AACN News—December 2004—Practice

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Vol. 21, No. 12, DECEMBER 2004

Practice Resource Network

Q: Our critical care unit is considering applying for AACN’s Beacon Award for Critical Care Excellence. Could you provide us direction on what to include in the narrative answer regarding the following application question: Is there a mechanism to debrief unit-based nursing staff after stressful incidents, including EOL, interpersonal, and/or abusive/violent situations?

A: Healthcare workers are exposed every day to stresses not normally encountered by the lay public. We celebrate the joy and happiness of patients and families who get better because of our interventions and efforts, and we share the frustration and sorrow when they do not.

Critical care nurses must be able to maintain a balance between empathy and a degree of desensitization that allows us to perform our jobs. When an event or situation that can overwhelm the effective coping skills of either an individual or a group occurs, how does your institution or unit assist staff members in coping?

To answer this question in the Beacon Award application, you will want to discuss how your unit or hospital assesses and identifies a critical incident, and what formal or informal process is in place to provide peer and professional support. For example, does your hospital or unit provide stress awareness education or tools to work through stressful situations? Has the staff been trained in communicating and managing hostile or aggressive patients and families? Does your chaplain service provide “de-fusing” counseling, and is it available 24 hours a day? Do you have a critical debriefing team? Do you have end-of-life and palliative care protocols for managing your patients? Does hospital staff have access to grief counseling? Does your unit or hospital provide a relaxing area or space for the staff? What does the unit staff do to “nurture” their peers on a regular basis or after a particularly stressful personal or professional situation?

When individual needs exceed the abilities to manage stress properly, they start down the slippery slope toward distress. Although stress is not unique to critical care nurses, certain critical incident stressors ultimately can alter their abilities to perform their jobs, as well as to impact their personal lives.

A successful Beacon Award applicant unit will be able to describe what programs or processes have been introduced and facilitated to debrief unit-based nursing staff after stressful incidents, as well as to describe the impact to patients, families and the interdisciplinary healthcare team.

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.


Clinical Inquiry Grant
Ten awards of up to $500 each are available to fund projects that directly benefit patients or families. Interdisciplinary projects are especially invited. The next application deadline is Jan. 15.

End-of-Life/Palliative Care Small Projects Grant
Two awards of up to $500 each are available each year to fund projects that focus on end-of-life or palliative care outcomes in critical care. Topics to be addressed may include bereavement, communication issues, caregiver needs, symptom management, advance directives and life-support withdrawal. The next application deadline is Jan. 15.

Mentorship Grant
Up to $10,000 is available to support research by a novice researcher working under the direction of a mentor who has expertise in the area proposed for investigation. The application deadline is Feb. 1.

Critical Care Grant
Up to $15,000 is available to fund research that focuses on one or more of AACN’s research priorities. These five priority areas, identified as relevant to AACN and its members, are:
• Effective and appropriate use of technology to achieve optimal patient assessment, management or outcomes
• Creating a healing, humane environment
• Processes and systems that foster the optimal contribution of critical care nurses
• Effective approaches to symptom management
• Prevention and management complications
The application deadline is Feb. 1.

Evidence-Based Clinical Practice Grant
Six awards of up to $1,000 each are available each year to fund projects that 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. The application deadline is March 1.

To find out about AACN’s research priorities and grant opportunities, visit the Research area of the AACN Website or e-mail research@aacn.org.

Panel to Select Distinguished Research Lecturer for 2006

Members of the DRL Review Panel have been announced. This group will review nominations and select the AACN Distinguished Research Lecturer recipient for 2006. Following are the volunteers who will serve on the panel this year:
Alyce Louise Ashcraft, RN, CNS, MN, PhD
Sonja R. Hardin, RN, MSN, PhD, CCRN
Christine Hedges, RN-BC, CNS, MN, PhD
Deborah J. Kenny, RN, MSN, PhD
Jeanne Perla, RN, MN, PhD
Debra L. Siela, RN, RN-BC, DNS, PhD, CCRN.

Is Your Unit a Beacon of Excellence?

With the first AACN Beacon Award for Critical Care Excellence presented during AACN’s National Teaching Institute and Critical Care Exposition in May, applications continue to be accepted and reviewed.

This program shines national recognition on units that attain high standards for quality, exceptional care of patients, and healthy, humane and healing work environments.

The Web-based application process asks 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, which may be submitted at any time, are 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 Website.

APNs Can Use Their Power to Empower

By Diane Byrum, RN, MSN, CCRN, CCNS,
and Jodi E. Mullen, RNC, MS, CCNS, CCRN
Advanced Practice Work Group

Power is a word that evokes both positive and negative emotions in nurses. It can be used to inspire greatness and motivate positive performance, or it can be used to finitely control behavior and demean a nurse’s self-concept.

