AACN News—February 2005—Practice

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Vol. 22, No. 2, JANUARY 2005

Advanced Practice Nurses Are Change Agents
Who Do You Turn To?

By Patricia A. Radovich, RN, CNS, MS, MSN, FCCM
Advanced Practice Work Group

You want to provide diversion for long-term patients or clients who are returning from the operating room with pressure ulcers. Your facility is implementing a new service line. A change in the care of patients is identified. Who do you call? The advanced practice nurse.

The APN may be either a nurse practitioner or a clinical nurse specialist who is an expert clinician and client advocate. The APN can also be influential when a change is needed in clinical care, staff education, interdisciplinary teamwork or the many other areas present in today’s complex practice environment. While providing direct patient care, APNs also instinctively attend the systems of care because they see them as the means to influence and enhance the care and outcomes of the patient.

The APN’s diverse educational and practice base is crafted from a variety of roles and spheres of influence. As a result, the APN has a variety of skills and expertise in the analysis of systems, care environments, collegial relationships, research and leadership. This diversity assists the APN to implement change across the healthcare spectrum.

The APN creates an environment in which the daily pursuit of excellence supports clinical inquiry to improve clinical and service outcomes. Examples include identifying ways to improve customer satisfaction, improving communication among team members, preventing complications through evidence-based practice, initiating programs to enhance and optimize outcomes and disseminating research findings. Through clinical expertise, APNs assess the patient’s and family’s current status, and identify actual and potential problems. Through this clinical knowledge, previous experience and ability to visualize the larger picture, approaches are developed to resolve problems.

In today’s complex healthcare setting, the diverse skills of the APN are increasingly important in supporting communication and collaboration among members of the healthcare team, influencing practice and optimizing outcomes for patients and implementing changes in the system.

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2. Disch J, Walton M, Barsteiner J. The role of the clinical nurse specialist in creating a healthy work environment. AACN Clin Issues. 2001;12:345-355.
3. Gail C, Field KW, Simpson T, Bond EF. Clinical nurse specialists and nurse practitioners: complementary roles for infectious disease and infection control. Am J Infect Control. 2004;32:239-242.
4. Henderson S. The role of the clinical nurse specialist in medical-surgical nursing. MedSurg Nurs. 2004;13(1):38-41.
5. Moloney-Harmon PA. The Synergy Model: contemporary practice of the clinical nurse specialist. Crit Care Nurse. April 1999;19:101-104.

Practice Resource Network

Q. We are starting to have patients come directly to our ICU from surgery, without spending time in the postanesthesia care unit. Are requirements different for patients recovering in the ICU?

A. Accepting patients on your unit for postanesthesia recovery will require that the nurses be able to provide the same standard of care that the patient would receive in the PACU. The nurse must understand and be competent in monitoring the patient through phase I, or the immediate postanesthesia period when the acuity, monitoring, assessment and nursing needs of the patient will be highest. Discharge from phase I monitoring and transition to the routines of ICU care must be predetermined by unit policy, physician order and valid measurement criteria. The postanesthesia recovery score (PARS) or Aldrete1 score is an example of one scoring system used in many PACUs for discharge from phase I.

For more information about patient assessment, monitoring and care during the postanesthesia period and the required nursing competencies, refer to the PeriAnesthesia Nursing Core Curriculum (product #128730) and the Standards of Perianesthesia Nursing Practice, available online at www.aspan.org.

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.

1. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg. 1970;49:924-933.

Public Policy Update

Healthcare Vies for Attention as 109th Congress Gets Under Way
As the 109th Congress began with 50 new members sworn in, unfinished healthcare-related business vied with the war in Iraq and Social Security reform for the attention of lawmakers. Several of the 41 new representatives and nine new senators have healthcare ties, including Rep. Bobby Jindal (R-La.), a former Health and Human Services Assistant secretary; Sen. Richard Burr (R-N.C.), a Brenner Children’s Hospital trustee; and Sen. Tom Coburn (R-Okla.), a family physician. Among the healthcare issues on Congress’ agenda are medical malpractice reform, the uninsured and patient safety.

Possible Health Professional Draft Plan Raises AMA Concerns
Concerns about a Selective Service System plan to possibly draft physicians, nurses and other health professionals are serious enough to have prompted a vote by the American Medical Association to communicate with the agency on the issue.

