AACN News—June 2005—Practice

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Vol. 22, No. 6, JUNE 2005


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 to 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/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/or 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.

Practice Resource Network

Q: What are emergency response teams?
A: National data regarding survival to discharge from an in-hospital cardiac arrest is approximately 1-in-3 patients.1 In response, hospitals are evaluating strategies to decrease in-hospital deaths that may be preventable. Studies indicate that prior to cardiopulmonary arrest, patients demonstrate serious clinical signs of deterioration.2,3 Hospitals have considered early evaluation of at-risk patients as one approach to improve patient care and overall morbidity and mortality. The emergency response team concept was pioneered in Australia and the United Kingdom. The aim is to proactively evaluate patients to prevent a wide range of emergencies, with a goal of preventing cardiopulmonary arrest.

The literature gives these teams different names, including Medical Emergency Team (MET), Rapid Response Team (RRT), Medical Emergency Response Improvement Team (MERIT), Multidisciplinary Rapid Response Teams, Intensive Care Rapid Response Teams and Medical Crisis Team. Regardless of the name, the primary objectives of these teams are to reduce patient mortality and morbidity through timely identification, intervention and treatment of at-risk patients before they require resuscitation.

Q: Does the use of an in-hospital emergency response team decrease in-patient mortality or decrease the number of cardiopulmonary arrests?
A: A prospective before-and-after trial of a medical emergency team determined the incidence of in-hospital cardiac arrest and death following cardiac arrest.4 The study concluded that “the incidence of in-hospital cardiac arrest and death following cardiac arrest, bed occupancy related to cardiac arrest, and overall in-hospital mortality decreased after introducing and intensive care-based emergency team.”4 Some studies concluded that there were fewer unanticipated intensive care admissions.4,5 Three studies concluded that clinically unstable inpatient early intervention by a medical emergency team significantly reduces the incident of and mortality from unexpected cardiac arrest in hospital.4,6,7

Some studies were unable to conclude whether the MET alters morbidity or mortality for hospital in-patients.8,9 Kenward et al studied a Medical Emergency Team one year after implementation demonstrated a reduction in cardiac arrest rate and overall mortality, but this was not statistically significant.10 Most studies concluded that further research is needed to determine the impact of these teams on overall morbidity and mortality. Overall emergency teams have had a positive impact on the quality of care.

References
1. Ebell MH, Becker LA, Barry HC, Hagen M. Survival after in-hospital cardiopulmonary resuscitation: a meta-analysis. J Gen Intern Med. 1998;13:805-816.
2. Franklin C, Mathew J. Developing strategies to prevent inhospital cardiac arrest: analyzing responses of physicians and nurses in the hours before the event. Crit Care Med. 1994;22:189-191.
3. Schein RM, Hazday N, Pena M, Ruben BH, Sprung CL. Clinical antecedents to in-
hospital cardiopulmonary arrest. Chest. 1990;98:1388-1392.
4. Bellomo R, Goldsmith D, Uchino S, et al. A prospective before-and-after trial of a medical emergency team. Med J Aust. 2003;179(6):283-287.
5. Bristow PJ, Hillamn KM, Chey T, et al. Rates of in-hospital arrests, deaths and intensive care admissions: the effect of a medical emergency team. Med J Aust. 2000;173:236-240.
6. Buist MD, Moore DE, Bernard SA, Waxman BP, Anderson JN, Nguyen TV. Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrest in hospital: preliminary study. BMJ. 2002;324:387-390.
7. DeVita MA, Braithwaite RS, Mahidhara R, Stuart S, et al. Qual Saf Health Care. 2004;13:251-254.
8. Daly FF, Sidney KL, Fatovich DM. The Medical Emergency Team (MET): a model of the district general hospital. Aust N Z J Med. 1998;28:795-798.
9. Salamonson Y, Dairyawasm A, Van Heere B, O’Connor C. The evolutionary process of Medical Emergency Team (MET) implementation: reduction in unanticipated ICU transfers. Resuscitation. 2001;49:135-141.
10. Kenward G, Castle N, Hodgetts T, Shaikh L. Evaluation of a medical emergency team on year after implementation. Resuscitation. 2004;61:257-263.

