AACN News—March 2003—Practice

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Vol. 19, No. 3, MARCH 2002

The Power of One: Moral Distress Is Common in Critical Care Nursing

By Kimberly Brown, RN, MSN, FNP, CS, CEN
Ethics Work Group

Moral distress is an all too common and frustrating aspect of critical care nursing. Just consider the following case scenarios.

Scenario 1s
Because of staffing constraints, Connie must again be assigned three patients. The one familiar face is Mr. C., a 60-year-old patient with acute pancreatitis and dehydration. What initially was believed to be a pancreatic ampula stone, has turned out to be adenocarcinoma. Mr. C. and his wife are being advised of his diagnosis as Connie begins her shift.

Patient #2 is a one-day postoperative CABG who is still intubated secondary to a lengthy smoking history. Patient #3 is a 33-year-old motor vehicle collision patient, postsplenectomy, right pneumohemothorax with continued bleeding. Nurses on the previous shift have spent the past two hours pushing blood and crystalloids to maintain blood pressure.

Although Mr. C. is Connie's most physiologically stable patient, it is clear by the way he grips her hand and looks desperately into her eyes that he needs her psychosocial support.
Eleven hours later, patient #3 has returned to OR; patient #2 has failed weaning and requires frequent sedation and analgesia; and Mr. C. is being transferred to the floor. Connie catches a last glimpse of him as he is wheeled out of the unit. Although she knew what he needed, she didn't provide it. She feels as if she has failed him.

Scenario 2
Emily is a 48-year-old woman with stage IV breast cancer with metastases to the spine and now the brain. Since her admission with status epilepticus two days ago, she has had a CT, MRI, multiple LPs, an EEG and numerous blood tests. She is mechanically ventilated and, despite weaning off lorazepam, her GCS is <5. John, the RN, is listening to the physician tell Emily's husband and two teenage daughters that she is much better today, that her seizure activity has decreased and the prognosis is good. He assures them that she will be home by Christmas, but will need frequent invasive tests to monitor her progress.

John knows that Emily will probably not survive this hospitalization and approaches the physician to discuss the information given to the family. The doctor simply rolls his eyes and mutters as he walks away. Once again, John finds himself knowing that futile care is being given with the potential for prolonged suffering and false hopes for the patient and family. And, once again, he is encouraged by his supervisor to keep quiet.

Conflict in Action
The hallmark of ethical dilemmas, which occur daily in the critical care unit, is the conflict between rights, duties, values and principles. In the scenarios presented, the nurses clearly know the correct ethical action.

For Mr. C., the nurse needed to be able to spend uninterrupted time with him and his wife as they begin to process his catastrophic diagnosis. The nursing relationship she had developed with the family would enhance communication and caring on all levels. However, staffing constraints and patient acuity prevented her from acting on what she knew was the right thing to do.

In Emily's case, John recognized the lack of veracity and false hope being communicated to the vulnerable family. He also recognized the potential discomfort continued invasive procedures would bring. Nevertheless, he was expected by the culture within his institution to act as silent partner to these occurrences, which he obviously believed to be morally wrong.

Knowing What's Right
What Connie and John experienced was moral distress. In studying nursing ethics, Andrew Jameton acknowledged that many nursing narratives deemed to be "moral dilemmas" did not meet the criteria. In contrast to dilemmas or uncertainty, moral distress involved knowing the right thing to do but, for a multitude of reasons, being unable to act on it. Since this introduction into the literature, many sources are beginning to recognize that moral distress is one of the leading causes of burnout and loss of nurses' moral integrity.

Alvita Nathaniel describes moral distress as the pain or anguish affecting the mind, body or relationships in response to a situation in which the nurse is aware of a moral problem, acknowledges moral responsibility and makes a moral judgment about the correct action, yet, as a result of real or perceived constraints, participates in a perceived moral wrongdoing.

Given the complex and demanding atmosphere of the critical care unit, nurses are at an even higher risk of experiencing moral distress. Factors contributing to this risk include the significant shortage of critical care nurses, unhealthy healthcare systems, high acuity patient populations, the multitude of technological advances in care of the critically ill, and novice nurses with inadequate training forced into care of multiple critically ill patients. Finding their "bold voices" will assist critical care nurses in the identification and resolution of these challenging issues. How do we begin?

Synergy Support
The AACN Synergy Model for Patient Care, developed by AACN Certification Corporation, recognizes that the needs or characteristics of patients and families influence and drive the characteristics or competencies of the nurse. Nurse characteristics in this model are clinical judgment, advocacy/moral agency, caring practices, collaboration, systems thinking, response to diversity, clinical inquiry and facilitator of learning.

