AACN News—November 2004—Practice

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Vol. 21, No. 11, NOVEMBER 2004


Practice Alert: Family Presence During CPR and Invasive Procedures

Expected Practice:
p Family members* of all patients undergoing CPR and invasive procedures should be given the option of being present at the bedside.
p All patient care units should have an approved written practice document (i.e., policy, procedure or standard of care) for presenting the option of family presence during CPR and bedside invasive procedures.
—Family members are those individuals who are relatives or significant others with whom the patient shares an established relationship.

Supporting Evidence:
p Research1-8 and public opinion polls9-10 have found that 60% to 80% of consumers believe that family members should be allowed to be present during emergency procedures and at the time of their loved one’s death.
p Despite support by professional organizations and critical care experts,11-17 only 5% of critical care units in the U.S. have written policies allowing family presence.18 Surveys of nurses’ practice have found that most critical care nurses have been requested by family members to be present during CPR and invasive procedures and have brought families to the bedside, despite the lack of formal hospital policies.18
p Studies have found the following benefits of family presence:
—For patients: Almost all children want to have their parents present during healthcare procedures;19-24 children believe that parental presence was the most beneficial intervention in managing their pain;21 and adult patients report that having family members at the bedside comforted and helped them.25.26
—For family members: Being present helped family members in removing doubt about the patient’s condition and witnessing that everything possible was being done;1,3,8,26-30 decreasing their anxiety and fear about what was happening to their loved one;19,26,31,32 facilitating their need to be together1,3 and the need to help and support their loved one;2,3,5,8,28,29,31,32 and experiencing a sense of closure3,29 and facilitating the grief process should death occur.2,6,26-31
p Studies have found that 94% to 100% of families involved in family presence would do so again.3,8,28,31
p Studies have found no patient care disruptions, no negative outcomes during family presence events,3,5,8,19,26-29 and no adverse psychological effects among family members who participated at the bedside.3,8,26

What You Should Do:
p Ensure that your healthcare facility has written policies and procedures that support family presence during CPR and invasive procedures.
p Policies and procedures and educational programs for professional staff should include the following components:
—Benefits of family presence for the patient and family11
—Criteria for assessing the family to ensure uninterrupted patient care.3,8,11,15,33
—Role of the family facilitator in preparing families to be present at the bedside and supporting them before, during, and after the event, including handling the development of untoward reactions by family members.11,33,34 Family facilitators may include nurses, physicians, social workers, chaplains, child life specialists, respiratory care practitioners, family therapists and nursing students.11,15,34
—Support for patient’s or family members’ decision not to have family members present.1
—Contraindications to family presence (i.e., family members who demonstrate combative or violent behaviors; uncontrolled emotional outbursts; behaviors consistent with an altered mental state from drugs or alcohol; or those suspected of abuse)3,8,11,15,33
p Develop proficiency standards for all staff involved in family presence to ensure patient, family and staff safety.
p Determine your unit’s rate of compliance in offering families the option of family presence during CPR and invasive procedures.
p If compliance is <90%, develop a plan to improve compliance:
—Consider forming a multidisciplinary task force (i.e., nurses, physicians, chaplains, social workers, child life specialists) or a unit core group of staff to discuss approaches to improve compliance.
—Re-educate staff about family presence and discuss the intervention as a component of evidence-based practice.
—Incorporate content into orientation programs as well as initial and annual competency verifications.
—Develop a variety of communication strategies to alert and remind staff about the family presence option.
—Develop documentation guidelines for family presence and include rationale for when family presence would not be offered as an option to family members.

Need More Information or Help?
p Call the AACN Practice Resource Network at (800) 394-5995, ext. 217. Practice Alerts are online.
p The guidelines for Presenting the Option of Family Presence11 during CPR and invasive procedures, developed by the Emergency Nurses Association and endorsed by AACN, are suitable for adaptation to critical care units and include educational slides and handouts, a family presence department assessment tool, a staff assessment tool, an educational needs assessment tool, a sample family presence guideline and other supporting documents. This resource (Product #120632) is available online or by calling (800) 899-2226.
p AACN endorses the American College of Chest Physician’s Critical Care Family Assistance Program. This toolkit empowers you and your team to create a family-friendly critical care environment at your hospital. This resource (Product #120631) is available online or by calling (800) 899-2226.

