In the Circle: Award Recognizes
Excellence in Caring Practices
Editor's note: Presented in honor of
John Wilson Rodgers, the Excellence in Caring Practices Award recognizes nurses
whose caring practices embody AACN's vision of a healthcare system driven by the
needs of patients and families. Following are exemplars submitted in connection
with the awards presented as part of AACN's Circle of Excellence recognition
program for 2003.
Donna Cadwallader, RN
Clarian Health, Methodist Hospital
With 29 years of experience, I am often
called upon to troubleshoot equipment and special patient problems. That is how
I met Bob, a 37-year-old man with a cervical spine injury, who was on a
ventilator and a therapeutic bed.
I volunteered to become involved in his
care because many nurses find caring for spinal cord injury patients to be
challenging and difficult. I do, too. However, I have had a soft spot for
patients with spinal cord injuries since I was a nursing student. I knew I could
make a difference and wanted to help Bob and his family cope with this
I have found that quadriplegics benefit
greatly by consistency and trust in the caregiver. To me, primary care nursing
for spinal cord injury patients is nursing at its best.
These patients, who have been active and
independent, suddenly find themselves totally dependent on others for their
basic care. They are scared and need someone who has answers and experience.
This is what I had to offer Bob.
Bob was a likeable and ideal patient. A
successful salesman, he was now working on the biggest sell of his life�selling
himself on his new life. His positive attitude inspired me as I tended to his
daily care and answered his many questions. Physically caring for him was hard,
but I looked forward to each day, with goals in mind, whether ensuring an early
tracheostomy or a special Thanksgiving visit with his 4-year-old son. It was
rewarding to plan care that addressed his total needs of body, mind and spirit.
I was thrilled to be able to make a difference in his recovery.
Debbie Chandler, RN, BSN
St Louis, Mo.
It was Feb. 14 when I received report on
B., the 37-year-old wife and mother of two boys, who had developed complications
from a partial pancreatectomy and needed more surgery. She was scheduled to
return to the operating room that day.
I knew from report that the prognosis was
poor. My first thought was to have her husband at her bedside. When I phoned
him, he sounded frightened to hear from me before 8 a.m. I attempted to calm him
and encouraged him to bring a family member.
Completing my assessments, I noted that B
was easily aroused by verbal stimuli. The attending ICU physician ordered her
sedation to be increased; however, I waited until her husband arrived.
He stood at the doorway, crying. I gently
explained, "She's awake and can hear us. I kept her awake so you could spend
some time with her and tell her you love her or whatever you need to say." I
took her hand and talked to her. When she opened her eyes, I gasped with joy. I
replaced my hand with his, and she smiled. Crying, he told her he loved her and
always would. She nodded and mouthed, "I love you," and squeezed his hand tight.
They held hands until the operating room personnel arrived.
The surgeon looked forlorn when he returned
from the operating room. I started to cry. The surgeon met with the family in
the private conference room to give them the worst news possible. We all
gathered around the patient's bed. We withdrew support and she died peacefully
in the hands of her son, husband and closest family members.
As her husband left, he thanked me again
and mentioned, "This is a Valentine's Day I will never forget."
Diane M. Fortune, RN, MSN, CCRN, CCNS
Chandler Regional Hospital
Angie was a 34-year-old woman diagnosed
with malaria. With her condition worsening daily, it was the time to talk with
her family about discontinuing support. However, the staff expressed discomfort
about dealing with her 6-year-old son.
I met with our social work department and
Angie's primary care physician. Our team met with family members and her son
Bobby's teacher to discuss his maturity and potential for understanding. Angie's
husband, Rob, their large family, the physician, and I met to discuss her
prognosis. The family asked for time to make their decision and about 30 minutes
later indicated they wanted to withdraw life support.
Our team met with Rob, Bobby and Bobby's
teacher. Rob explained, "Mommy is not getting better and is probably going to go
to heaven," then introduced me. I talked with Bobby about what he remembered
best about Angie, what he thought about heaven, and the changes and equipment he
would see. I answered his questions directly and simply. Bobby indicated he
wanted to see his mother.
Bobby stood on a stool, holding his
mother's hand and talking with her. He asked questions about the equipment.
After about 30 minutes, Bobby leaned over, kissed his mother's cheek, and said,
"I love you. I will miss you," then indicated he was ready to go. We walked out
of the ICU into the warmth of his loving and supportive family. As I
turned to go, Bobby gave me a strong hug
and said, "Thank you." An hour later, Angie died peacefully with her husband and
parents at her side.