Synergy results when the patients' needs and characteristics are matched with the nurses'competencies. For synergy to exist and for moral distress to be minimized, support must be given by the profession and individual institution to allow each nurse to achieve the desirable competencies.

For example, providing ample training to novice critical care nurses and continued education to experienced clinicians supports the development of clinical judgment. Classroom training is not sufficient. Instead, bedside experience must provide mentored practice to allow for safe and modulated growth in new patient care situations. Ethical decision making and understanding of system support and how it interfaces with nursing will assist each nurse in finding her personal way to navigate patient care dilemmas and avoid moral distress.

Speaking up about the truth with "bold voices" will help critical care nurses to provide optimal care.

1. Nathaniel A. Moral distress among nurses. American Nurses Association Ethics and Human Rights Issues Update. Spring 2002;4.
2. Jameton A. Dilemmas of moral distress: moral responsibility and nursing practice. AWHONNS Clin Issues Perinat Womens Health Nurs. 1993;4:542-551.

Across the Continuum of Care: Inclusive Leadership Supports Progressive Care Nurses

By Melissa A. Fitzpatrick, RN, MSN, FAAN
Cochair, Progressive Care Task Force

Since their inception, progressive care units have represented the "step down" from critical care and the "step up" from the general medical-surgical floor. Patients on progressive care units are typically not sick enough to be in an ICU but too sick for medical-surgical, nurse-to-patient ratios. As a result, progressive care nurses often feel as though they reside in "no-man's land"´┐Żneither a part of the critical care service nor a part of the medical-surgical division.

Traditional organizational charts place progressive care units in the medical-surgical arena, though the two care environments are very different. Today, again despite differences, progressive care units are often grouped with critical care. What can a progressive care nurse do? Where do they go for resources and support? How can they get past the "us versus them" scenario that is all too common between the staffs at various points along the continuum of care?

Shared Leadership
One answer is a reporting mechanism that has staff at various points along the continuum of care accountable to the same leadership team. With the advent of service lines, grouping like patients and providers into a division or service has helped to ameliorate the divisiveness and isolation that has plagued progressive care unit staff.

For example, having one director over the coronary care unit, cardiothoracic and the cardiac progressive care unit can bring the environments of care and the care providers together. Instead of being distracted by the geography in which the care is delivered, one leadership team responsible for care delivery throughout the acute phases of cardiac care can take a more patient-focused approach to problem solving. When one director or manager is responsible for these three cardiac units, he or she can see the issues more globally and remove the "us/them" language from conversations. In effect, such an organizational structure helps to put the "we and us" back into the dialogue.

This type of shared leadership structure can best support a philosophy of shared decision making, open dialogue and mutuality. Instead of saying, "That's how we do it in the CCU," the conversation becomes more driven by what the cardiac patient and family need as they move through the continuum. The "dumping syndrome" is no longer acceptable when all nurses within the service are accountable to the same standards of practice and communication expectations, and to seeing the patient's needs through to discharge. When nurses are all part of the same larger team, all reporting to the same leadership team, it can break down many of the barriers and obstacles that have fragmented patient care for too long.

A Success Story
I have seen such an inclusive leadership concept work wonders in a cardiac setting in New England, after the director responsible for the CCU and CT ICU resigned. The CPCU director, who had been in his role for many years, had dealt with many of the "stepchild" symptoms related to managing a progressive care area. I decided that appointing him to also lead the two critical care areas might help to bridge the gaps that existed among these areas.

The assistant directors in the critical care areas joined the assistant director of the CPCU and two clinical nurse specialists in rounding out the leadership team. They spent considerable time initially getting to know the director, who had to convince the critical care nurses that he could support them and advocate for their needs. At weekly team meetings, issues about patient flow, giving report, visiting hours and floating quickly surfaced.

At first, the dialogue centered around "turf," with each leader advocating for what was best for his or her own staff. However, as greater understanding developed, the dialogue became focused on the patient's experience, and what could be done to best meet the patient's wishes and to achieve the best outcome for the patient. Gradually, the walls, both physical and imaginary, started to crumble.

The CPCU staff was teamed with critical care nurses to learn new assessment skills, while enhancing continuity of care. When the critical care nurses reluctantly accepted an assignment on the CPCU, they learned that the CPCU nurses had admirable expertise, time management and delegation skills. Issues, concerns and praise were shared openly at joint staff meetings, which were scheduled monthly. Social events encompassed all three areas, and an all-inclusive cardiac esprits de corps evolved.