References
1. Bauchner H, Waring C, Vinci R. Parental presence during procedures in an emergency room: results from 50 observations. Pediatrics. 1991;87:544-548.
2. Sacchetti A, Lichenstein R, Carraccio CA, et al. Family member presence during pediatric emergency department procedures. Pediatr Emerg Care. 1996;12:268-271.
3. Meyers TA, Eichhorn DJ, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation: the experiences of family members, nurses, and physicians. Am J Nurs. 2000;100(2):32-42.
4. Taylor N, Bonilla L, Silver P, Sagy M. Pediatric procedures: do parents want to be present? Crit Care Med. 1996;24(suppl):131.
5. Bauchner H, Vinci R, Bak S, Pearson C, Corwin M. Parents and procedures: a randomized controlled trial. Pediatrics. 1996;98:861-867.
6. Meyers TA, Eichhorn DJ, Guzzetta CE. Do families want to be present during CPR? A retrospective survey. J Emerg Nurs. 1998;24:400-405.
7. Boie ET, Moore GP, Brommett C, Nelson DR. Do parents want to be present during invasive procedures performed on their children in the emergency department? A survey of 400 parents. Ann Emerg Med. 1999;34(1):70-74.
8. Mangurten J, Owens J, Vinson L, et al. Family presence during resuscitation interventions and invasive procedures in a pediatric emergency department: attitudes and experiences of healthcare providers and family members. Unpublished data. Dallas, Tex: Children’s Medical Center of Dallas; 2004.
9. NBC Dateline Poll. Should family members of patients be allowed in the emergency department during emergency procedures? Available at: http://www.nbc.com. Accessed August 17, 1999.
10. USA Today Poll. Would you want to be in the emergency department while doctors worked on a family member? USA Today. Available at: http://www.USATODAY.com. Accessed March 7, 2000.
11. Emergency Nurses Association. Presenting the Option of Family Presence. 2nd ed. Des Plaines, Ill: Emergency Nurses Association; 2001.
12. Jacobs BB, Hoyt KS, eds. Trauma Nursing Core Course: Provider Manual. 5th ed. Park Ridge, Ill: Emergency Nurses Association; 2000.
13. Eckle N, Haley K, Baker P, eds. Emergency Nursing Pediatric Course: Provider Manual. 2nd ed. Park Ridge, Ill: Emergency Nurses Association; 1998.
14. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: 7D: the tachycardia algorithms. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000;102(8 Suppl):I158-I165.
15. Clark AP, Aldridge MD, Guzzetta CE, et al. Family presence during cardiopulmonary resuscitation. Crit Care Nurs Clin N Am. In press.
16. Guzzetta CE. Critical care research: weaving a body-mind-spirit tapestry. Am J Crit Care. 2004;13:320-327.
http://community.nursingspectrum.com/MagazineArticles/article.cfm?AID=11204. Accessed October 12, 2004.
18. MacLean SL, Guzzetta CE, White C, et al. Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses. Am J Crit Care. 2003;12:246-257.
19. Wolfram RW, Turner ED. Effects of parental presence during children’s venipuncture. Academic Emerg Med. 1996;3(1):58-63.
20. Gonzalez JC, Routh DK, Saab PG, et al. Effects of parent presence on children’s reactions to injections: behavioral, physiological, and subjective aspects. J Pediatr Psychol. 1989;14:449-462.
21. Jerrett MD. Children and their pain. Child Health Care. 1985;14(2):83-89.
22. Ross DM, Ross SA. A study of the pain experience in children. Final report. Bethesda, Md: National Institute of Child Health and Human Development; 1984. Ref No 1 R01 HD 13672-01.
23. Fiorentini SE. Evaluation of a new program: pediatric parental visitation in the postanesthesia care unit. J Post Anesth Nurs. 1993;8:249-256.
24. Diniaco MU, Ingoldsby BB. Parental presence in the recovery room. AORN Journal. 1983;38:685-693.
25. Eichhorn DJ, Meyers TA, Guzzetta CE, et al. Family presence during invasive procedures and resuscitation: hearing the voice of the patient. Am J Nurs. 2001;101(5):26-33.
26. Robinson SM, Mackenzie-Ross S, Campbell-Hewson GL, et al. Psychological effect of witnessed resuscitation on bereaved relatives. Lancet. 1998;352:614-617.
27. Anderson B, McCall E, Leversha A, et al. A review of children’s dying in a paediatric intensive care unit. N Z Med J. 1985;107:345-347.
28. Doyle CJ, Post H, Burney RE, et al. Family participation during resuscitation: an option. Ann Emerg Med. 1987;16:673-675.
29. Hanson C, Strawser D. Family presence during cardiopulmonary resuscitation: Foote Hospital emergency department’s nine-year perspective. J Emerg Nurs. 1992;18:104-106.
30. Timmermans S. High touch in high tech: the presence of relatives and friends during resuscitation efforts. Scholarly Inq Nurs Pract. 1997;11:153-168.
31. Powers KS, Rubenstein JS. Family presence during invasive procedures in the pediatric intensive care unit. Arch Pediatr Adolesc Med. 1999;153:955-958.
32. Shapira M, Tamir A. Presence of family members during upper endoscopy. J Clin Gastroenterol. 1996;22:272-274.
33. Mangurten J, Scott SH, Guzzetta CE, et al. Changing conventional practice: implementing family presence during resuscitation interventions and invasive procedures. Am J Nurs. In press.
34. Clark AP, Calvin AO, Meyers TA, Eichhorn DJ, Guzzetta CE. Family presence during cardiopulmonary resuscitation and invasive procedures: a research-based intervention. Crit Care Nurs Clin N Am. 2001;13:569-575.