This experience, though incredibly sad, is
one of the most fulfilling I have had. We could not improve Angie's outcome, but
we made the experience as positive as possible for those she left behind.
Robin Kretschman, RN, CCRN, CHPN
Tallahassee Memorial Healthcare
One patient and his family's experience
impacted me in ways I will never forget. Joe walked into the hospital with
pneumonia. The effect of taking nonsteroidal anti-inflammatory drugs at home
became apparent as an erosion of a large vessel produced a massive
gastrointestinal bleed. He coded in the operating room.
Post-op, he was ventilated and in
multisystem failure. Although his care was complicated on many levels, that is
not what made this case difficult. How to communicate bad news, how to establish
goals of care and how to negotiate a plan of care in the face of medical
futility were what made it difficult.
When Joe was no longer responsive, I felt
like I was "losing." The physician's greatest difficulty became communication
with Joe's wife. I realized that I would only "lose" if I was unable to
Shirley had been emotionally unable to
spend long periods of time in the room. After my shift, I went to her. Slowly,
she processed. I answered her questions without rushing. About 45 minutes into
our time together, a new strength could be felt in her words, now calm and
deliberate. She was going home to shower and then she'd be back. Joe died
peacefully before the end of the next shift, Shirley at his side.
Resolved to change the system, I am now
certified in critical care, and hospice and palliative nursing. I am an
Education for Physicians on End-of-Life Care trainer and the improvement adviser
for the multidisciplinary team leading a systemwide, end-of-life/palliative care
project funded by the Robert Wood Johnson Foundation Pursuing Perfection
Every Joe and Shirley will have caregivers
that feel supported by a system that equips them to provide every aspect of
appropriate care. We will transform our institution and we will develop a
reproducible model for change.
Sandra J. Lynch, RN, BSN
Fairview University Medical Center
I came to know Asha and her mother Fatuma
while working as a staff nurse in a university-affiliated solid organ transplant
unit. Asha, who was born in the United States to her recently immigrated Somali
parents, was born with a congenital small bowel defect that left her unable to
digest properly. She was sustained on IV hyperalimentation, which eventually led
to irreversible liver failure. Asha became the second pediatric patient in our
hospital to receive a liver/small bowel transplant.
I became Asha's primary nurse after she
received her transplant. Despite her complex recovery process, Asha demonstrated
a strong inner spirit that carried her through this difficult surgical
experience. It was through the process of coming to know and understand Asha's
mother that I discovered the source of her strength and resilience.
Fatuma's journey from her war-torn home of
Mogadishu, Somalia, to the United States had been one fraught with danger.
Fatuma had learned that, to survive, you had to trust the right people. Earning
Fatuma's trust was not an easy task but was necessary for the care of her
daughter. It was through our common experience as mothers that Fatuma and I were
able to cross cultural barriers to develop a relationship of trust and caring.
Despite potential cultural and language
barriers, I was able to provide support, communicating caring and respect with
each encounter. When further treatment appeared futile, I was able to assist the
family in their struggle to provide a peaceful and dignified death for Asha that
was culturally congruent and supportive of their Muslim beliefs and practices.
Fact Sheet Covers Progressive Care
Recognizing that progressive care is a part
of the continuum of critical care, AACN has compiled a Progressive Care Fact
Sheet, which is now available online.
The fact sheet follows up on the work of a
volunteer task force and advisory panel established by AACN in 2001 to define
the progressive care environment and patient populations served, as well as the
core competencies and basic knowledge and skill requirements of progressive care
The document traces the evolution of
progressive care areas, which today encompass intermediate care units, direct
observation, step-down units, telemetry units and transitional care units that
admit a level of patients that would have been cared for in ICUs five years ago.
Nominations Are Due Dec. 1 for 2005
Distinguished Research Lecturer Award
Dec. 1 is the deadline to submit
nominations for the 2005 AACN Distinguished Research Lecturer Award. The
recipient will present the Distinguished Research Lecture at the 2005 NTI in New
The awardee receives a $1,000 honorarium
and $1,000 toward NTI expenses and a crystal award. The lecture is sponsored by
a grant by Philips Medical Systems.
For more information, contact Research
Associate Dolores Curry at (800) 394-5995, ext. 377; e-mail,
Grant Supports End-of-Life or
Palliative Care Studies
Applications Due Feb. 15, 2004
A one-time, $4,700 grant for research
focusing on end-of-life or palliative care outcomes in critical care is
available from AACN. Proposals are due Feb. 15, 2004.
