evidence of research
validate that knowledge of mechanical ventilation is an essential part of
critical care nursing practice, and the interventions required to care for the
critically ill are within the scope of practice of critical care nursing. Care
of the mechanically ventilated patient is a responsibility of the critical care
nurse; therefore, being knowledgeable and responsible for that care includes
understanding the therapy. These patients are critically ill and their
well-being, their lives, depend on how quickly and correctly the nurses respond
to their needs. Therefore, critical care nurses must fully understand the
ventilators they use and be able to respond appropriately if the need arises.
This does not mean we should do what respiratory therapists do, unless we are
trained and are competent to do so.
In the medical ICU where I work, weaning trials are
common and a major focus of the care we provide. In fact, we are proud of the
outcomes of our multidisciplinary, collaborative, long-term mechanical
ventilation program. We have learned that systematic reduction of variation and
care delays is essential to the successful attainment of positive program
outcomes. Our team is staffed with respiratory therapists who are extremely
knowledgeable and collaborative.
We arrived at a truly collaborative unit many years
ago when, to facilitate timely and appropriate weaning of our ventilated
patients, we decided to train some of our nurses to make selected ventilator
changes, such as Fio2, PSV and CPAP. These cross-trained nurses change settings
when needed �now"and intervene when no therapist is available. This allows
nurses to make changes and to continue to assess the patient and respond with
other interventions as appropriate. As with any intervention nurses initiate in
our institution, appropriate documentation is accomplished by critical care
nursing and respiratory care flow sheets. The therapist and physician are
notified of the intervention as soon as possible. This approach precludes
lengthy, nonproductive delays or a nurse spending vital time on the phone trying
to locate a therapist or physician.
Because they are knowledgeable, capable and
essential clinicians, we rely heavily on respiratory therapists in practice.
However, they cannot be continuously at the bedside. In many hospitals, true
collaboration between therapists and nurses exists; in others, it is simply a
Collaboration is clearly the kind of practice we
need to ensure good patient outcomes. In fact, abundant evidence exists that
links collaborative practice to positive outcomes. In the case of care of the
ventilated patient, the more nurses and therapists know, the better the care. To
know what the nurse can do or what may be harmful, we must fully understand what
�turning the knobs"does to the patient. Nurses would not give a drug to a
patient without knowing the potential affects, nor would a knowledgeable nurse
make a ventilator change without understanding the potential responses.
The development of a truly collaborative practice
ensures that the contributions of all healthcare professionals are recognized
and used to the benefit of the patient. Let�s collaborate with our respiratory
therapy colleagues and do the right thing for our ventilated patients. Use your
bold voices to identify practices that prevent your ability to provide safe
passage for your patient and work hard to ensure that trusting and respectful
collaborative practice exists. As AACN President Dorrie Fontaine encourages,
this is truly �rising above"artificial boundaries and makes our work environment
one in which the best clinicians want to work. The development of such a
practice setting is simply the right thing to do for our patients.
Tell us about your successful collaborative practice
models with respiratory care practitioners. E-mail
or call (800) 394-5995, ext. 502.
Apply Online for AACN Beacon of Excellence
Applications are now being accepted for AACN�s new
Beacon Award for Critical Care Excellence to recognize exceptional critical care
units. This program will give national recognition to units that attain high
standards for quality, exceptional care of patients, and healthy, humane and
healing work environments.
The Web-based application process will ask you to
evaluate your critical care unit in six criteria areas:
� Recruitment and retention
� Education, training and mentoring
� Evidence-based practices
� Patient outcomes
� Healing environments
� Leadership and organizational ethics
Applications may be submitted at any time and will
be evaluated on a quarterly basis. Awards are granted twice a year. The
application fee is $1,000 per unit. There is no limit on the number of units
that may apply from a single facility.
For more information, visit the AACN Web site.
Grants Support Clinical Projects and
AACN offers a variety of small and large research
grants. Following is information about grants for which application deadlines
Clinical Inquiry Grant
This program provides awards of $500 each to fund
projects that directly benefit patients and families. Interdisciplinary projects
are of special interest. Grant applications must be received by Jan. 15.
