AACN News—September 2003—Practice

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Vol. 20, No. 9, SEPTEMBER 2003

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
Carmel, Ind.
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 life-changing injury.

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.
Barnes-Jewish Hospital
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, Ariz.
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, Fla.
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 communicate.
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 Initiative.
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
Blaine, Minn.
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 nurses.

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 Orleans, La.

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, dolores.curry@aacn.org.

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 caregiver
� 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

Q: What is transmyocardial laser revascularization (TMLR)?

A: 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) effect.2

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 growth factor.5

TMLR is reserved for patients with ischemic heart disease who are not candidates for more conventional intervention or surgery.2 The evidence shows that laser revascularization significantly improves regional function and microperfusion, but does not change global left ventricular function.6 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). 2002;38(6):585-91.
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 practice@aacn.org.

2003-04 AACN Grants Support Clinical Projects and Research

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 Senate versions.

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 http://capwiz.com/criticalcare/home/ 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 SARS Outbreak
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 Nursing.

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 Candidates
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 Lives
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 Alliance

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 www.nursing-alliance.org.

Registration Fee: $675
Early Bird Registration Deadline: Jan. 30, 2004
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 Web site.
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, ahrqpubs@ahrq.gov.

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."

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