Practice Alerts: Live Your Contribution With Competence

By Cathy J. Thompson, RN, PhD, CNS, Patricia A. Daansen, RN, BSN, CCRN, and Mary Lou Sole, RN, PhD, CCNS, FAAN
AACN Research Work Group

Because critical care nurses are challenged by the realities of overwhelming research evidence, AACN has developed tools to help them ensure that their practice is research-based. In keeping with President Kathy McCauley’s charge to “Live Your Contribution,” AACN’s Practice Alerts are designed to “help nurses and other healthcare practitioners carry their bold voices to the bedside to directly impact patient care. AACN believes that using the best evidence available is ethically imperative in practice—and now we are providing the tools to do that.

Initiated by the 2003-04 Research Work Group, the Practice Alerts are intended to:
• Close the research/practice gap.
• Provide guidance for research-based patient care.
• Standardize bedside practice.
• Disseminate information about new advances and trends.

The Practice Alerts are concise translations of the scientific evidence presently available in the literature, the “bottom-line” for research-based practice. They consist of “Expected Practice” statements, “Supporting Evidence” for the recommendations, “What You Should Do” to implement the practices and “References.” You can find existing Practice Alerts online. The following Practice Alerts that should be a part of your practice are currently available:
• Ventilator-Associated Pneumonia
• Pulmonary Artery Pressure Monitoring
• Dysrhythmia Monitoring
• ST-Segment Monitoring
• Family Presence During Resuscitation (See page 4.)

Building on the work of the prior group, the 2004-05 Research Work Group is identifying the opportunities for additional Practice Alerts, as well as resources to implement and evaluate their use. Plans are to add a section on how to implement the practice with diverse populations, such as children, neonates and the elderly, or under special conditions, when appropriate. Topics the work group has identified for dissemination include:
• Prevention of Deep Vein Thrombosis
• Prevention of Central Line Blood Stream Infections
• Blue Dye in Tube Feedings
• Tube Feeding Placement and Residuals
• Use of Therapeutic Beds

Each of the Practice Alerts will now include an audit tool, which will assist in evaluating implementation of the Practice Alerts’ research-based recommendations. These tools have been developed for existing alerts and are now available on the Web site. In addition, a PowerPoint presentation, specific to each alert, will be available for downloading for staff and continuing education credit. There is no charge to use the Practice Alerts or the online resources that accompany them.

Complete the AACN Practice Alert Survey

The Research Work Group was also charged with evaluating the impact of the Practice Alerts in the clinical setting. To meet this goal, a brief follow-up survey has been developed. We invite you to help us in this endeavor by completing the survey online. Your feedback is invaluable in helping AACN provide quality resources to influence excellence in critical care nursing practice.


Members of the Research Work Group for 2004-05 are (from left)
Joanne M. Kuszaj, Patricia A. Daansen, Janie Heath (AACN board liaison),
Deborah Barnes (staff liaison), Cathy J. Thompson, Sherill A. Cronin,
Christine L. Schulman, Susan B. Fowler and Mary Lou Sole (chair).


Grants

Clinical Inquiry Grant
Five 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
One award of up to $500 is available 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.

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 available online. The application deadline is Feb. 1.

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.

Family Presence in the Acute or Critical Care Unit
This one-time $5,000 grant supports research focusing on family presence in the acute and critical care unit. Research topics can include, but are not limited to:
• Family presence during procedures and/or resuscitation
• Open/negotiated visitation, including pets and children
• Family-centered care concepts
• Implementation and evaluation of the Critical Care Assistance Program
Applications are due Feb. 1.

Evidence-Based Clinical Practice Grant
Three awards of up to $1,000 each are available 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 Web site or e-mail research@aacn.org.


Distinguished Research Lecturer Nominations Due Dec. 1

Dec. 1 is the deadline to submit nominations for the Distinguished Research Lecturer Award for 2006. The recipient will present the Distinguished Research Lecture at the 2006 NTI in Anaheim, Calif. The lecture is sponsored by a grant by Philips Medical Systems.

The recipient for 2006 will be selected in January by the Distinguished Research Lecturer Review Panel. (If you are interested in serving on this panel, please update your Volunteer Profile online.) The awardee receives a $1,000 honorarium and $1,000 toward NTI expenses, as well as a plaque.

