AACN News—October 2004—Practice

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Vol. 21, No. 10, OCTOBER 2004


Nominations Invited for Distinguished Research Lecturer

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 ideal candidates for this award should:

• Be nationally recognized for publications, presentations, and/or mentorship in research relevant to acute and/or critical care clinical practice,
• Be viewed as a consultant in their area of expertise,
• Have made significant contributions to acute and critical care
nursing practice through research
• Be a dynamic and interesting speaker (nominators should cite an example of nominee’s expertise in public speaking).

The recipient for 2006 will be selected in January by the Distinguished Research Lecturer Selection 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, dolores.curry@aacn.org.

Grants

Clinical Inquiry Grant
Ten awards of up to $500 each are available each 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 Web site or e-mail research@aacn.org.

Practice Resource Network

Q: My critical care unit is considering applying for AACN’s Beacon Award for Critical Care Excellence. However, in reviewing the information, it appears we do not meet the standard set for some of the questions. Is it possible to be recognized if we do not meet or exceed standard for all of the questions?

A: Yes, it is worth the time and effort to apply for the award. The process allows some units to assess their processes, culture and outcomes against excellence measures. In the application evaluation, meeting or exceeding the standard is only a part of the criteria used to evaluate the applicant’s unit. Each question is evaluated on adherence to the standard measure and in the defense or clarification you provide in the narrative portion of each question.

For example, one of the questions is: What is the number of Bold Voices Commitment statements signed by RNs in your unit? The standard is 100%. So, how would you provide clarity in the comment section as to whether you meet the standard? The expert panel will evaluate your comments based upon several questions. How did you achieve 100% compliance? What are you doing to try to meet the standard? Excellence is evaluated on how well you describe your unit’s work on this measure.

In her NTI address, 2003 President Connie Barden, RN, MS, MSN, CCRN, CCNS, said that signing the commitment statement acknowledges each individual nurse’s intention to create a new future with a healthy work environment that works for everyone. The pledge reads:

• I will identify the most pressing challenge in my immediate work environment.
• I will initiate the dialogue with my colleagues to find solutions to this challenge.
• I will remain actively involved in the solutions until they are working.

Have you integrated the commitment statements into the culture of your unit and, if so, how? Are the statements posted on your unit for everyone, families and patients included, to see? Are the commitment statements included as a part of the evaluation process and used to improve the working environment of your unit? Do you use the statements to guide new employee and preceptor orientation program?

Answering all or some of these questions will help the expert panel understand and evaluate the practice and culture in your unit.

For more information about the Beacon Award for Critical Care Excellence, visit the AACN Web site.

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.

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 Web site.


In the Circle
Special Award Recognizes Excellence in Research

Editor’s note: Part of AACN’s Circle of Excellence recognition program, the Excellence in Research Award recognizes nurse researchers who are furthering the mission, vision and research priorities of AACN. Following are excerpts from the exemplars submitted in connection with this award for 2004.

Anna Gawlinski, RN, DNSc, FAAN, CS-ACNP
Los Angeles, Calif.
UCLA Medical Center and School of Nursing
My vision of facilitating research-based practice taps the best of nursing’s potential for patient care and outcomes. During the past two decades, I have consistently worked toward making that vision a reality.

My work in research utilization and research conduct and my commitment to the systematic assessment of research-based practice are the key ways that I contribute to critical care nursing. The impact of my contributions to critical care nursing has been through synthesis of scientific and theoretical knowledge that has shaped policy and practice, both locally and nationally. I have been fortunate to have mentored numerous staff nurses, undergraduate and graduate nurses who are now leaders in critical care nursing. I have had the opportunity to write and edit AACN research-based protocols that help both staff nurses and advanced practice nurses facilitate research-based practice at their own institutions. My goals are to conduct research to test the kinds of interventions that nurses perform each day in the care of critically ill patients.

I believe my most outstanding research contribution to critical care nursing is in facilitating research-based practices in the care of the critically ill cardiovascular patient. My own program of research in advanced heart failure patients has helped clinicians to better monitor and intervene based on hemodynamic and oxygenation indices. I have become a recognized leader in facilitating “best practice” for patients with advanced heart failure, acute myocardial infarction and acute coronary syndrome.