The Selective Service has indicated it is reviewing the Health Care Personnel Delivery System, authorized by Congress in 1987, which would require about 3.4 million male and female healthcare workers, ages 20 to 44, to register with the service if ordered by the president and approved by Congress.

Nursing Programs Turn Away 125,000 Qualified Applicants
The National League for Nursing has released preliminary data from the 2004 National Nursing Education Database Survey. The startling results show that thousands of qualified applicants, represented by an estimated 125,000 applications, were turned away from nursing programs at all levels. Despite what seems a healthy increase in the number of graduations, admissions and enrollments in all nursing programs for the 2003-04 academic year, the supply will fall well short of the demand, and the gap will continue to grow unless the critical shortage of faculty is addressed, the NLN said.

Hospital CEOs Name Biggest Headaches
Hospital chief executive officers named financial challenges, such as unpaid medical bills or Medicaid reimbursements, as the biggest headache in healthcare for 2004, according to an annual survey by the American College of Healthcare Executives. Of the 480 CEOs who responded to the October membership survey, 71% ranked financial challenges among their top three concerns. Another 36% named care for the uninsured among their three leading worries.

Thirty-three percent named workforce shortages in the top three, a sharp drop from the 58% in 2003 and 71% in 2002. Nevertheless, Thomas Dolan, ACHE president and CEO, said workforce shortages remain a pressing issue. Registered nurses topped the executives’ list of critical labor shortages, with 87% listing demand for registered nurses as the most pressing shortage, followed by imaging technicians at 66% and pharmacists at 54%.

Study Finds High Rate of Errors and Near Errors Among Nurses
A new Agency for Healthcare Research & Quality-funded study shows that nearly 30% of the hospital staff nurses who participated in a study of errors and near errors reported making at least one error during a 28-day period. One-third of the nurses surveyed reported a near error in which they caught themselves before they were about to make an error. The study, titled “The Prevalence and Nature of Errors and Near Errors Reported by Hospital Staff Nurses,” was published in the November 2004 issue of Applied Nursing Research.

AHRQ Redesigns Web Page
AHRQ has redesigned its nursing Web page to make it easier for users to access information. Historically, the agency has provided substantial funding to nurse researchers for grants, cooperative agreements and dissertation support in a variety of areas. As AHRQ continues to respond to the research needs of its key audiences—clinical decision makers, health system leaders, and federal, state and local policymakers—it will be counting on nurses to play an active role in helping to address research needs. The new nursing Web page is available at www.ahrq.gov/about/nursing/.

Bill Would Ease Restrictions on Foreign Nurses
A law to help undo bureaucratic tangles that place restrictions on foreign nurses was introduced by U.S. Rep. Tom Lantos (D-Calif.). Lantos also promised to explore longer-term solutions to a growing lack of visas for new and qualified nurses.

As of Jan. 1, the State Department only processes qualifying applications from the Philippines, China and India if they had been filed prior to 2002. The government announcement also noted immigrant visa quotas for these three countries are approaching their maximums, leaving ongoing applications to be processed only as new visas from those countries open up.

With congressional action, unused visas for people from countries with unmet quotas can be re-assigned to these three other locations, Lantos said. A bill authorizing the practice would help alleviate the immigration backlog and ease an ongoing nursing shortage epidemic.

Hospital Nurse Performance Measures Released by NQF
The National Quality Forum has released a report that details 15 voluntary, nursing-sensitive consensus standards for hospitals to use in evaluating nursing performance. This is the first set of national standardized performance measures to assess the extent to which nurses in acute care hospitals contribute to patient safety, healthcare quality and a professional work environment.

The report describes the 15 standards endorsed by the NQF, how to implement them and priorities for research. Listed in three categories, the standards provide the public with a way to assess the quality of nursing inpatient care. The standards also help providers identify critical outcomes and processes of care, and can be used by purchasers to reward hospitals that have high-performing nursing services.

The NQF report recommends that hospitals analyze these measures at the unit level to allow staff nurses to view their work over time. Individual units should define each measure for their specific use. The three categories are patient-centered outcome measures, nursing-centered intervention measures and system-centered measures.