The 2006 Distinguished Research Lecturer nomination form is available online. For more information, call (800) 394-5995, ext. 321; e-mail, research@aacn.org.


Nursing Code of Ethics an Important Practice Tool

By Cynda Hylton Rushton, RN, DNSc, FAAN
Chair, Ethics Work Group

As baby boomers age and medical technology advances, the demands and dilemmas of providing critical care intensify. Many patients arriving in the ICU were in good health before suffering unexpected illness or injury. They—and their families—expect their lives to be restored to health. Others arrive in the ICU with chronic, life-threatening conditions requiring skillful balancing of critical care and palliative interventions. They, too, often hope for life-saving or life-improving outcomes.

In the pursuit of a cure, an array of technology for virtually every physiologic system is employed. With the focus on disease, diagnosis and procedures, a
technology-focused model often prevails. In an environment that demands quick decisions and actions, nurses are challenged to maintain the nursing model, with its more holistic focus on the patient and family and the insights it gives on end-of-life decision making.

When a patient initially enters critical care, the threshold for tolerating burdens and complications of treatment to achieve cure or survival may be high. Yet, as nurses provide interventions and witness the patient’s changing condition, they may begin to question whether benefits outweigh burdens and ask, “Why are we doing this?”

If there is no framework for raising and resolving such issues, nurses may feel their professional integrity is threatened. The moral distress that accompanies such feelings adds to the stress inherent in the ICU and impacts quality of patient care and workforce issues.

A Foundation
Aware of the pressures nurses face, AACN has taken bold steps to promote a healthy work environment for critical care nurses and the nursing profession. An important tool is to apply the profession’s Code of Ethics for Nurses to everyday practice. As a foundation for nursing practice, the code explicates professional norms and guides nurses in carrying out their obligations. Yet, few nurses are aware of the contents of the code or the guidance it offers.

Developed by the American Nurses Association, the code consists of nine provisions, each with an interpretive statement.1 Every nurse has an obligation to be familiar with and to practice in accordance with the code and its provisions:
1. The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth and uniqueness of every individual, unrestricted by consideration of social or economic status, personal attributes or the nature of health problems.
2. The nurse’s primary commitment is to the patient, whether an individual, family, group or community.
3. The nurse promotes, advocates for and strives to protect the health, safety and rights of the patient.
4. The nurse is responsible and accountable for individual nursing
practice and determines the appropriate delegation of tasks consistent with the nurse’s obligation to provide optimum patient care.
5. The nurse owes the same duties to self as to others, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth.
6. The nurse participates in establishing, maintaining and improving healthcare environments and conditions of employment conducive to the provision of quality healthcare and consistent with the values of the profession through individual and collective action.
7. The nurse participates in the advancement of the profession through contributions to practice, education, administration and knowledge development.
8. The nurse collaborates with other health professionals and the public in promoting community, national and international efforts to meet health needs.
9. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintain the integrity of the profession and its practice, and for shaping social policy.

No Concrete Answers
These provisions constitute the framework that supports nurses as they practice their profession, whatever the setting. Yet, a code of ethics is not a source of concrete answers.2 “The principles are too broad and must be thoughtfully applied in practice.”3

The Ethics Committee of the Society of Critical Care Medicine acknowledged this need for thoughtful application in presenting its recommendations for end-of-life care in the ICU.4 Noting that “practical aspects of end-of-life care are inseparably wed to many intensely controversial ethical issues,” the committee examined a lengthy list of specific practices, such as using opioid analgesics to ensure the comfort of the patient. “Recommendations such as these,” the committee concluded, “can only attempt to articulate practices that are based on sound ethical reasoning and that are consonant with current cultural and legal norms.”

Thus, nurses are challenged to attain “state-of-the-art” practices, ethically as well as clinically. To aid in this critical task, the ACCN Ethics Work Group will develop a series of articles applying all nine provisions of the code to critical care nursing practice. Watch for these in AACN News and on the AACN Web site.

References
.org/ethics/code/ethicscode150.htm. Accessed on Sept 27, 2003.
2. Aiken, TD, Catalano, JT. Legal, Ethical and Political Issues in Nursing. Philadelphia, Pa: F.A. Davis; 1994.
3. Scanlon C, Glover J. A professional code of ethics: providing a moral compass for turbulent times. Oncol Nurs Forum. 1995;22:1515-1121.
4. Truog RD, et al.Cist AF, Brackett SE, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001;29:2332-2348.

Members of the AACN Ethics Work Group are (from left) John F. Dixon
(board liaison), Denise C. Thornby, Andrea M. Kline, Henry B. Geiter Jr.,
Diane J. Mick, Cynda H. Rushton (chair), Terese Verklan and Teresa
Wavra (staff liaison).