I believe I have made a difference in the care of these patients by the systematic integration of research into practice. For example, through use of research methods and outcomes measurement, I have worked with UCLA’s acute MI team to develop a program that ensures each patient receives research-based care. Nationally, evidence-based practice therapies to treat acute myocardial infarction are under-utilized, despite knowledge that such therapies reduce mortality and morbidity. UCLA’s program is one of the leading users of research-based practices for acute MI patients. Our research team developed and implemented a treatment protocol that focuses on initiating research-based practices, which ultimately reduces mortality and morbidity in this critically ill patient population. I continually value the scientific approach to our nursing practice and use this approach to assist bedside practitioners in solving clinical practice issues.

Mary Lou Sole, RN, PhD, CCNS, FAAN
Winter Park, Fla.
University of Central Florida School of Nursing
My research has focused on patients’ physiological responses to critical illness and prevention of complications associated with critical care. For the past 17 years, I have studied airway management strategies to prevent ventilator-associated pneumonia, including risk factors, contamination of suction equipment, airway management practices of nurses and respiratory therapists, and potential effects of endotracheal tube cuff pressure leaks.

In 1987, I was one of the first nurses to conduct physiological research using mixed venous oxygen saturation monitoring. The studies evaluated Svo2 during patient care and ventilatory weaning, and provided seminal data that have improved quality of care and laid the foundation for additional nursing research. In 1990, I was one of the first nurses to study closed endotracheal suctioning and the effects on patient care.

However, my most outstanding contribution to critical care nursing is my recent study of suctioning techniques and airway management practices of nurses and RTs. My colleagues and I conducted research on contamination of oral and endotracheal suction equipment. This was the first study to investigate contamination of equipment as a risk factor for VAP. During this study, we noted a decrease in endotracheal cuff pressures—another possible VAP risk factor. We verified this decrease in cuff pressures in a follow-up study. No one has evaluated cuff pressures for many years, as airway management is often taken for granted. The STAMP findings demonstrate gaps in airway management practices that may contribute to VAP. Results emphasize the importance of basic nursing and RT practices in preventing VAP, which few individuals have evaluated.

This national study was conducted with limited grant funding, yet yielded clinically significant results and insights into practice similarities and differences. The STAMP study collected data from 1,665 nurses and RTs, at 27 sites from throughout the country. Findings note that evidence-based practice is not utilized by many of the nurses and RTs in practice. These findings will encourage changes in staff education and practice. The STAMP study, modeled after AACN’s Thunder methodology, provided an opportunity for 27 different sites to participate in the research. This proved to be a positive experience for those sites that participated, and they are seeking additional opportunities to participate in research.

Debra K. Moser, RN, DNSc, FAAN
Lexington, Ky.
University of Kentucky, Nursing School
I consider my most outstanding research contribution to critical care nursing to be the development of a sustained program of research that has contributed to changing nursing and medical practice related to care of patients with heart failure and those suffering acute myocardial infarction.

As a researcher, I have focused on examination of the impact of psychological and social factors on physiological variables in patients with acute cardiac events and heart failure, and on nonpharmacological interventions to improve physiological and psychological outcomes in such patients. I was the first researcher to demonstrate, in a series of studies, that a biofeedback-relaxation intervention emphasizing stress reduction could improve multiple clinical, physiological and psychological outcomes in advanced heart failure. In addition, my colleagues and I were the first to demonstrate the independent contribution of anxiety to development of in-hospital complications (i.e., malignant dysrhythmias, recurrent ischemia, reinfarction and cardiac death) in AMI patients, and the moderating effect of perceived control on this relationship. This work provided a foundation for interventions in the AMI population to improve outcomes.

My colleagues and I were the first to demonstrate the important physiological, clinical and psychological benefits of a cognitive, bio-behavioral intervention—biofeedback/relaxation—in the management of patients with advanced heart failure. With minimal training, this intervention can be incorporated into clinical practice. We also demonstrated, in a randomized controlled trial, that nurses providing patient education and counseling intervention improves quality of life and decreases rehospitalization rates and costs in heart failure patients with both preserved and nonpreserved systolic function. This work was practice-changing because it is the first study of heart failure disease management in patients with diastolic failure, and it demonstrated the effectiveness of nurses providing patient education and counseling in reducing hospitalizations and improving quality of life.