Among the many definitions for this word is “the capacity to perform and act effectively.” It’s the one that APNs use on a daily basis to promote safe, effective, evidence-based practice.

Influencing bedside nursing practice through formal and informal power structures empowers those at the grassroots level to take interest in their own profession. Empowerment is a generally positive word that implies choice, independence and integrity. Empowerment enables, equips or supplies a nurse with the knowledge and information needed to take control of themselves and their profession to positively impact patient outcomes.

On a daily basis, nurses perform as patient advocates to effectively care for their patients. They exercise both formal and informal types of power at the bedside. Power to control what nursing care the patient receives, power to make clinical judgments about patients’ conditions, and power through knowledge and experience to influence decisions of other disciplines that positively affect patient outcomes. The table describes the types of formal and informal power and how it is expressed.

Because of their job positions and advanced training, APNs are in a unique position to use both formal and informal power to effect positive practice changes for patients and families. The APN will act as a change agent by assessing the need for change, researching best practice standards, dispersing this information to key positions that make change or will be directly involved in the change, and supporting the change process.

The types of power mentioned previously position the APN at the center of practice changes (Figure).

The APN is able to obtain and disperse information to administrators, physicians and nurses. By using expert power, the APN also has the ability to network with key stakeholders and influence decisions about changes. When working with patients and families, the APN utilizes expert-connection power to empower them to make informed decisions. The APN may exert more influence in this situation. However, the patient and family provide the APN with information that contributes to mutually agreed upon goals and outcomes. Finally, the APN empowers the staff nurse to make informed patient care decisions by obtaining and providing information and education which impact patient an family outcomes.

Following is an example of how an APN might utilize power to effect a change in practice:

Though a variety of sources, including physicians, nurses, journal articles and networking, the APN has identified a need for tighter glycemic control in critically ill patients. The APN surveys the current research and networks with other institutions to investigate protocols, successes and pitfalls. This information is dispersed to physicians, administrators and nurses. Next, the APN would begin development of glycemic protocols involving physicians, staff nurses, pharmacists and dieticians. A study would need to be conducted to assess the current glycemic control for critically ill patients. The APN would pilot the new protocol and then conduct a comparison study.

During this entire process, the APN communicates information regarding current practice as well as the results of utilization of the new protocol for glycemic control. The physician and nurse are interested in the effects of the new protocols on improving patient outcomes, while administrators are interested in the effect on length of stay and cost of care. The APN can be successful in changing the practice of glycemic control that not only saves hospital days and expenses but also, more importantly, improves patient outcomes. The facilitation of empowerment and the use of power for the APN are not to control, but to guide administrators, physicians, nurses, patients and families, and other colleagues to create “a healthcare system driven by the needs of patients and families where critical care nurses make their optimal contribution.”

Note: Special thanks to Kim Blount, RN, MSN, CCRN, cardiovascular clinical nurse specialist, Carolinas Medical Center, Charlotte, N.C., for assisting with the article.

1. Heineken J, Wozniak DA. Power perceptions of nurse managerial personnel. West J Nurse Res. 1998;10(5):591-599.
2. Roberts DW, Vasquez E. Power: an application to the nursing image and advanced practice. AACN Clin Issues Crit Care Nurse. 2004;15(2):196-204.

Task Force to Develop Scope and Standards for ACNPs

Appointments to the Acute Care Nurse Practitioner Scope and Standards Task Force have been announced. This group is charged with developing the Acute Care Nurse Practitioner Scope and Standards document.

Many of the group members were selected from the pool of volunteers registering in AACN’s just-in-time Volunteer Profile Database online. Following are the volunteers who will participate as members of the task force this year:

Deborah E. Becker, RN, MSN, APRN-BC, CRNP, (chair)
Carol J. Bickford, RN, PhD, BC
Deborah L. Bingaman, RN, MS, CCNS, CPNP
Denise Buonocore, RN, CCRN, APRN-BC
Mary E. Holtschneider, RN, BSN, MPA, EMT (board liaison)
Jill N. Howie, RN, NP
Marilyn P. Hravnak, RN, PHD, CCRN, APRN-BC
Joan E. King, RN, PHD, ACNP
Sheila Melander, RN, DNS, APRN, ACNP
Jacqueline Rhoads, RN, PhD, ACNP-BC, ANP-C, CCRN
Kitty Werner, MPA

Bickford and Werner were invited to join the task force as representatives of the American Nurses Association and National Organization of Nurse Practitioner Faculties, respectively.