Work Group Examines Needs of Advanced Practice Nurses

By John J Whitcomb, RN, MSN, CCRN
Chair, Advanced Practice Work Group

Initiatives to meet the practice needs of advanced practice nurses in acute and critical care were the focus when the 2004-05 Advanced Practice Work Group met in August in Costa Mesa, Calif.

Specifically, the group is charged with:
• Reviewing and making recommendations for resources to support advanced practice members, including journals, catalog products and Web links.
• Evaluating topics and speaker selections for the Advanced Practice Institute, held in conjunction with AACN’s National Teaching Institute, and providing feedback based on recommendations from the NTI Work Group.
• Developing the API based on gap analysis and reviewing the Call for Abstracts to ensure that advanced clinical topics include a patient management and pharmacology focus.
• Selecting topics and accepting assignments for advanced practice articles to appear in AACN News.

This year’s Advanced Practice Work Group is made up of members selected from a pool of highly talented and accomplished professionals who volunteered to serve. One of the goals for the selection of this year’s group was to ensure a wide range of expertise, representation from different parts of the country and knowledge of both acute pediatric and adult critical care. In addition to Chair Lt. Cmdr. John J. Whitcomb, RN, MSN, CCRN, United States Navy, University of San Diego Hahn School of Nursing and Health Sciences, San Diego, Calif., work group members include Barbara “Bobbi” Leeper, RN, MN, CCRN, FAHA, clinical nurse specialist, Cardiovascular Services, Baylor University Medical Center, Dallas, Texas; Patricia Radovich, RN, MSN, MS, CNS, FCCM, clinical nurse specialist, Hepatology/Transplant, Loma Linda University Medical Center, Loma Linda, Calif.; Laurie Finger, RN, APRN, MN, CCRN, CCNS, clinical nurse specialist, Tulane Hospital for Children, New Orleans, La.; Diane Byrum, RN, MSN, CCRN, CCNS, outcomes manager, Trauma Services, Carolina Medical Center, Charlotte, N.C.; Kelly Thompson-Brazill, RN, MSN, ACNP, nurse practitioner, Trauma and Surgical Critical Care, University Health Systems of Eastern Carolina, Greenville, N.C.; and Marilyn Hravnak, RN, PhD, ACNP-BC, FCCM, assistant professor, School of Nursing, University of Pittsburgh, Pittsburgh, Pa. Jodi Mullen, RNC, MS, CCRN, CCNS, clinical nurse specialist, pediatric ICU, Children’s Medical Center, Dayton, Ohio, is the AACN board liaison, and AACN Clinical Practice Specialist Linda Bell, RN, MSN, is the national office staff liaison.

The group’s agenda targets information sharing, AACN resources and opportunities, and the API curriculum.

Information Sharing
AACN President Kathy McCauley, RN, PhD, BC, FAAN, President-elect Debbie Brinker, RN, MS, MSN, CCNS, CCRN, and CEO Wanda Johanson, RN, MN, met with the group to provide context and inspiration for the upcoming year.

Mullen updated the group on AACN’s priority issues of Healthy Work Environment, Palliative and End-of-Life Care, and Staffing. She noted that AACN was in the process of developing standards defining a Healthy Work Environment. Bell also provided an overview of AACN’s current work in the practice and education areas, including the convening of an ACNP Scope and Standards Task Force.

In addition, the group heard from AACN Public Policy Specialist Janice Weber, RN, MSN, who provided an overview of public policy initiatives. She stressed that resources, such as the Legislative Action Center and State Bill Tracking service, allow nurses to access information about the process and progress of specific legislation. Legislation impacting advanced practice nursing requires individual practitioners to become involved at the state level.

AACN Resources and Opportunities
The group is tasked with critically evaluating available APN resources to determine their relevance and whether they need updating to keep pace with the rapidly changing environment of acute and critical care nursing. Among the resources that are available are:
• AACN Resource Catalog, which contains resources pertaining to educational needs, references, CE opportunities, and patient and family brochures, as well as lectures on tape
• AACN Web site, which offers up-to-date information related to a variety of areas, including chapters, practice issues, public policy issues and membership
• Journals, part of membership fees, including the American Journal of Critical Care and Critical Care Nurse. AACN Clinical Issues: Advanced Practice in Acute and Critical Care is also available to AACN members at a reduced subscription rate
• The API as a forum to share and learn cutting-edge practice, network and discuss issues surrounding advanced practice nursing
• Volunteer opportunities, including serving on a review panel, writing certification test items, reviewing or authoring manuscripts for a journal, serving as a mentor, and serving in a leadership position at the local or national level
• Affiliation with the American College of Nurse Practitioners

API Curriculum
A major charge for the Advanced Practice Work Group was to review and select topics and speakers and topics for the API. The goal was to meet the needs of the advanced practice nursing community at the highest level possible. The criteria for selecting a topic included representing an advanced level of learning, being cutting edge, including diagnosis and management, and having scientific basis. Also considered was whether proposals included evidence-based practice, outcomes that demonstrated the value of the APN role, the financial impact of the role, and ways to market the role.