Advice for New APNs
Nurse Shares What She Would Have Done Differently

By Laurie S. Finger, RN, CNS, MN, MS, CCRN, CCNS, APRN
Advanced Practice Work Group

When I started as an advanced practice nurse, I didn’t really understand what I was getting into. I had some rather grandiose ideas about how I would make a difference to the patients and nurses on my units. When things happened slowly, I became disheartened and frustrated.

If I had known then what I know now, I would have gone about things differently.

After speaking with several other APNs and reading more about APN practice, I realized I was not alone in my feelings. So, I decided to list a few of the things that I wish I’d known as a new APN:

What do you expect?
Review your job description. Explore the expectations of your boss or supervisor. How do they compare with your expectations? If you will be reporting to more than one person, meet with everyone whose expectations you will be expected to meet. Ideally, this should be done before you accept a job. If the expectations are incompatible and irreconcilable, don’t accept the position. Never assume that you can grow to live with expectations that don’t match your own. This often results in conflict and dissatisfaction.1

Set small, realistic goals.
Set no more than three goals for your first six months. Make them realistic, measurable and attainable, but most of all simple. If you set goals that are unachievable, you will become disillusioned. This will lead to the “frustration phase” of APN role development,2 which is defined by feelings of inadequacy, discouragement and insecurity. Regularly evaluate your progress. Initially, you may want to meet with your supervisor weekly to review your progress and seek advice. When you are more comfortable, these meetings can be monthly, or even quarterly.

Don’t try to change the world on your first day, or for that matter, in your first year.
We all have ideas about how we can improve the functioning of the patients, nurses and systems with which we work, but we can’t realistically expect these changes to occur overnight. Changes in practice are best approached from a performance improvement perspective. Gather data from patients to support the need for change. Present a specific case that would have benefited from the change in question. Recruit staff that you know already support the change. Encourage them to “talk it up” among their peers. Post articles relating to your proposed change. Once the change is implemented, don’t forget to evaluate its effect on your patient population and on the nurses implementing it. Document the financial benefits and detractors of the change. Although this should never be the first consideration, it is a bonus in these days of cost containment if you can show a decrease in length of stay, a decrease in costs or a better patient outcome.

Working as an APN in the same unit or with the same nurses you worked with as a bedside nurse may be difficult.
Your former peers may not see you as different, though you are in a new role. Some may feel threatened by your new authority. They may remember a time in your career when you had less knowledge or experience than they. They may question, “Who do you think you are?” Similar issues may face APNs who have no history at their present place of employment, but who may have less experience than tenured staff. The best way to deal with those who question your authority is to proactively ask them for help in adjusting to your new role or surroundings. Avoid stepping on toes and graciously accept all advice, even if you don’t follow it. Showing respect for the staff’s suggestions and previous knowledge and experience will assist you in garnering that same respect.

Find a mentor.
This could be your immediate supervisor, but it doesn’t have to be. The secret to a successful mentoring relationship is for you to choose someone you believe has a vested interest in your success, but who will also be frank with you regarding your failures. You may choose another APN or leader with whom you work. The right mentor can open doors to expansive possibilities through his or her knowledge of the politics of the system in which you work. They may also assist your implementation of change by openly supporting the change directly or, indirectly, by introducing you to key personnel.

It’s okay to say “no” sometimes.
Keep your job description and goals nearby and refer to them often when trying to decide which requests, appointments, meetings and committee assignments you will accept. If you accept everything that comes along, you may end up disillusioned and discouraged and headed for the frustration phase already discussed. Sometimes you may want to accept a commitment that doesn’t specifically help you meet your goals or fit your job description, simply because it involves an area you care about. But remember, there are only a limited number of hours in the day or the week, so accept only the commitments you are sure you can meet. I have finally learned the hard way to say, “I am very interested in that project/topic/committee etc., but unfortunately I cannot take on anything else at this time.”

Join a peer support group.
If a support group doesn’t already exist, develop one. Find those “like-minded” individuals with whom you can problem solve and even commiserate. If you are the only APN at your institution, join a ready-made support group. For example, ANPACC and PICUAPN are two e-mail Web-based discussion lists specifically for acute and critical care APNs (adult and pediatric, respectively). Through these listservs, the APN can find advice and information on topics of concern. They provide an excellent forum for networking, with APNs from other areas of the country and the world. ANPACC is partnered with AACN, and PICUAPN is partnered with the Pediatric Society of Critical Care Medicine. You can access information on joining them through links on the AACN (www.aacn.org > Clinical Practice > Advanced Practice) and PSCCM Web sites. Another great way to network and keep informed on the issues confronting nurses in general and in your specific specialty is to join national professional organizations.