Embracing such an inclusive leadership model was certainly a stretch for all involved. By focusing on how the areas were alike instead of how they were different, the staff involved was able to rise to the challenges. The outcomes were positive for the patients, for staff retention and comradery, and for leadership development. An unexpected outcome was that the physicians also started to communicate better.

Although not a panacea, this model moved the organization closer to a patient- and family-centered environment in which cardiac nurses, including CPCU nurses, made their optimal contribution.

NTI Session Targets Conflict: Learn How to Maximize Mediation

Using Mediation and Facilitation to Improve Patient Safety" is the topic that will be discussed during a special preconference session at AACN's 2003 National Teaching Institute and Critical Care Exposition, May 17 through 22 in San Antonio, Texas.

AACN is being joined by other members of the Nurse Manager Leadership Collaborative, the American Organization of Nurse Executives and the Association of periOperative Registered Nurses in sponsoring this full-day session on Sunday. Presenters Debra Gerardi, RN, MPH, JD, and Ginny Morrison, JD, will discuss the importance of managing competing interests in the creation of a culture of safety.

Geared to all levels of clinicians, this session will focus on skills that are applicable for managing conflicts involving patients, families and clinical team members. Techniques used in mediation and facilitation will be applied to the creation of a critical care patient safety team to demonstrate how conflict management techniques can be used to overcome the barriers that can prevent the implementation of safe clinical practices.

The participants will have the opportunity to practice the skills needed to resolve conflict as they rehearse a crucial conversation involving disclosure of a clinical error. Areas that will be covered include an effective patient safety program, JCAHO requirements for patient safety, common conflicts that can lead to unsafe clinical practices, the symptoms of conflict, the importance of confidentiality in mediation, and the important components of a disclosure conversation.

For additional information about or to register for NTI 2003, call (800) 899-2226 or visit the NTI Web site at http://www.aacn.org > NTI. The discounted, early-bird registration deadline is April 8.

PACEP Level II Topics Debut Online

Level II topics for the Pulmonary Artery Catheter Education Project are now available. PACEP is a state-of-the-art educational program on how to use the pulmonary artery catheter in the clinical environment and measure learning outcomes for the end-user. The goal is to provide efficient transformation of useful hemodynamic information to allow the clinician to practice in a safe and competent fashion through Web-based technology.

Level II topics are Physiologic Concepts of Hemodynamic Monitoring Part II, Interpretation of Hemodynamic Information Part II, Therapeutic Interventions Part II, Hemodynamic Waveforms: Abnormal Waveform Values and Patterns Part II, and Technical Aspects of Hemodynamic Monitoring Part II.

PACEP is a collaborative education effort by AACN, the American Association of Nurse Anesthetists, the American College of Chest Physicians, the American Society of Anesthesiologists, the American Thoracic Society, the National Heart Lung Blood Institute, the Society of Cardiovascular Anesthesiologists and the Society of Critical Care Medicine. It is not intended to be a credentialing tool or a means of determining individual competency. Although there is a fee to obtain continuing education credit, access to PACEP is free. Visit http://www.pacep.org to register and explore this comprehensive educational program.

Practice Resource Network

Q: I know that transducers need to be leveled at the phlebostatic axis when monitoring, but I am getting conflicting information about where the phlebostatic axis is located. What is the phlebostatic axis and how do I locate it?

A: The phlebostatic axis is an external landmark for locating the left ventricle and aorta. When using a transducer to monitor pressures in the circulatory system, systemic or intracardiac, the stopcock instead of the transducer is used as the zeroing point, and must be referenced to the phlebostatic axis. Davoric recommends that the stopcock closest to the transducer be used as the zeroing port.1
The vertical distance between the catheter tip and the transducer creates a hydrostatic pressure in the fluid-filled system. If the zero point is not level with the phlebostatic axis, the fluid in the system will create an increase or decrease in the pressure being applied to the transducer.1-3

For every inch of deviation from the phlebostatic axis, the change in pressure is approximately 1.82mm/Hg. For example, placement 1 inch above the phlebostatic axis will cause the pressure to be 1.82 mm/Hg lower than actual, and 1 inch below the phlebostatic axis will cause the pressure to be 1.82mm/Hg higher than actual.

To determine the phlebostatic axis, place the patient in a supine position. Draw an imaginary vertical line down the patient's chest from the fourth intercostal space at the sternal angle; then draw an imaginary horizontal line midway between the patient's anterior and posterior chest wall. The intersection of the two lines is the phlebostatic axis. To ensure that the reference point remains consistent and pressures are accurately trended, mark the location with an indelible marker.1,2

Q: What is the recommended method of securing or stabilizing the transducer and the zeroing stopcock?