Public Policy Update

Healthcare Agenda Not Expected to Change
President Bush is expected to continue to push his healthcare agenda of capping medical malpractice awards, and expanding health savings accounts and association health plans during his second term. With the exception of campaign remarks suggesting that individuals be allowed to buy health insurance across state lines, Bush has not revealed any new health policies. In the end, analysts say healthcare was not a major issue with voters.

Although Congress has passed some major legislation this year, a huge stack of unfinished business and “dead” bills related to healthcare and other issues remained when the largely divided 108th Congress adjourned. The Republican majorities in the House and Senate, the Nov. 2 election and the ideological divide between the more conservative House and more centrist Senate combined to produce a stalemate on legislation to address prescription drug costs and a number of other issues. For example, initiatives that would have capped damages in medical malpractice lawsuits and allowed U.S. residents to purchase lower-cost prescription drugs from abroad both failed to win approval. The House also blocked a Senate proposal to allow the FDA to regulate tobacco, and lengthy negotiations regarding legislation to establish a trust fund to compensate individuals with asbestos-related illnesses failed to produce an agreement.

Among other major issues left for the next Congress to consider are bills that would limit class-action lawsuits and medical liability claims and bills on asbestos compensation and patient’s rights.

Voters Decide Policy Issues
The American electorate that narrowly divided in the 2004 presidential race swung many ways on a raft of ballot initiatives, ranging from legalizing marijuana in three states to banning same-sex marriage in 11. Voters in 34 states weighed in on a total of 163 local referenda and ballot initiatives. Among hot-button issues were several related to healthcare:
• California voters approved a groundbreaking measure that earmarks $3 billion for embryonic stem cell research. The adoption of California’s Proposition 71 by a margin of 59% to 41% to allocate state bonds over 10 years for the research puts the state at loggerheads with President Bush.
• Voters in Alaska, Montana and Oregon addressed the use of marijuana. Alaska residents defeated a measure to legalize possession, sale and cultivation of marijuana by anyone older than 21. The measure would have allowed the weed to be regulated like alcohol or tobacco. Montana became the ninth state to allow use of marijuana by patients whose doctors have prescribed it for various medical ailments, but Oregon rejected an initiative that would have dramatically expanded its existing medical marijuana program.
• On tort reform, results were mixed in Nevada, Wyoming, Oregon and Florida on medical malpractice measures. Florida voters passed a package of measures that would limit lawsuits and cap noneconomic damages. Nevada voters approved caps on no-economic damages, but caps were defeated in Wyoming.
• Voters in several states approved increases in state taxes on tobacco products to generate extra revenue for healthcare programs and initiatives. In Oklahoma, voters passed a 55-cent per pack increase on cigarettes, along with other tobacco tax increases, to help extend health coverage to the uninsured, increase Medicaid funding, and support emergency care and cancer research. The measure is expected to bring an additional $234 million per year in state and federal matching funds for Medicaid. In Colorado, a 64-cent per pack increase on state cigarette taxes and a doubling of taxes on other tobacco products is expected to raise an estimated $175 million annually for smoking prevention and other healthcare programs, including $80 million to expand the State Children’s Health Insurance Program.

ED Patients Won’t Have to Give U.S. Status
The Bush administration is backing off plans to require hospitals to ask emergency department patients their immigration status. Hospitals and advocates for immigrants had protested that the move would make people afraid to seek care and lead to serious public health problems.

Last year’s Medicare prescription drug law includes $1 billion over four years for hospitals that treat undocumented immigrants and absorb most of the cost of that care. A proposal developed over the summer would have required hospitals to ask about citizenship and how people entered the country to ensure that the new federal money was being spent on emergency services for undocumented aliens.

Mark McClellan, administrator of the federal Centers for Medicare and Medicaid Services, said that the public health concerns helped lead him to decide to determine eligibility in other ways. “As a result of these pending changes, providers will not be asked—and should not ask—about a patient’s citizenship status in order to receive payment under this program,” McClellan said in a letter to hospital and advocacy groups. Among the suggestions made to the administration was to collect documentation, such as Social Security numbers and foreign driver licenses that would indicate immigration status. McClellan said new rules would be issued soon.
California, Texas, Arizona, New York, Illinois and Florida are in line for the largest shares of the money. Federal law requires hospitals to care for anyone who walks through their doors. The costs of such care have forced many hospitals, especially those in border communities, to close their doors or reduce service. The House rejected legislation proposed by Rep. Dana Rohrabacher, R-Calif., in May that would have explicitly required hospitals to determine immigration status, leading to deportation proceedings against people in the country illegally.