Learn as much as possible about the business aspects of your practice.
You may need to familiarize yourself with Medicare, Medicaid, billing and reimbursement as well as salary, benefits and collaborative practice negotiation. Some schools do an excellent job preparing APN students for these issues, but many do not. Seek out peers and ask how they accentuated their knowledge of the business end. If possible, enroll in a healthcare business or management class or continuing education program.

Not everyone understands or appreciates what an APN does.
Accept this fact. Remedy it when possible, but don’t let it get you down. However, you can also try what Debi Lambert, clinical nurse specialist at Children’s Hospital of Saint Francis in Oklahoma suggests: “Develop a brief description of the APN role and have it printed on the back of your business card.” Give it to all the people who ask, “What do you really do all day?”

Give yourself a break.
We are often our own worst critics. Don’t expect to get everything right on the first try. One of the hardest things to accept is that you may have been an “expert” nurse with 10 years of experience yesterday, but today you are starting over again as a “novice” APN. Patricia Benner3 has proven her theory over and over again. The stages she describes are as natural and as inevitable as the stages of human development. We cannot circumvent that development.

There are many things we learn in school and through our earlier nursing experience that serve us well as APNs, but there are always things we learn the hard way. Hopefully this list will assist others to be exceptional APNs.

References
1. Glen S. Waddington K. Role transition from staff nurse to clinical nurse specialist: a case study. J Clin Nurs. 1998;7:283-290.
2. Brykczynski K. Role development of the advanced practice nurse. In: Hamric A, Spross J, Hanson C, eds. Advanced Nursing Practice: An Integrative Approach. 2nd ed. Philadelphia, Pa: W.B. Saunders;2000:107-134.
3. Benner P. From Novice to Expert. Commemorative Edition. New Jersey: Prentice Hall Health; 2001.

July 1 is the deadline to apply for the following AACN nursing research grants:

Clinical Inquiry Grant
This grant provides five awards of up to $500 each to qualified individuals carrying out clinical research projects that directly benefit patients and/or families. Interdisciplinary projects are especially invited. Ten awards are available each year.

End-of-Life/Palliative Care Small Projects Grant
This grant provides one award of up to $500 each to qualified individuals carrying out a project focusing on end-of-life and/or palliative care outcomes in critical care. Examples of topics are bereavement, communication issues, caregiver needs, symptom management, advance directives and life support withdrawal. Two awards are available each year.

Medtronic Physio-Control AACN Small Projects Grant
Cosponsored by Medtronic Physio-Control, this grant funds one award up to $1,500 to a qualified individual carrying out a project focusing on aspects of acute myocardial infarction, resuscitation or sudden cardiac death, such as the use of defibrillation, synchronized cardioversion, noninvasive pacing, or interpretive 12-lead electrocardiogram. Examples of eligible projects are patient education programs, staff development programs, competency-based educational programs, CQI projects, outcomes evaluation projects, or small clinical research studies.

In the Circle
3M Healthcare Award Cites Excellent Clinical Practice

Editor’s note: Sponsored by 3M Health Care, this award recognizes acute and critical care nurses who embody, exemplify and excel at the clinical skills and principles that are required in their practice. It is part of AACN’s Circle of Excellence recognition program. Following are excerpts from exemplars submitted in connection with this award for 2004.

Laura Hinson, RN, BSN, CCRN
Trinity, N.C.
High Point Regional Health System
An experience with a family changed my focus with respect to critical care nursing. I met this family when the patient was admitted to our ICU. After spending some time in the hospital, the wife and son had to make a decision as to whether to proceed with a tracheostomy or to withdraw life support. The decision was theirs. As a facilitator, all I could do was discuss the options and encourage them to consider what the patient would decide, if he were able. Because it was unlikely that the patient would be able to return to his prior level of functioning, the wife and son decided to terminally wean the patient. He died shortly after extubation.