A: Different methods can be used to stabilize the transducer system. When establishing the standard for your hospital, consider factors, such as ease of leveling the zeroing point to the phlebostatic axis, visibility of the transducer system, potential contamination of the system, potential artifact related to movement of the transducer and patient comfort.

In one method, the transducer(s) is positioned on a transducer holder and mounted to an IV pole. This method allows for leveling the transducer(s) at one time and keeps the transducer system visible. However, it requires that the system be releveled each time the patient is repositioned.

Another method involves taping the transducer to the patient at the phlebostatic static axis.1 With this method, the zero point moves with the patient but may require taping multiple transducers to the patient, increasing the potential for contamination when the system is opened for zeroing, causing discomfort when the patient is turned to the side of the transducer and requiring that a portion of the patient's chest be continually exposed so the system remains visible.

A third method involves securing the transducer(s) to a rolled towel that is placed on the mattress at the level of the phlebostatic axis.1 This method also allows for leveling the transducer(s) at the same time and keeping it visible. However, it requires that the tranducer(s) be releveled with changes in patient position and may increase the potential of contamination when the system is opened for zeroing.

1. Darovic GO. Hemodynamic Monitoring: Invasive and Noninvasive Clinical Application. 3rd ed. Philadelphia, Pa: WB Saunders Co; 2001:125-128.
2. McHale DJ, Carlson KK, eds. AACN Procedure Manual for Critical Care. 4th ed. Philadelphia, Pa: WB Saunders; 2001:479-480.
3. Keckeisen M. Pulmonary Artery Pressure Monitoring [AACN Protocols for Practice]. Aliso Viejo, Calif: AACN; 1998:10-12.

Myth vs. Reality: While You Were Sleeping´┐ŻDo Patients Feel Pain?

By Susan Barnason, RN, PhD, CCRN, CS
Research Work Group

Myth: When a critically ill patient has received sedation, they "appear" to be sleeping and therefore are not experiencing pain.

Reality: When sedation is used for the critically ill patient, additional vigilance in the assessment and management of pain is warranted.
Sedation can be a necessary adjunct to nonpharmacological interventions to manage critically ill patients, such as to manage mechanical ventilator dysynchrony, relieve anxiety and dyspnea or reduce patient's oxygen consumption.1-3 There is no best way to sedate a patient.

However, research is being reported on evidence-based practices that can optimize sedation of the critically ill patient. An example is a recently published algorithm for sedation and analgesia of the mechanically ventilated patient.1 Even in this sedation protocol exemplar, best practices indicate there is a need to assess if the patient is comfortable and if the patient has met his goal. If the response is "no," the clinician is directed, per the algorithm, to reassess the patient for pain, agitation and anxiety, and delirium. These frequently occurring problems, which often cluster, challenge nurses to become more analytical in the management of multifaceted patient problems.

Establishing an optimal sedation goal based on the underlying trigger for use of sedation is important. The critical care nurse should consider whether patients are experiencing pain or experiencing other physiological or psychological disruptions, such as hypotension, delirium and sleep deprivation, which need to be addressed. Nurses' management of patient sedation should be guided by assessment of both the level and the effectiveness of sedation in attaining or maintaining the sedation goal.4

Nurses can evaluate a patient's level of sedation by several means. Some of the sedation assessment tools that are available are the Ramsey Sedation Scale, Motor Activity Assessment Scale, Riker Sedation-Agitation Scale and Vancouver Interaction and Calmness Scale.

More recently, the use of technologies, such as the BiSpectral Index Monitor, have gained attention as a potentially more objective means to evaluate level of sedation.3 The BIS was originally developed for use with the anesthetized patient by measuring EEG signal changes over time. The BIS score can range from 0 to 100, with a higher value indicating higher levels of consciousness. Although studies have recognized the usefulness of BIS monitoring with patients who are receiving both sedatives and neuromuscular blocking agents, additional research is needed to determine the optimal levels of BIS scores that correlate to levels of sedation.

In evaluating sedation effectiveness, critical care nurses must carefully consider other patient factors, such as pain, that can impact sedation effectiveness. The experience of pain can often have a cumulative effect and contribute to further physiological and psychological deterioration. In fact, a large number of critically ill patients are not able to use a numeric or verbal rating scale to indicate pain intensity, particularly when the patient is also sedated. Pain assessment can be augmented with other pain assessment tools, such as the Behavioral Pain Scale,5 which evaluates facial expression, upper limb movement and compliance with ventilation. Equally important are other conditions the patient has or is experiencing that could induce pain. All these factors need to guide critical care nurses in determining the use of analgesics in conjunction with sedation therapy.