Study Finds Nurse Staffing Regulations Increase Wages, Improve Working Conditions
Working conditions and wages have improved for nurses in California since nurse staffing regulations were enacted, according to a study published in the Journal of Nursing Administration. However, the study raises more questions than answers because it is unclear whether the ratios have improved the safety or health of patients.

For the study, Joanne Spetz of the Center for Health Workforce Studies at the University of California-San Francisco conducted anecdotal surveys of hospital executives around the state. In the study, Spetz questioned whether higher-quality care could be attributed to the ratios and whether an enriched nursing staff is the most effective way to improve patient care.

According to the study, hospitals have raised nurses’ wages, improved health and pension benefits, increased signing bonuses for new recruits and developed programs to train current employees to work as nurses in an effort to help mitigate the current nursing shortage in the state and comply with ratios.
From 1999 to 2003, the number of registered nurses in the state increased 11% to 299,000. However, federal labor statistics show that the state continues to have a shortage of about 18,000 nurses. By 2010, the state will have a shortage of more than 42,000 nurses, and by 2015, that shortage could increase to more than 78,000 nurses.

Brenda Klutz, deputy director of licensing and certification for the Department of Health Services, said that an unintended effect of the ratios has been that they have contributed to a shortage of nurses in long-term care facilities, nursing homes and assisted-living facilities, in part because hospitals have drawn more nurses away from such jobs.

Many hospitals also have eliminated support staff positions to reserve budget funds to hire additional nurses. Also, according to the study, some hospital executives said they have had to accept fewer transfer patients from rural communities and have redirected complex patients to trauma centers.

CNA Sues Schwarzenegger, DHS for Delaying Nurse Staffing Ratios
Members of the California Nurses Association have filed a lawsuit in Superior Court alleging that Republican Gov. Arnold Schwarzenegger and the California Department of Health Services illegally delayed until 2008 the implementation of a law that would decrease from six to five the number of patients for which a nurse is responsible. The law was scheduled to take effect Jan. 1.

In the lawsuit, CNA reiterates its claim that Schwarzenegger’s order to delay implementing the ratio endangers patient care. The lawsuit states, “The immediate victims [of the delay] will be the patients who suffer serious injury and death as minimum standards of safe care and patient protections are stripped away by the very agency charged under law with responsibility for ensuring the protection of hospital patient health and safety.” In the suit, CNA also said that the current nursing environment does not require an emergency regulation by Schwarzenegger.

Survey Reveals Need for Improving NQF Safety Practices
More than 1,000 hospitals responded to the Leapfrog Group’s survey measuring hospitals’ progress toward reaching the group’s patient safety goals. Survey results show that only 21% of hospitals are fully compliant with 27 safety practices developed by the National Quality Forum. Eighty percent indicated they have implemented procedures to avoid wrong-site surgeries, and 70% now require a pharmacist to review all medication orders before medication is given to patients.

However, 70% did not have an explicit protocol to ensure adequate nursing staff; 50% did not have procedures in place to prevent pressure ulcers; and 40% lack policies requiring workers to carry out hand hygiene before and after seeing a patient. Approximately 20% of respondents have fully implemented computerized physician order entry or plan to do so by 2006.

The survey measures hospitals’ use of CPOE, referral of patients for certain high-risk procedures based on volume, staffing of ICUs with specially trained physicians and implementation of NQF’s patient safety practices.

Public Policy Snapshot

Free Survey Tool Pinpoints Patient Safety

The Agency for Healthcare Research & Quality, in partnership with the Department of Defense, American Hospital Association and Premier Inc., recently released a new patient safety survey. The questions are designed to help healthcare organizations gauge employees’ attitudes about patient safety. The survey is available online at www.ahrq.gov/qual/hospculture. You can tailor the survey to your own specifications before administering it to your staff.

AHRQ sponsored development of this survey as part of its goal to support a culture of safety and quality improvement in the nation’s healthcare system. This survey tool can be used to assess the safety culture of a hospital as a whole or for specific units within hospitals, as well as to track changes in patient safety over time and to evaluate the impact of patient safety interventions.


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.

Is Your Unit a Beacon of Excellence?

The AACN Beacon Award for Critical Care Excellence 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 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.

For more information, visit the AACN Web site.
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