About 18 months later, the wife was admitted to our ICU after a major surgery. The son was again placed under the stress of a critically ill parent. She developed acute renal failure and would require hemodialysis to survive. As an only child, the son was torn between proceeding with hemodialysis, which would likely be permanent, and honoring his mother’s wishes. He made the decision not to proceed with dialysis.

I have strived for years for the ability to piece together information to try to solve the problem, to anticipate the needs and to grasp “the whole picture.” Although I have the clinical knowledge and understanding, it did not matter in this case. It’s not always how much you know or how much clinical expertise you have that matters. Sometimes, it’s just about listening to your patient and his or her family, providing support, understanding the conflicting emotions of people under stress and being sensitive to their needs. When you reach the point where they are able to integrate all of these qualities every day, with every patient, you have achieved excellence. I continue to strive for that day.

Myra L. McElroy Popernack, RN, CCRN
Hummelstown, Pa.
Penn State Children’s Hospital
MS Hershey Medical Center
A. was a 16-year-old, multiple trauma victim with a severe head injury. The handsome teen was somewhere between life and death. His parents and younger sister grieved deeply. His parents’ understanding was that A. would not wish to exist in a vegetative state. They requested that life support be withdrawn and that organ donation be explored.

Considering the dismal prognosis, a decision was made to proceed with nonheart-beating organ donation. As I assisted with the necessary preparations, I assured A.’s parents that I would stay after my shift and accompany A. to the operating room. As they said their tearful goodbyes, they knew that there was the possibility his breathing might not cease, therefore aborting the organ donation.

In the OR, A.’s body was prepped for the procurement team’s immediate response. I softly offered words and a touch of comfort. After extubation, timing began. Four minutes of asystole were required to proceed, but his breathing stabilized, and his youthful, teenage heart continued beating as mine sank. The OR team disbanded and we returned to the pediatric ICU. A.’s parents and I embraced and sobbed. By not agreeing to introduce therapies to prolong a vegetative state, the plan was to provide comfort and to allow time for his body to follow the spirit it had lost 10 days prior. The following day, time’s job was done.

Based on more than 26 years of pediatric ICU experience, I assert that expert nurses bring more of their humanness to the bedside as they are challenged by tragedy and ethical decisions. In crisis, the needs of the child are often surpassed by the needs of the family. This was such a case. Through connecting on a personal level and discerning what A.’s family needed, I made a difference—not for A. but for the family he left behind.

Terry Ann Simmons, RN, BSN, CCRN
Winchester, Conn.
New Britain General Hospital
The unit seemed quiet that night. There were no phones ringing or alarms sounding. However, as I passed the monitor bank, I noticed that one of the patterns looked too widely spaced to be “sinus rhythm, 72 beats per minute,” as the digital readout indicated.

Hurrying past the high-tech equipment, I reached the patient’s room. My own heart raced as I looked at the ashen face of the elderly man lying in the bed. I called to him and placed my stethoscope on his chest. His heart rate was 35 beats per minute, but he was responding! It turned out his poor color was partly due to years of smoking and the pneumonia for which he had been admitted. His blood pressure and urine output were fine. He said all he really needed was a good night’s sleep.

I took report from the new nurse who had been caring for the man. As we reviewed the rhythm strips printed from the monitor, the intern sitting next to us noted he had difficulty finding the man’s radial pulse while drawing a blood gas. This was an opportunity to put all our information together and update the patient’s plan of care.
Guided by AACN’s vision of “a healthcare system driven by patient needs,” we made sure the man got the best night’s sleep possible before a cardiology consult first thing in the morning. The patient’s daughter confirmed that her father had not sought medical care for years, and would not have been very cooperative in the middle of the night. It is important that my colleagues are supported as they gain experience, and that patients and families know we are not working on them, but always with them.

ANA Code of Ethics for Nurses
Provision Stresses Accountability and Responsibility

Editor’s note: The American Nurses Association’s Code of Ethics for Nurses contains nine provisions that are the foundation of nursing care. The purpose of the code is to provide concise statements of ethical obligations and duties to all nursing professionals.1 It is the profession’s ethical standard and commitment to society, and all acute and critical care nurses should practice in accordance with this code. Following is the third in a series of articles applying the provisions of the ANA Code of Ethics to critical care nursing practice. This article highlights the fourth provision and its underlying principles.
By M. Terese Verklan
RN, CNS, MSN, PhD, CCNS
Ethics Work Group

Accountability” and “responsibility” are words we frequently hear at work and at home as we go about our daily routines. Although, in the political arena, they are used to highlight honesty and openness, in the healthcare environment, they are applied to emphasize the professionalism of nursing. “Respon-
sibility” and “accountability” are also words found in the ANA Code of Ethics for Nurses. The Code provides the structure from which a nurse may evaluate his/her ethical obligations and duties.1

Provision 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.