Members of the Advanced Practice Work Group are (from left)
Jodi E. Mullen (AACN board liaison), Marilyn P. Hravnak,
Laurie S. Finger, John J. Whitcomb (chair), Barbara L. Leeper,
Linda Bell (staff liaison), Patricia A. Radovich, Kelly A. Thompson-Brazill
and Carolyn Diane Byrum.


Practice Resource Network


Q: Our critical care unit is considering applying for the Beacon Award for Critical Care Excellence, but needs direction on what to include in the narrative answer regarding the following application question: When the goals of care change from acute to comfort care for the patient, do you initiate palliative, end-of-life or hospice care in the ICU?

A: The goal in this narrative is to briefly describe the culture, processes and outcomes of the unit. The foundation of this question is related to seamless transition from curative to palliative or hospice care near the end of life and the integration of this philosophy into your unit’s culture.

When answering this question, begin by reviewing the National Consensus Project for Quality Palliative Care’s “Clinical Practice Guidelines for Palliative Care.” These guidelines will assist you in evaluating your infrastructure and programs regarding palliative, end-of-life or hospice care in the ICU. The guidelines are available in the “Ethics” area of the AACN Web site.

These guidelines include eight domains, which are followed by specific clinical practice guidelines regarding service delivery and professional behaviors. The domains are:
• Structure and Processes of Care
• Physical Aspects of Care
• Psychological and Psychiatric Aspects of Care
• Social Aspects of Care
• Spiritual, Religious and Existential Aspects of Care
• Cultural Aspects of Care
• Care of the Imminently Dying Patient
• Ethical and Legal Aspects of Care

Each guideline includes specific criteria for assessment of identified expectation. Your narrative discussion should include both the formal and informal processes your unit uses to meet the criteria identified under each guideline.

Typically, the culture of acute and critical care focuses on saving lives and restoring health. Palliative care is both a philosophy of care and an organized,
highly structured system for delivering care. The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and families, regardless of the stage of the disease or the need for other therapies.

The effort to integrate comprehensive palliative care services into acute and critical care requires the expertise of various providers in order to adequately assess and treat the complex needs of seriously ill patients and their families.

A successful Beacon Award application unit will describe how palliative, end-of- life or hospice care is introduced and facilitated, as well as the impact it has on 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.


Public Policy Update

Senators Successful in Securing Funds to Ease Nursing Shortage
At the urging of Sens. Barbara A. Mikulski (D-Md.) and Susan M. Collins (R-Maine), a Senate committee has approved increased funding for programs to recruit and retain more nurses. The Senate Appropriations Committee passed the FY 2005 Senate Labor, Health, and Human Services Appropriations Bill (S2810) that would increase funding for the Nurse Reinvestment Act and other nursing workforce development programs (Title VIII) by $20 million, bringing the total funding to almost $162 million for these vital programs.

The bill increases federal funding for the Nurse Reinvestment Act and other nursing workforce development programs to recruit and retain nurses. The senators fought two years ago to pass the Nurse Reinvestment Act, including programs that offer people financial assistance to cover the costs of nursing education and training. Since the Nurse Reinvestment Act passed in 2002, they have headed the effort to fund these programs.

More specifically, the bill increases federal funding for scholarship and loan repayment programs for nurses who work in facilities with a critical shortage of nurses. The bill also provides funds to cancel education loans for nurses who agree to teach at schools of nursing. Last year, nursing schools turned away almost 16,000 qualified applicants to baccalaureate nursing programs alone because they did not have enough faculty.

In February, the Bureau of Labor Statistics reported that registered nursing will have the greatest job growth of all U.S. professions in the time period spanning 2002 to 2012. During this 10-year period, healthcare facilities will need to fill more than 1.1 million RN job openings to accommodate growing patient needs and to replace retiring nurses.

Earlier this year, more than 40 senators, led by Mikulski and Collins, wrote to the Appropriations Subcommittee that funds these nursing workforce development programs to request $205 million for these programs in 2005. The House FY 2005 Labor, Health, and Human Services Appropriations bill and the president’s 2005 budget contain only a $5 million increase for these nursing programs. The next step is for the full Senate to consider the bill.