End-of-Life Palliative Care Small Projects Grant
This program provides $500 each for projects that
address a range of topics, including bereavement, communication, caregiver
needs, symptom management, advance directives and life-support withdrawal. Grant
applications must be received by Jan. 15.
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 proposed research may
not be used to meet the requirements of an academic degree. Grant applications
must be received by Feb. 1.
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. Grant applications must be received by Feb. 1.
Hospice in Critical Care
This one-time, $4,700 grant will be awarded to a
qualified individual carrying out a project that focuses on end-of-life or
palliative care outcomes in the critical care area. A broad range of topics may
be addressed. However, special consideration will be given to projects that
focus on implementation of palliative care or hospice in the critical care unit.
Proposals are due Feb. 15.
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. Grant applications
must be received by March 1.
To find out more about AACN�s research priorities
and grant opportunities, visit the AACN Web site or e-mail
Practice Resource Network
there a policy or guideline regarding when it is helpful or advisable to use the
continuous cardiac output Svo2 pulmonary artery catheter? Specifically, for
which patient population and which clinical scenario?
evidence-based Protocol for Practice on Svo2 Monitoring provides the rationale
for use, as well as the recommendations for practice based on the available
research. The module is available online at www.aacn.org > Bookstore > AACN
Product Catalog. (Item #170703; $11 for AACN members and $14 for others). In
addition, the American Society of Anesthesiology has a publication titled
Guidelines for Use of Pulmonary Artery Catheters, which specifically references
use PA catheters with surgical patients. This document references the continuous
Svo2 monitoring catheter, which you might find helpful. It is available online
at www.asahq.org > Publications and Services > General Publications.
If you have a practice-related question, call AACN�s
Practice Resource Network at (800) 394-5995, ext. 217, or e-mail your question
Public Policy Update
Workplace Changes Needed to Keep Patients Safe
Nurses� work environments need substantial changes
to better protect patients from healthcare errors, according to a report
released by the Institute of Medicine. Titled �Keeping Patients Safe:
Transforming the Work Environment for Nurses,"the report calls for changes in
how nurse staffing levels are established and mandatory limits on nurses� work
hours. The recommendations are part of a comprehensive plan to reduce problems
that threaten patient safety by strengthening the work environment in the areas
of management, work-force deployment, work design and organizational culture.
Following are some of the findings and
recommendations in the report:
� As the health professionals who interact most
frequently with patients in all settings, nurses� actions are directly related
to better patient outcomes. Nurses also defend against medical errors. For
example, a study in two hospitals found that nurses intercepted 86% of
medication errors before they reached patients.
� ICUs should increase internal oversight when
staffing falls below one nurse for every two ICU patients.
� Measures of staffing levels should be developed
for hospital report cards and, whenever possible, healthcare facilities should
avoid using nurses from temporary agencies to fill staffing shortages.
� Long work hours pose one of the most serious
threats to patient safety, because fatigue slows reaction time, decreases
energy, diminishes attention to detail, and otherwise contributes to errors.
State regulatory bodies should prohibit nursing staff from working longer than
12 hours a day and more than 60 hours per week.
� To improve nurses� work environments and restore
trust, organizations should involve nurse leaders in all levels of management
and solicit input from nursing staff on decisions about work design and
implementation. Nurses are in prime positions to help pinpoint inefficient work
processes that could contribute to errors, identify causes of nursing staff
turnover, and determine appropriate staff levels for each unit.
� Healthcare organizations should dedicate financial
resources to support nursing staff in the ongoing acquisition and maintenance of
knowledge and skills, the report says.
Implementation of the recommended changes in nurses�
work environments would likely help healthcare organizations recruit and retain
nurses, the report says.
The study was sponsored by the U.S. Department of
Health and Human Services� Agency for Healthcare Research and Quality. The
Institute of Medicine is a private, nonprofit institution that provides health
policy advice under a congressional charter granted to the National Academy of
Sciences. Copies of the report are available online at
Are Patients Happy if You Are Happy?