New VA Nurses’ Contract Sets Standard
Members of the United American Nurses, AFL-CIO, who work in 21 Veterans Affairs facilities across the country, have overwhelmingly approved a new contract that sets the standard for RNs in the federal sector. UAN, the largest nationwide RN union, represents 6,000 registered nurses in the VA system. The new national master agreement covers all UAN RNs. Additional facility-specific issues will be negotiated at the local level.

The contract term is three years, commencing upon approval by the undersecretary for health for the VA. The contract, which was ratified by 97% of nurses voting, includes landmark health and safety language that requires the use of mechanical lift devices, latex minimization, work environment security, and yearly health and safety training for all RNs.

Nurses will have expanded input into decision making on issues, such as staffing methodologies and quality improvement boards. Under the new agreement, nurses who blow the whistle on unsafe patient practices may now file objections to assignments and are protected from retaliation by new patient safety incident reporting procedures. Nurses also made strides in securing fair and timely proficiencies, which are a key component to advancement in the VA system, and the right to promotion reconsideration.

Columbia Nursing School Proposes Universal Healthcare Plan
According to a report released by Columbia School of Nursing, an essential health benefit plan could be made available to all Americans, including the more than 43 million uninsured, for an annual premium of $2,000. The plan is modeled on the success of advanced practice nurses in New York City who have provided independent primary care to patients for more than 10 years. Featured in the September/October issue of Nursing Economics, “Essential Health Care: Affordable for All?” characterizes the growing lack of access to affordable care as a national crisis and details a plan for attacking this problem by providing essential services that cover the medical needs most relevant to the current demographics of the uninsured population.

New Drugs and Therapies Fueling Rising Healthcare Costs
The nation’s healthcare bill is high and headed higher. Yet, most hospitals lose money or barely break even. Doctors complain they are getting squeezed. Employers bemoan rising healthcare costs as a threat to global competitiveness.

Despite these problems, new innovations and better methods of treatment extend patients’ lives and fuel demand for better healthcare. Some say these potentially life-saving innovations are the prime reason for rising healthcare costs. For example, drug-coated stents that prevent cleared arteries from clogging again cost $2,500 each, but are an improvement over the noncoated stents that cost $1,000. In addition, approximately 40% of the extended life expectancy in 52 countries is attributable to new drugs, but these pharmaceuticals have come at a cost of about $5,000 per person, according to economist Frank Lichtenberg.

The American healthcare bill, the government estimates, will be $1.79 trillion this year, or $6,167 per person. By all accounts, there is plenty of waste and inefficiency in healthcare, ranging from unnecessary clinical tests to the bureaucratic sea of paper used to handle bills, claims and patient records say analysts. Healthcare economists estimate that ridding the system of such inefficiencies would reduce total healthcare costs by 10% to 20%. But the main reason healthcare spending is rising is that modern medical technology has steadily made it possible to do more for more people. Although innovation in the healthcare industry comes at a cost, most observers agree that the benefits of new drugs and life-saving devices far outweigh the costs.

(Source: Steve Lohr, “Health Care Costs Are a Killer, but Maybe That’s a Plus,” New York Times, September 26, 2004. Frank R. Lichtenberg, “The Impact of New Drug Launches on Longevity: Evidence From Longitudinal Disease-Level Data from 52 Countries: 1982-2001,” National Bureau of Economic Research, June 2003.)

Overtime Regulations Revised
The new overtime regulations, which went into effect Aug. 23, are the Department of Labor’s most significant revision to the way time-and-a-half pay is calculated. Part of the Fair Labor Standards Act, the rules are designed to help employers determine which workers are eligible for overtime. Debate has raged over the revisions since they were proposed a year ago. Labor experts say it may take months or years before the regulations are fully understood and enforced.
Stating the Facts

New Jersey: Background Checks Urged
Healthcare institutions must tell prospective employers about problem employees, including physicians and nurses, and criminal background checks of healthcare workers would be required for license renewals, under a bill making its way through the New Jersey State Legislature.

The impetus for the legislation was the spate of killings by Charles Cullen, a nurse who moved easily among New Jersey and Pennsylvania hospitals, in part because of employer silence. But the bill will also help identify poorly performing professionals so they can receive the education and training they need, said Sen. Joseph Vitale, D-Middlesex, chairman of the state Senate Health Committee and a bill sponsor.

The bill passed the Senate late last month and is now in the Assembly. Healthcare facilities would also be required to report to the state Division of Consumer Affairs instances when healthcare professionals are discharged, had privileges revoked or had limits placed on their duties, because of impairment, misconduct or incompetence.