RN Hiring Eased for All But Largest Providers
Small and medium healthcare providers filled vacant registered nursing jobs faster in the 2003 calendar year or their most recently completed fiscal year than a year earlier, according to a survey by the American Society for Healthcare Human Resources Administration, Chicago, Ill. The median number of days needed to hire an RN by healthcare providers with up to 999 workers fell about 18% to 45 days in 2003, according to the survey, now in its third year. Providers with 1,000 to 2,499 employees experienced similar relief: The median days needed to recruit RNs at midsize organizations fell to 49 from 60. Large healthcare providers, with 2,500 or more workers saw the median increase to 61 days from 60. The data, compiled by Health Forum, included responses from 91 small, 75 medium and 94 large providers. The survey was conducted between January and May 2004.

Studies Needed Before Mandating Minimum Nurse-Patient Ratios
Researchers have concluded that the literature does not support the establishment of mandatory, minimum nurse-to-patient ratios at hospitals. The findings, published in the July/August 2004 Journal of Nursing Administration, were based on an analysis of peer-reviewed literature to determine whether the literature supports the ratios for acute care hospitals and whether nurse staffing is associated with patient, nurse/employee, or hospital outcomes.

Only one recent study was found that addressed minimum nurse staffing ratios. However, evidence did suggest that richer nurse staffing that included, for example, skill mix and competence, is associated with lower failure-to-rescue rates, lower inpatient mortality rates and shorter hospital stays.

The abstract is available online at www.jonajournal.com> Current Issue > Archive > July/August 2004.

Disaster Medicine Becomes a Specialty
As the nation focuses on the threat of terrorism, a whole new specialty is emerging to train healthcare providers for the worst-case scenario: disaster medicine. The specialty builds on traditional emergency medicine, combining emergency medical and trauma skills with crisis management and new forms of triage.

Disaster medicine is designed to treat trauma that most healthcare providers have never seen, such as postexplosion injuries and crush-injury syndrome. Other techniques include the removal of flying debris and shrapnel, traumatic amputations, and the treatment of open brain injuries.

A growing number of federal, state and university programs, including the Basic Disaster Life Support courses given by states and developed with the American Medical Association, are under way to train doctors, nurses and emergency-care personnel on the skills they need to handle the most catastrophic events. Efforts are also spreading to bring citizens into the effort. The Centers for Disease Control and Prevention’s Web site includes information for consumers on how to deal with mass trauma and injuries such as burns. And, consumers can find a wealth of information online about state and local disaster medicine programs and specialists who are trained to respond in a disaster.

Much of the focus is on how to most effectively treat large numbers of injured people. Because standard systems used to prioritize care in accidents and emergencies aren’t adequate to deal with tens of thousands of cases, experts are developing new systems for prioritizing the delivery of emergency care. One effort involves training civilian doctors in advanced disaster triage systems, such as the military’s MASS (move-assess-sort-send) system. Emergency personnel would have to make much harsher choices about who lives and who dies than they might in, say, a school-bus crash. Hospitals and local jurisdictions can use the National Incident Management System, a set of standards available online from the Department of Homeland Security, to develop plans for making such decisions.

Disaster medicine courses are also teaching medical professionals how to evaluate patients for exposure to various chemical, biological and radioactive agents; managing psychological and physical trauma; and dealing with ethical issues such as the balance between the responsibility to treat patients with potentially contagious conditions and the rights of medical personnel to protect themselves.

The University of Alabama at Birmingham’s Center for Emergency Care and Disaster Preparedness, in partnership with Vanderbilt University School of Nursing and Louisiana State University, formed a consortium that developed a four-day training program to prepare healthcare professionals to respond to incidents involving weapons of mass destruction, using role-playing exercises about communicating with other public officials during a crisis. With federal funding, the group also is developing a curriculum on biological terrorism, chemical attacks, radiation and other mass-casualty incidents.

The Joint Commission on Accreditation of Health Care Organizations last year began requiring hospitals to demonstrate their preparedness for disasters such as bioterrorism, including putting medical personnel through extensive drills.

Public health experts are concerned that a national training program in disaster medicine is still not in place. And state officials warn there is a looming shortage of medical and healthcare workers because of budget cuts, which could make disaster response difficult.

Some of the efforts involve volunteers. The National Disaster Medical System coordinates federal medical response to major emergencies. Members are typically volunteer healthcare professionals who respond to both out-of-state and local emergencies. The federal government also established the Medical Reserve Corps after the 9/11 attacks to provide an organized way for medical and public-health volunteers to offer their skills during crises.