There�s a 60% likelihood that, if employees are
happy, patients are happy and vice versa, but it�s impossible to say which
group�s increase drives the other, according to a study by Press Ganey
Associates. The firm based its findings on a comparison of approximately 19,500
inpatient satisfaction surveys with 50,500 employee satisfaction surveys at 33
hospitals in 19 states. Additional information is available online.
Commission on Collegiate Nursing Education
Amends Accreditation Standards
The Commission on Collegiate Nursing Education has
amended the standards used to ensure quality in baccalaureate and graduate level
nursing programs. The revised Standards for Accreditation of Baccalaureate and
Graduate Nursing Programs, which will be effective Jan. 1, 2005, reflects
improved consistency in the use of terminology, clarification of intent, and the
elimination of redundancy. In addition, the revised standards identify specific
sets of professional nursing guidelines that programs must use as the foundation
for curricula. The document may be accessed online.
Dean Calls For New Nursing Incentives
Warning of a looming nurse shortage in America,
Vermont Gov. and Democrat presidential hopeful Howard Dean has called for a ban
on mandatory overtime for nurses and new tuition assistance for those in school.
�I was taught a lot of good medicine by nurses,"said
Dean, who is a medical doctor.
He also called for better staffing ratios and higher
pay, telling healthcare professionals that his background as a physician makes
him a candidate who can be trusted on healthcare issues.
Dean put no price tag on his proposal and conceded
that much of it would have to be accomplished through local bargaining. However,
he said the president could set the tone leading to those changes. He said steps
must be taken to encourage more people to enter the nursing profession. Dean
said there�s an urgency to the effort because nursing shortages are already
popping up and will only get worse.
Dean�s proposal includes:
� Banning mandatory overtime so that nurses are not
forced to work double shifts when staffing is short
� Setting federal minimum staffing requirements and
bolstering Medicare reimbursements to pay for additional nurses
� Boosting recruitment for nursing school among men
� Boosting pay for nurses and putting in place
programs to assist nursing students with tuition
� Allowing nurses to establish a practice
independently from physicians, a measure that could drastically increase the
availability of basic health care in rural areas
Information about the healthcare platforms of the
other candidates is available online.
California Nurse-Patient Ratios Will Cost
Hospitals At Least $900 Million
Hospitals throughout California are spending more
money to comply with a state law on nurse-patient ratios.
The law, signed by outgoing Gov. Gray Davis two
years ago, mandates a certain number of nurses on the hospital floor for every
patient in a bed, depending on the department. The new ratios take effect in
January. Legislation that would penalize hospitals that do not meet the new
ratios stalled last month in the state Legislature.
Hospitals may absorb some of these costs by cutting
budgets in other areas, healthcare officials say. However, most of the increased
costs will likely be passed to insurance companies, which, in turn, will pass
them on to businesses, and eventually trickle down to employees.
There also are concerns about the mandated ratios
not allowing much flexibility in delivering care. For example, ratios are based
on the type of licensed beds at a hospital. When a hospital gets busy and runs
out of general beds, it could not put some patients in available ICU beds,
because ICU-licensed beds would have to maintain the same nurse-patient ratio.
Hospitals say they simply can�t fill all the job
vacancies. It�s even a challenge tapping into local schools: Nursing programs at
area colleges and universities have been capped because of state budget cuts.
Recruitment had gone beyond U.S. borders, with hospitals recruiting nurses from
countries such as Canada, England and the Philippines.
U.S. Urged to Suspend Smallpox Program
The federal government should suspend phase two of
its smallpox vaccination program until it can better evaluate the need and
risks, according to an Oct. 22, 2003, Web site article of Health Affairs, the
policy journal of the Health Sphere. The potential development of weapons of
mass destruction by Iraq shaped initial debate over the program, but there is no
way to know if the absence of such weapons indicates a lower risk for the U.S.,
according to the authors. Relatively few people�38,000�were vaccinated in phase
one of the program, compared with the government�s initial goal of approximately
500,000 hospital and health workers.
The article is available online at
10th State Removes Physician Supervision of Nurse
Alaska became the 10th state in less than two years
to opt out of a federal physician supervision requirement for nurse
anesthetists. The opt-out is effective immediately.