Information must also be reported if the employee voluntarily resigns while under review by the institution. Besides nurses and physicians, the measure would apply to all healthcare professionals regulated by state boards, such as medical examiners, dentists, optometrists, pharmacists, chiropractors, therapists, veterinarians and nurses aides.

Currently, a nurse must pass a criminal background check only when first receiving a license. The bill would require a check also when the license is renewed—every two years for nurses—a provision that received “complete agreement across the board” from hospitals and other stakeholders, Vitale said. The licensee will be responsible for paying for the background check. Negotiations on the bill included all the stakeholders, such as representatives from nursing and hospital associations, labor unions, the state Attorney General’s Office and the state Department of Health.

Vitale plans to introduce a companion bill early next year that would create a database with start and end dates and place of employment for healthcare professionals. The information would make it difficult for someone to create employment gaps on a resume to omit a job where they caused problems.

California: DHS Issues Emergency Regulations to Delay Nurse Staffing Rules
The California Nurses Association condemned a decision by Gov. Arnold Schwarzenegger to suspend major provisions of California’s law requiring safe registered nurse-to-patient staffing ratios. Under California’s rules for emergency regulations, Schwarzenegger has the authority to suspend laws or regulations for up to 120 days, subject to approval by the state’s Office of Administrative Law. However, the law permits extensions beyond the 120 days. CNA said it was taking its own emergency actions in response to the announcement, including a mobilization at the Governor’s Office at the Capitol on Dec. 1, one month before the improved ratios in Medical and Surgical units were scheduled to go into effect.

In 2003, the state’s Department of Health Services announced the regulations to implement a law signed in 1999 by former Gov. Gray Davis that was intended to increase patient safety and ease the state’s nursing shortage by improving working conditions. Under the new rules—the first such guidelines in the nation—a nurse will not have to care for more than eight patients at a time. One part of the rules that lowered to six the number of patients each nurse in medical-surgical units could be assigned was implemented on Jan. 1, 2004.

Under the regulations announced in 2003, the nurse-to-patient ratio for medical-surgical units was scheduled to be lowered to 1 to 5 by Jan. 1, 2005. In addition, the regulations stated that licensed vocational nurses could comprise no more than 50% of the licensed nurses assigned to patient care and that only registered nurses could care for critical trauma patients. The rules also required at least one triage nurse in an emergency department to be a registered nurse. In addition, the rules said that nurses in telemetry and step-down units could care for no more than three patients at a time by 2008.

Under the proposed changes, DHS would delay until at least January 2008 lowering the nurse-to-patient ratio in medical-surgical units to 1-to-5. DHS also would give hospitals the option of temporarily suspending compliance with staffing ratios for emergency departments—currently set at 1-to-4—in case of an “unforeseeable influx” of patients. In addition, the proposed changes would reverse a requirement stipulating that hospitals must replace nurses on bathroom breaks. Under the proposed changes, nurses would be considered on duty during bathroom breaks or while making telephone calls if they are physically located in the unit.

The proposed changes were submitted to the Office of Administrative Law, which was expected to approve them. A public hearing on the changes likely will be held in mid-January. The proposal also would move up the deadline for a planned study of the effect of the state’s nurse staffing requirements to make results available to DHS by early 2007.

DHS officials said they believed it was urgent to revise the new rules after 11 hospitals cited the staffing requirements as contributing to facility closures or service reductions. The California Healthcare Association estimates that 85% of hospitals in the state currently do not meet the existing nurse-to-patient ratio requirements. State officials said that hospitals that have complied with the new ratios have had to turn away ambulances, leave beds empty and reduce support-staffing levels to make funds available for nurse salaries. DHS decided to delay the new ratios until 2008 so that officials could perform a two-year study to ensure the requirements do not have unintended consequences.

Florida: Patients’ Rights Amendment Passed
Patients now have the right to review, upon request, records of healthcare facilities’ or providers’ adverse medical incidents, including those that could cause injury or death. The amendment to the state constitution provides that patients’ identities should not be disclosed. Current Florida law restricts information available to patients related to investigations of adverse medical incidents, such as medical malpractice.

Public Policy Snapshot
Pondering stem cell research

The controversy over stem cell research has touched almost every statehouse in the country. More than 30 bills that address some form of stem cell research are currently under consideration at the state level, and Congress is reviewing six more. The map below shows which states (in greent) have stem cell bills pending in the Legislature.

Note: Of the states shown below, almost half are out of regular session for 2004.

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

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AACN Action Alerts provide strategic information to all those who wish to affect key policy issues of interest to critical care nurses. If you would like to receive future Alerts, register at the Legislative Action Center Online. Click on Action E-List at the bottom of the page.
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