The myth that the "sleeping" or sedated patient feels no pain must be unraveled. The sedated critically ill patient is a challenge that can be best managed initially by a comprehensive approach to patient assessment and, ultimately, the patient's response to sedation management.

1. Jacobi J, Fraser GL, Coursin DB, Riker RR, Fontaine D, Wittbrodt ET, Chalfin DB, Masica MF, Bjerke S, Coplin WM, Crippen DW, Fuchs BD, Kellerher RM, Marik PE, Nasraway SA, Murray MJ, Peruzzi WT, Lumb PD. Clinical practice guidelines for the sustained use of sedatives and analgesics in the critically ill adult. Crit Care Med. 2002;30:119-141.
2. Arbour R. Sedation and pain management in critically ill adults. Crit Care Nurse. 2000; 20:39-58.
3. McGaffigan PA. Advancing sedation assessment and promote patient comfort. Crit Care Nurse. February 2002; (suppl):29-36.
4. Weinert CR, Chlan L, Gross C. Sedating critically ill patients: factors affecting nurses' delivery of sedative therapy. Am J Crit Care. 2001; 10:156-167.
5. Payen J-F, Bru O, Bosson J-L, Lagrasta A, Novel E, Deschaux I, Lavagne P, Jacquot C. Assessing pain in the critically ill sedated patient by using a behavioral pain scale. Crit Care Med. 2001; 29:2258-2263.

To Build a Collaborative Practice, APNs Must Promote Their Roles

By Linda Griego Martinez, RN, MSN, CS, CCRN
Advanced Practice Work Group

Using advanced practice nurses as part of a variety of medical practices is not new. However, many physicians still neither understand what APNs do or how they can benefit their practices nor are they able to differentiate between the different types of APNs.

The first step in building a role for yourself within a practice is to articulate clearly what type of APN you are. Talk with your physician colleagues about your educational background and what your education and licensure allow you to do. The next step will be to explain how you can promote the practice and enable them to provide optimal care.

Having a written proposal describing how you would fit into the practice is a good idea. Because this proposal should include how billing would be handled, you must be familiar with the laws concerning billing for the type of practice model you are proposing.

Demonstrate how performing certain tasks, such as taking histories and physicals, can save the physicians time. Reassure them that you will need them to validate your competence for whatever procedures and orders you write. This will also give them an idea of what your advanced degree allows you to do.

Even after a practice decides that an APN will be useful, the actual work may be slow at first. Physicians who have been accustomed to practicing on their own may have a hard time knowing when to delegate tasks to you. Again, take the initiative. Volunteer to do certain tasks for them such as, "I'll be happy to round at skilled unit X on my way into work and check on Mrs. Y's pacer incision for you." Accept whatever is agreed to with enthusiasm.

Some of the procedures or tasks they decide to delegate may be those that they don't like to do or find too time consuming. Accept them with enthusiasm, taking advantage of every opportunity to demonstrate that you are knowledgeable and responsible. As you gain their trust, they will listen to your suggestions more and more.

My physician colleagues not only have come to trust my physical assessments, but now also rely on my ability to help them deal with any complex psychosocial issues. This is one area where advanced education in family theory and counseling has helped immensely.

Referring physicians and emergency department physicians are also important to the practice. Again, being able to articulate who you are and what your role is within the practice will help these other physicians understand how to interact with you. Most are eager to have their patients' needs met in a timely fashion. Always conduct yourself in a professional manner and ask intelligent questions that show you understand what they need. You will find them seeking you out because they know you are readily accessible and will act responsibly.

Pharmacology Content Available for First Time at API in San Antonio

4 Sessions Designated for CE credit

Now, advanced practice nurses can earn CE contact hours with pharmacology content at AACN's National Teaching Institute and Critical Care Exposition.

Beginning with the 2003 Advanced Practice Institute, scheduled in conjunction with the 2003 NTI in San Antonio, Texas, pharmacology content will be offered at designated educational sessions. For 2003, these sessions are "Pharmacological Paralysis: Look for the Twitch," "Scary, Scary Drug Interactions, "The ABC's of Cardiac Pharmacology" and "Optimizing Hemodynamics: Quick Tips for Drug Titration."

The NTI is scheduled for May 17 through 22.

A total of 6.0 hours of pharmacology content will be designated in the "Rx" category and available to APNs who require this content for licensure or recertification.


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