These are just a few significant contributions from a program of research testing nonpharmacological interventions that bring a unique and needed nursing perspective to the treatment of patients with heart failure. Current treatment of heart failure is driven largely by a medical perspective. Although this perspective has resulted in great improvements in the management of these patients, many believe that the greatest strides will be made when an integrated, interdisciplinary approach that includes the nursing perspective guides heart failure care.

In the Circle
Award Honors Excellent Clinical Nurse Specialists

Editor’s note: A part of AACN’s Circle of Excellence recognition program, this award recognizes acute and critical care nurses who function as clinical nurse specialists. Following are the exemplars submitted in connection with this award for 2004.

Michele Manning, RN, MSN, CCRN, CCNS
Akron, Ohio
Akron General Medical Center
One of Michele’s most challenging and memorable patients was Jenny, a woman

in her 30s, who arrested in the cardiac surgery unit shortly after mitral valve replacement. Jenny was resuscitated, but even after intra-aortic balloon pump insertion and vasoactive medications, it was apparent her only hope was a ventricular assist device and transplant. While the surgeon was implanting a biventricular assist device, Michele focused her attention on the family, answering questions and helping them understand the gravity of the situation.

Jenny’s husband was understandably upset, but also appeared very angry. When the surgeon finally had the opportunity to talk with the family, Jenny’s husband became hostile, threatening the surgeon and CSU staff. Michele quickly involved security and social work to help diffuse the situation and ensure the safety of the healthcare team. Further discussions with the family revealed that Jenny’s husband had abusive tendencies, including toward Jenny.

Over the next several days, Michele remained at the bedside, supporting and mentoring the nurses as they cared for Jenny amid the ventilator, Bi-VAD, CCVHD, vasoactive infusions and multiple transfusions of blood and blood products. Michele also worked to develop a trusting relationship with the family, especially Jenny’s husband. She felt it was important to support him through open visitation as often as possible. She answered questions truthfully and acknowledged his remorse, which facilitated him to grieve. The healthcare team also developed a comfort level with Jenny’s husband, although a plan for managing hostility and anger was in place.

Jenny lived for five days before she developed multi-organ system failure and was removed from life support. In the end, Jenny’s husband calmly and quietly expressed his appreciation of all the staff as he cried and said goodbye.

Linda DeStefano, RN, MSN, CCRN, CCNS, ACNP, FCCM
Irvine, Calif.
Saddleback Memorial Medical Center
Linda practices as a clinical nurse specialist in a community hospital with 22 mixed-service critical care beds. When she started her job, daily multidisciplinary rounds were not a part of the ICU routine. With some initial resistance, Linda created and implemented a formalized approach to this process. She met with members of the team to discuss her ideas and share her vision of the positive effect this could have on patient care. To help everyone get started, she created laminated “pocket cards” describing the expectations of each team member. These were that:

• The role of the bedside nurse is to present the key factors related to the admission and discuss current issues that require an ICU level of care.
• Linda and the intensivist would lead discussions and provide informal expert medical consultation and direction to the team.
• The respiratory therapist would provide information about oxygenation status, blood gas values, ventilator settings or weaning parameters.
• The clinical pharmacist would focus on appropriate drug utilization, including antibiotic therapy, dosages, actual or potential drug interactions, polypharmacy issues, efficacy, and therapeutic drug
levels.
• The dietitian would evaluate the appropriateness of delivery and adequacy of feedings, encouraging the enteral route whenever reasonable.
• The chaplain and social worker would discuss any issues with the family, and support systems, psychosocial or spiritual concerns.

Each discipline provides vital contributions to the team based on their area of expertise. ICU rounds have become a welcomed expectation. Linda serves as a true example of a professional nurse and promotes professional practice to the entire team. She has made tremendous contributions to patient outcomes, staff satisfaction, and improved teamwork and communication among the disciplines.