Although a broad range of topics may be
addressed, special consideration will be given to projects that focus on
implementing palliative care or hospice care in the critical care unit.
Among the topics that may be addressed are:
� Bereavement, including family, patient or
� Communication issues, including verbal,
nonverbal or written
� Caregiver needs, including stress,
education or emotional support
� Symptom management, including nausea or
vomiting, pain, anxiety, skin breakdown or dyspnea
� Advance directives, such as staff and
patient education, program development or ethical considerations, etc)
� Life-support withdrawal, including
ethical and legal concerns, or clinical protocols
Additional information and the application
are available online.
Practice Resource Network
What is transmyocardial laser revascularization (TMLR)?
Transmyocardial laser revascularization is a
surgical procedure that creates transmural channels in the myocardium. The
procedure is done under general anesthesia on a beating heart. It requires a
left anterior thoracotomy incision in the fifth intercostal space to expose the
myocardium of the left ventricle. A laser is used to create channels through the
ischemic myocardium, 1 mm in width and approximately 1 cm apart.1
Originally, TMLR was developed to recreate
the situation that exists in a reptilian heart,1
which is perfused directly from the ventricular chamber through a network of
sinusoids that bathe the myocardium. The purpose was to supply blood directly to
the ventricular myocardium through channels made in the wall of the ventricle.
How TMLR works is not completely
understood, and whether the myocardium can be perfused directly via these
channels is controversial. Other proposed mechanisms include neoangiogenesis
(the development of new blood vessels), myocardial denervation (the removal of
nerve supply to the tissue), myocardial inflammation and psychological (placebo)
Several studies have shown a significant
decrease in angina class from the baseline.2,3
Other studies have shown perfusion improvement, denervation4 and histological
evidence supporting angiogenesis by upregulation of the vascular endothelial
TMLR is reserved for patients with ischemic
heart disease who are not candidates for more conventional intervention or
The evidence shows that laser revascularization significantly improves regional
function and microperfusion, but does not change global left ventricular
Patients who undergo TMLR have improved status that allows physical activity,2
reduced incidence of angina and cardiac-related rehospitilizations.2,3
1. Ballard JC, Wood LL, Lansing AM.
Transmyocardial revascularization: criteria for selecting patients, treatment
and nursing care. Crit Care Nurse. 1997;17(1):42-49, 59.
2. Kinduris S. Transmyocardial laser
revascularization: a past or future treatment method? Medicina (Kaunas).
3. Allen KB, Dowling RD, Fudge TL,
Schoettle GP, Selinger SL, Gangahar DM, et al. Comparison of transmycardial
revascularization with medical therapy inpatients with refractory angina. N Engl
J Med. 1999;341(14):1029-1036.
4. Muxi A, Magrina J, Martin F, et al.
Technetium 99m-labeled tetrofosmin and iodine 123-labeled
metaiodobenzylguanidine scintigraphy in the assessment of transmyocardial laser
revascularization. J Thorac Cardiovasc Surg. 2003;125(6):1493-1498.
5. Horvath KA, Chui E, Maun DC, et al.
Up-regulation of vascular growth factor mRNA and angiogenesis after
transmyocardial laser revascularization. Ann Thorac Surg. 1999;68(5):1893-1894.
6. Holmstrom M, Hanninen H, Simpanen J, et
al. Wall motion and perfusion analysis of transmyocardial laser
revascularization. Scan Cardiovasc J. 2003;37(2):91-97.
If you have a practice-related question,
call AACN's Practice Resource Network at (800) 394-5995, ext. 217, or e-mail
your question to firstname.lastname@example.org.
2003-04 AACN Grants Support Clinical Projects and
Evidence-Based Clinical Practice Grant
This program provides awards of $1,000 to
stimulate the use of patient-focused data or previously generated research
findings to develop, implement and evaluate changes in acute and critical care
nursing practice. Grant proposals are accepted twice a year and must be received
by either March 1 or Oct. 1.
AACN Clinical Practice Grant
This $6,000 grant supports research that is
focused on one or more of AACN's clinical research priorities. Oct. 1 is the
annual application deadline for this grant.
AACN-Sigma Theta Tau Critical Care Grant
This $10,000 grant is cosponsored by AACN
and Sigma Theta Tau International. The grant may be used to fund research for an
academic degree. Oct. 1 is the annual application deadline for this grant.
