AACN News—March 2004—Opinions

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Vol. 21, No. 3, MARCH 2004


President's Note

Rising Above: New Questions, New Opportunities
Cutting Through the Fog

By Dorrie Fontaine, RN, DNSc, FAAN
President, AACN

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 pneumonia.

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 Dorrie.Fontaine@aacn.org. 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.
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Letters

�Being With� an Experience to Cherish
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 healthcare professionals.

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
Naperville, Ill.

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 boat.

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

Your opinions are important! Share them with others by contributing to the printed dialogue each month in AACN News. Send your �Letters� to: AACN News, 101 Columbia, Aliso Viejo, CA 92656; fax, (949) 362-2049; e-mail, aacnnews@aacn.org. AACN News reserves the right to edit letters for style, clarity and space.