Rising Above: New Questions, New
Cutting Through the Fog
By Dorrie Fontaine, RN, DNSc, FAAN
Yoga class is a whole new experience for me. I
signed up when I decided it would be good to stretch my body just like I�m
stretching my mind during this year as president. It�s not always clear which
challenge is tougher. In comparing notes with a recently graduated nurse who
sits next to me, I found that we both included reducing stress and flexibility
among our goals for the class.
The familiar San Francisco fog was creeping in as,
hamstrings stretched, I walked home one evening. Before long, I would see only
the top of the Golden Gate Bridge from my street corner. The next morning, I
probably would hear the familiar foghorn, two miles away in the Pacific. Some
think the foghorn too loud. Others think it romantic. Whatever the perception,
it alerts ships to danger�land, bridges, rocks.
Inevitably, my thinking started to stretch, nudging
me into that familiar questioning zone you share with me in these monthly
�notes.� That zone where we view the familiar from another vantage point, where
we rise above to consider the new opportunities prompted by our new questions. I
thought about the new AACN Practice Alerts online resource that AACN launched
last month. In doing so, AACN took another bold step to circulate the latest
evidence about burning clinical practice questions that builds on the success of
AACN�s highly regarded research-based practice protocols.
How often do we practice in the fog because we
literally don�t know what is the best practice? Recently, the respected
nurse-physician editor team of the American Journal of Critical Care called for
more user-friendly means of disseminating information. (Bryan-Brown C, Dracup K.
Evidence-based pandemonium. Am J Crit Care. 2004;13:10-12).
�How can we get information we really need to care
for our patients?� they asked. Think aspirin and beta blockers for cardiac
patients, for example. It has taken an astounding 15 years for solid evidence
about their efficacy to diffuse into accepted practice.
Practice alerts are clinical foghorns. They shout:
Based on the best evidence available, here is a clinical practice you must adopt
or risk the equivalent of running a patient aground, causing undue harm.
Practice alerts will cut through foggy practice,
helping 400,000-plus critical care nurses and benefiting tens of thousands of
ventilator patients every year. Practice alerts will set the clinical standard
for every acute and critical care unit, undoubtedly starting with those that
have achieved or are seeking national designation of excellence like AACN�s
Beacon Award for Critical Care Excellence.
When posted in a patient care unit, practice alerts
will boldly declare: The nurses in this unit use the best knowledge available to
care for patients and families. Experienced clinicians will be reassured that
they are providing state-of-the-art care. New graduates will develop greater
confidence knowing they are not inadvertently giving obsolete and unsafe care.
Practice alerts are succinct and dynamic directives.
They address expected practice, supporting evidence, how to make practice
changes, key references and additional information sources. AACN will develop
alerts based on frequency of the practice and the availability of convincing
evidence that points to the need for immediate changes in clinical practice.
Prompted by its increasing prevalence and nationwide requests for practice
protocols and guidelines, the first alert addresses ventilator-associated
Looking ahead�and yes, rising above�practice alerts
will inevitably prompt new questions. Questions like: What high-risk clinical
activities are done with little or no evidence of their efficacy? Asking the
question is the first step in finding the evidence. As a clinician, you are in
the best position to raise the questions. As an advanced practice nurse, you are
in the best position to guide the search for answers. As a manager, you are in
the best position to partner with clinicians and advanced practice nurses to
ensure that the answers become the norm for excellent care.
Ritual practice. Foggy practice. New graduates.
Stress. Foghorns. Alerts. Flexibility. Evidence-based practice. Practice alerts
influence every one of these. Ultimately, they prompt new questions and offer
new opportunities for answers.
Does your practice include high-risk clinical
activities with little or no evidence of their efficacy? Send me your answer at
It could become the basis for a future practice alert.
p.s. I want to especially acknowledge members of the
2003-04 Research Work Group who developed the AACN Practice Alert service:
Marianne Chulay, RN, DNSc, FAAN (chair), Caryl Goodyear-Bruch, RN, MSN, CCRN
(board liaison), Mary Jo Grap, RN, PhD, ACNP, Linda Henry, RN, MS, CCRN, Cheryl
McKay, RN, MSN, CCNS, Jessica Palmer, RN, MS, MSN, Maurita Soukup, RN, DNSc, BS,
Murray Speers, RN, BSN, CCRN, and staff liaisons Debbie Barnes, RN, MS, MSN,
CCRN, clinical practice specialist, and Justine Medina, RN, MS, MSN, practice
and research director.
�Being With� an Experience to
By the time I finished reading the �President�s
Note� column (AACN News, February 2004), I knew that I have �been with� many
times during my 30-plus years in critical care.
I learned from some kind and insightful doctors,
from professional education, and from the ethicist who chaired the hospital
ethics committee that I was privileged to serve with. But, I also learned much
from the patients themselves and from their families, as well as other
It wasn�t easy to �be with,� but once I experienced
the awesome fulfillment that comes from serving patients and families in this
role, I will always remember these cases along with the most remarkable �saves�
that we had.
As I finished grad school in 1985, I asked to write
my comps on the right to die by forgoing treatment. It was not an everyday topic
then, and I was first denied that subject. It took some convincing, but I forged
ahead. There wasn�t much in the literature about end-of-life care, terminal
weaning or withdrawal, or futile care.
In 1995 I was forced to leave my clinical specialist
role after discussing with the son of an 80-year-old postop CABG patient who was
on life support after a CVA, how his father�s wishes not to be kept alive on
machines could be honored. He presented his father�s power of attorney for
healthcare and asked for a terminal wean. I do not for a minute regret �being
with� this patient and his son as they had their final hours together.
I hope every nurse can experience the satisfaction
that comes from �being with.�
Lynn Cannon, RN, MS
Everyone Needs to Work Together
After reading the �President�s Note� column (AACN
News, January 2004), I wanted to share my own experiences and how they have
affected me deeply.
In my first 13 years as a critical care nurse, I was
fortunate to have worked in primarily collaborative and patient-focused
environments. I have been respected by my peers and the physicians, spoken at
local conferences and continued over the years to further my education.
However, I was not prepared for my last two years. I
am now moving to the operating room, because I am ready to leave administrative
work and get back to patient work. I have learned a lot, and if I were in the
same spot again, there are things I would do differently.
For collaboration to work, everyone needs to work
together�to know the plan and agree to work toward the goal. There may be
several ways to reach the goal. Support the individuals and their uniqueness and
strengths, but also remember there is a learning curve. Take punishment out of
the equation and build trust, respect and caring for one another. Set up systems
that evaluate and solve the mistakes. If there is the human factor, make a plan
to help the nurse learn and grow. We need all of our critical care nurses.
Manipulating the system and going for personal, underlying agendas can rock the
In response to your questions I would like to say
that nurses know what patient-focused collaborative care is and seek it out.
Nurses need to able to take the risk and adventure at all levels (bedside to
administration) that go with collaboration and not have to be looking over their
shoulders. The language is out there. The concepts are out there. We need to go
out there and just do it.
Deborah Moulton, RN, CCRN
South Portland, Maine
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