To find out more about AACN's research
priorities and grant opportunities, visit the AACN Web site.
For the Record
Nurse Competence in Aging is a five-year
initiative funded by an Atlantic Philanthropies (USA) Inc., award to the
American Nurses Association through the American Nurses Foundation. The funding
source cited for AACN's $13,000 participation grant was incomplete in an article
in the June 2003 issue of AACN News.
Public Policy Update
AACN Advocates for Additional Federal
Dollars for Nursing Programs
The House of Representatives narrowly
passed a $356.7 billion Department of Labor-Health and Human Services
appropriations bill with $112.7 million in funding for nursing services,
including the Nurse Reinvestment Act. The funding levels passed by the House are
$50.1 million for advanced nursing education, $9.9 million for nursing workforce
diversity, $26.8 million for nurse education and practice, $19.8 million for
loan repayments and scholarships, $2.98 million for nurse faculty loans, and
$2.98 million for geriatric nurse education.
The Senate was expected to vote on the
bill, H.R. 2660, when they returned following the recess. The bill would then be
sent to a conference committee to address any differences between the House and
In anticipation of the Senate vote, AACN
along with 20 other nursing organizations was contacting senators to enlist
their support for a minimum of $175 million in funding in fiscal year 2004.
The funds would be used for the Nurse
Reinvestment Act and other nursing programs funded by the HRSA.
AACN urges members to visit the
Legislative Action Center at
and to e-mail their congressional representatives to urge them to provide at
least $175 million in fiscal year 2004 to fund nursing workforce development
(Title VIII, Public Health Service Act). However, AACN supports a $250 million
funding level as the full amount needed to fulfill the promise of the Nurse
Reinvestment Act and address the growing crisis caused by the nursing shortage.
GAO Says Hospitals Not Ready for Major
Established infectious disease control
measures are adequate to contain severe acute respiratory syndrome (SARS) in the
United States this year, but a large-scale outbreak could overtax both hospital
and workforce capacity, a Senate subcommittee has been told.
In testimony before the subcommittee, a
General Accounting Office official advised that the healthcare system should
prepare for overcrowding as well as shortages of healthcare workers and medical
equipment, particularly respirators. A study conducted by the GAO last year of
more than 2,000 hospitals, the GAO found a wide variation in the availability of
medical equipment. Half the hospitals had fewer than six ventilators for every
100 staffed beds
As of July 11, SARS had infected more than
8,000 people in 29 countries, killing 800 people. However, the virus was
contained in the United States to 211 possible cases and no related deaths. Of
these cases, 175 are classified as "suspect" and 36 as "probable."
Edwards Proposes RN Recruitment Plan
Presidential hopeful Sen. John Edwards (D-N.C.)
has announced a proposal to draw 100,000 people into the nursing profession with
$3 billion in incentives over the next five years. Edwards said his plan would
entice 50,000 former nurses back to work by improving working conditions. The
plan not only would offer federal grants to hospitals to improve work
environments, but also ban mandatory overtime.
In addition, Edwards proposes paying
tuition and fees for 50,000 students studying to be nurses. After graduating,
the students would be required to work for at least four years in areas where
nurses are in short supply.
Edwards also called for a new federal study
of workplace safety issues and the establishment of a Presidential Commission on
AACN commends Edwards for recognizing
the critical need for a comprehensive plan that will invest in nursing and
address the complex factors of the growing nursing shortage.
Healthcare Ads Target Presidential
The Service Employees International Union
recently launched advertisements in New Hampshire and Iowa as part of a "major
push" to place healthcare high on the 2004 campaign agenda, the Washington Post
reports. The labor union paid $245,000 to air a 30-second ad in the two states
over 11 days as part of an "Americans for Health Care" project. The ad features
local nurses discussing the problems of increased healthcare costs and the
uninsured. One nurse states, "We've got to ask every candidate running for
president what they're going to do about healthcare and how they're going to pay
for it. And we can't quit until we get some real answers." In addition, the SEIU
has paid for a billboard ad that will feature nurses and appear at airports in
Manchester, N.H., and Cedar Rapids and Des Moines, Iowa. The ad states, "Health
care better be your top priority." Although the SEIU has not endorsed any
specific healthcare proposal introduced by a presidential candidate, it wants to
keep "the pressure on politicians to devise solutions."