Where to find information on disaster medicine:
The Centers for Disease Control and Prevention (www.cdc.gov)—Mass Trauma Web page has primer for doctors on explosions and blast injuries and brain injuries in mass trauma events, plus information for consumers on how to deal with mass trauma and injuries.
The Department of Homeland Security (www.ready.gov)—Provides information for consumers on what might happen in a nuclear, biological, chemical or radiation disaster, as well as natural disasters and explosions; tips on assembling a first-aid kit and other emergency supplies.
The National Disaster Medical System (ndms.dhhs.gov)—Coordinates federal medical response to major emergencies; links to the Web sites of state Disaster Medical Assistance Teams, or DMATs.
Bioterrorism and Emerging Infections (www.bioterrorism.uab.edu)—Developed by University of Alabama School of Medicine’s Center for Emergency Care and Disaster Preparedness and funded by the federal Agency for Healthcare Research and Quality. Educates medical professionals about treating smallpox, anthrax, botulism, viral hemorrhagic fevers, plague, tularemia, west nile virus, SARS and monkeypox.
Association of State and Territorial Health Professionals (www.statepublichealth.org)—Has links to every state health department, including names and phone numbers of officials responsible for disaster response and medical care; lists of public-health hotlines.
Medical Reserve Corps (www.medicalreservecorps.gov)—Has links to state medical-reserve volunteer units and Citizen Corps Council involved in forming local MRC units.

JCAHO 2005 Patient Safety Goals Approved
The Joint Commission on Accreditation of Healthcare Organizations has approved the 2005 National Patient Safety Goals, which will become effective Jan. 1. The 2005 goals include reconciling a patient’s medications on admission with each transfer to another setting, service, level-of-care or discharge. These goals were selected because of the huge opportunity for improvement in many hospitals.

Among the new requirements, healthcare organizations must work to ensure critical test results are communicated promptly; identify and take action to prevent errors involving look-alike and sound-alike drugs used at the organization; and assess each patient’s risk for falling and take steps to address those risks.

A complete list of the goals and requirements is provided, as well as links to JCAHO for frequently asked questions and program specific goals for ambulatory care, assisted living, behavioral healthcare, critical access hospitals, certified-disease-specific care, home care, hospitals, laboratories and long-term care.

Experts agree that the greatest opportunity for improvement is reconciliation of medications. The biggest challenge will be to determine the best method to achieve this and how to assess compliance. The JCAHO is still in the process of developing guidance for this goal and plans to include information in its FAQs at a later date.
Resources for implementing reconciliation processes are available from a number of sources. The Institute for Healthcare Improvement (www.ihi.org) provides tracking tools, physician order forms, flow sheets and protocols for medication reconciliation review. The Massachusetts Coalition on Prevention of Medical Errors (www.macoalition.org) has posted similar resources, including best practices and a toolkit, on its Web site.

The new goals, FAQs and program specific goals are available online at www.jcaho.org > Accredited Organizations.

House OKs New Flexible Schedules to Attract Nurses
Nurses at Veterans Administration hospitals could opt for more flexible schedules under a bill the House passed to address a shortage of nurses. The bill proposes three alternative schedules designed to attract and retain more nurses at Department of Veterans Affairs hospitals:
• Nurses who work three regularly scheduled 12-hour shifts in one week, for a total of 36 hours, would be paid as though they had completed a 40-hour week.
• Nurses working seven regularly scheduled 10-hour shifts in a two-week period would be paid for 80 hours.
• Nurses working full time for nine months could choose to get paid over 12 months.

“Offering more family-friendly schedules is critical to keeping experienced nurses employed in the VA,” said Rep. Robert Simmons, R-Conn., chairman of the House Veterans Affairs Committee’s health subcommittee. The bill passed on a 411-1 vote. Rep. Nick Smith, R-Mich., was the lone member to vote against it. Identical provisions are being considered by the Senate Veterans Affairs Committee and could be attached to another bill by the end of the year.

The House bill would also create a pilot program utilizing private recruiting, advertising and public relations firms to help recruit and retain nurses. It also directs the VA to make grants to states to pay for hiring, retention and incentive programs.

The Department of Veterans Affairs healthcare system is looking to fill 4,500 nursing slots, a vacancy rate of 9 percent. That shortfall could become more critical as the number of veterans enrolled in the system grows from 7.6 million to an estimated 8.4 million by 2010. The VA is also looking hard at attracting younger nurses. A report by the agency a year ago showed the average age of a VA nurse was 48.9, compared with a nationwide average age of 4l.8 for all nurses.


Public Policy Snapshot

Enrollment in Nursing Programs

Although enrollment in nursing programs increased more than projected, thousands of qualified students are still being turned away, according to the most recent annual survey by the American Association of Colleges of Nursing. In fact, the survey found that, despite a critical shortage of nurses, more than 11,000 qualified students were turned away from baccalaureate programs. The reasons: a limited number of faculty, clinical sites and classroom space.

The data, comparing 2002 and 2003, showed that nursing school enrollments are up in all regions of the United States. In addition, enrollment in RN-to-baccaularueate programs increased 8.1%.

Source: American Association
of Colleges of Nursing

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