Taking advantage of an anesthesia care rule that
allows states to become exempt from the supervision requirement, Alaska Gov.
Frank Murkowski wrote to the Centers for Medicare & Medicaid Services that his
state was opting out because �the exemption from this federal Medicare
regulation will provide significant long-term benefits to all Alaskans.�
Iowa, Nebraska, North Dakota, Idaho, Minnesota, New
Hampshire, New Mexico, Kansas and Washington already had opted out of the
Grants Awarded for Bioterrorism Training and
Health and Human Services Secretary Tommy G.
Thompson has announced $26.6 million in new grants to strengthen bioterrorism
training and education for the nation�s health professions workforce. These
first grants in HHS� Bioterrorism Training and Curriculum Development Program
will fund continuing education for healthcare practitioners and curriculum
development in health profession schools. Additional information is available
online at www.hrsa.gov.
Nurses Urge Renaming of TB Respirator Rule
Two health professional organizations are urging the
Occupational Safety and Health Administration to create a separate respiratory
protection regulation by renaming the tuberculosis respirator protection
standard. The groups assert this would allow OSHA to incorporate all airborne
infectious diseases into the standard. But labor officials disagree.
Labor officials say such a move would leave
healthcare workers inadequately protected from infectious diseases, such as
severe acute respiratory syndrome, which they say require worker protection
measures much more stringent than called for under the TB rule. However, the
health professional organizations are signaling they would entertain revisions
to the current standard.
For example, the groups are urging OSHA to
�determine respiratory protection requirements for healthcare workers based on
the size of the infectious microbe."The groups argue that �the need for a new,
separate respirator standard to protect against airborne infections is
underscored by the trend toward the emergence of newer, more virulent strains of
infectious diseases that will continue to have worldwide impact.�
In comments submitted jointly by the American
Association of Occupational Health Nurses and the Association of Occupational
Health Professionals on the agency�s rulemaking for assigned protection factors,
the groups recommend changing the title of its respirator protection standard
from �Respiratory Protection for M. Tuberculosis,"to �Respiratory Protection for
Airborne Infectious Diseases."
OSHA extended the public comment period on assigned
protection factors and had no comment on the recommendation. The respirator TB
standard calls for personal protective equipment and fit testing saying,
�Frequent random inspections shall be conducted by a qualified individual to
assure that respirators are properly selected, used, cleaned, and
maintained."Regarding fit testing, the standard states, �Every respirator wearer
shall receive fitting instructions, including demonstrations and practice in how
the respirator should be worn."Additional information is available online at
www.osha.gov. Search in the index for Respiratory Protection.
Public Policy Snapshot
Factors Found to Influence Withdrawal of
Mechanical ventilation is the most common form of
advanced life support in the ICU, yet the factors associated with physicians�
decisions to withdraw ventilation from critically ill patients in anticipation
of death are often unclear. In an observational study, investigators in ICUs,
mostly in North America, tried to determine what influenced the outcomes of
these discussions about end-of-life care. They focused on the factors that led
physicians to withdraw ventilatory support in anticipation of death.
According to the study:*
� One of the four factors influencing the decision
to withdraw ventilatory support was the patient�s reliance on medications to
maintain blood pressure.
� The other three factors involved more subjective
judgments by the ICU physicians, including their predictions of survival and
cognitive function beyond the ICU, and their perceptions of the patient�s
� Physicians influence the decision-making process
by virtue of how they forecast the patient�s future, and the family influences
these decisions by helping physicians to understand the patient�s desires.
The researchers note that their results call into
question the traditional biomedical model of withdrawal of life support that
focuses on the patient�s age and physiological determinants such as worsening
organ function. Although they are encouraged that their findings suggest that
the process of withdrawal of life support is attentive to patients� wishes, they
are also concerned that when patients� are unable to communicate their
preference, neither family members nor physicians may accurately represent their
* Source: Withdrawal of mechanical ventilation in
anticipation of death in the intensive care unit. New England Journal of
Medicine, Sept. 18, 2003.
For more information about these and other issues,
visit the AACN Web site.