Survey Studies Patients Who Fast to End
Modern Healthcare Daily recently reported
that in the rancorous debate over euthanasia, assisted suicide and other ways
for terminally ill patients to end their lives, doctors note that one option is
always legal: a sane, alert person can simply refuse to eat or drink. Although
the option is rarely used, the first survey of nurses whose patients took it has
contradicted the prevailing assumption that such a death is painful and
gruesome. Almost all the 102 Oregon nurses surveyed said their patients who
refused water and food had died "good deaths," with little pain or suffering,
generally within two weeks.
The study, which appeared in the July 24,
2003, issue of the New England Journal of Medicine, raises difficult questions
for those on both sides of the debate. Although the authors were hesitant to
publish it for fear of encouraging suicides, the lead author said they decided
to do so because it was clear that some patients were already choosing such
deaths and the medical community needed to set standards.
Foreign RNs Need Certificate
The Department of Homeland Security has
issued a final rule requiring nurses and certain other healthcare workers from
overseas to obtain a certificate from an approved credentialing organization
verifying their education, training, licensure and experience before they can
enter the United States. The long-anticipated rule, published in the July 25,
2003, Federal Register and effective Sept. 23, 2003, pertains to foreign-born
nurses, physical therapists, occupational therapists, speech-language
pathologists, medical technologists, medical technicians and physician
assistants, even if they trained in the United States.
Immigration attorneys expect the
requirement to increase the time to hire and employ such workers by as much as
three to six months. Nurses who already have temporary visas and are seeking
admission, readmission, or an extension or adjustment of their stay will not be
subject to the requirement if their applications are approved by July 26, 2004.
After that, a waiver of the requirement may be granted on a case-by-case basis.
Public Policy Snapshot
Nurse in Washington Internship Program
Feb. 29-March 3, 2004
Sponsored by the Nursing Organizations
The Nurse in Washington Internship program
provides nurses the opportunity to learn how to influence healthcare through the
legislative process. Participants learn from a distinguished faculty of health
policy experts and government officials, many of whom are nurses. NIWI
highlights include opportunities to network with other nurses, an executive
branch briefing and visits with members of Congress. This four-day learning
experience will energize and prepare attendees to become actively involved in
the health policy process at the local, state or national levels. The
internship, in its 20th year, culminates with a day on Capital Hill, when
participants visit their legislators to discuss topics and issues of concern.
Registration forms, as well as information about available scholarships, are
available on the Nursing Organizations Alliance Web site at
Registration Fee: $675
Early Bird Registration Deadline: Jan. 30,
Location: Hyatt Regency Washington, D.C.
Hotel Reservation Deadline: Jan. 23, 2004;
call (202) 737-1234
Public Policy Information Online
Healthy Work Environments
The American Organization of Nurse
Executives has released the second volume in its monograph series on the nursing
work environment. The report, titled "Healthy Work Environments: Striving for
Excellence, Volume II," offers insights from a key informant survey on the
nursing work environment conducted by McManis & Monsalve Associates in
collaboration with AONE. A total of 21 hospitals and 61 individuals participated
in the survey, contributing experiences, best practices and lessons for
strengthening the nursing work environment.
The report can be downloaded from AONE's
Five Steps to Safer Healthcare
Posters and fact sheets offering patients
tips on playing a role in improving the safety of the care they receive have
been released by the Department of Health and Human Services, the American
Hospital Association and the American Medical Association. The materials, which
the groups encourage providers to display in their waiting and examination
areas, are available in English and Spanish and aim to help patients avoid
medical errors related to prescription drugs, laboratory tests and procedures.
Copies of the information, titled "Five Steps to Safer Health Care," are
available in English at www.ahrq.gov/consumer/5steps.htm
or in Spanish at www.ahrq.gov/consumer/cincorec.htm. Copies can also be obtained
by calling (800) 358-9295; e-mail,
Disaster Response Planning Tool
The American Hospitals Association has
issued a disaster readiness advisory announcing a free computer model that
hospitals can use to plan prophylaxis clinics for dispensing critical drugs or
vaccinations in the event of disease outbreaks or bioterrorism. AHA urged
hospital emergency planning staffs to download the model from the AHA Web site
and use it to assess what it would take to operate such a clinic in their
community. It also reminded hospitals to work with their state or local public
health agencies and hospital associations to plan responses to such events,
including practice drills.
"Now that the government's voluntary
smallpox vaccination campaign has ended, many AHA advisors have urged that more
emphasis be placed on hospital planning for postevent responses," the advisory
noted. "This model is an important step in that direction."