One of the tenets of professionalism is acceptance of responsibility and being accountable for your practice. Assessment of the changing status of the critically ill patient entails collecting and interpreting complex data, and altering the plan of care. The nurse is responsible for using prudent clinical judgment to ensure that the appropriate members of the healthcare team are aware of changes in the patient’s clinical condition. When nurses accept a treatment order, they are responsible for evaluation of a dynamic situation and are accountable for actions implemented in response.

Responsibility means accepting the accountability associated with the performance of one’s duties. Nurses are accountable for their own competency and have an obligation to both maintain and cultivate their skills. Being a nurse requires lifelong learning and moves on a continuum from novice to expert.2 The AACN Synergy Model for Patient Care states that novice nurses are responsible for following algorithms, decision trees and protocol with all populations. The novice nurse will be uncomfortable with deviating from protocols or plan of care related to the limits of their ability to make clinical decisions. Therefore, the novice nurse frequently delegates the decision making to other clinicians with more experience.3 The experienced nurse’s clinical judgment has evolved to the point that the synthesis, interpretation and decision making of complex and possibly conflicting data becomes second nature. Instead of following protocols, experienced nurses are able to evaluate research-based algorithms and protocols to tailor them to the specific needs of each patient. The experienced nurse is also responsible for teaching, coaching and mentoring the less experienced healthcare provider.

Accountability means nurses will be responsible for their actions as well as for the quality of the care that is provided. By working on behalf of the patient, nurses become patient’s advocates. In essence, nurses represent patients when they cannot represent themselves, even if there is diversity from the nurses’ personal values. Accountability also includes identifying occasions for moral actions. Being accountable ensures that the nurse serves as a moral agent and identifies as well as resolves ethical and clinical concerns within an environment that supports ethical decision making and advocacy for patients. Nurses may be faced with situations that require them to act immediately on patients’ behalf, even though the consequences of such action may present substantial risks of reprisal.4

Charge nurses or instructors delegating clinical assignments are accountable and responsible to delegate based on the needs of the patient matched with a nurses competencies.3 Delegating activities according to the health professional’s competency will promote a work environment that encourages collaboration and values others’ contributions toward achieving optimal patient goals. Neither the delegator nor the delegatee can ethically assign or accept a duty or task they are not competent to carry out.5 Policies and procedures help define the competencies and the skill mix needed to provide patient care. Creating a healthy work environment will foster trust and confidence among caregivers.6 This will lead to a shared sense of accountability and responsibility by the entire team.

References
1. ANA Code of Ethics for Nurses With Interpretative Statements. Available at: http://www.nursingworld.org/ethics/code/ethicscode150htm. Accessed January 22, 2005.
2. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Menlo Park, Calif: Addison-Wesley;1984.
3. The AACN Synergy Model for Patient Care. Available at: http://www.certcorp.org/certcorp/certcorp.nsf/vwdoc/SynModel?opendocument. Accessed May 3, 2005.
4. Role of the Critical Care Nurse. AACN Public Policy Position Statement.Accessed May 18, 2005.
5. Synder DA, Medina J, Bell L, Wavra TA, eds. AACN Delegation Handbook 2004.Accessed May 3, 2005.
6. Written Statement to the IOM Committee on Work Environment for Nurses and Patient Safety. AACN, Public Policy, January 24, 2003. Accessed on May 3, 2005.


In the Circle
Award Cites Nontraditional Setting

Editor’s note: Part of the AACN Circle of Excellence recognition program, this award is designed to recognize excellence in the care of critically ill patients in environments outside of the traditional ICU/CCU setting. Following is the exemplar submitted in connection with this award for 2004.

Margaret “Peggy” Porter, RN, RNC, BSN, CCRN
Wheeling, W.Va.
Ohio Valley Medical Center, Interium Health Care
As I approached the crib, the familiar sounds of the ventilator gave me a sense of comfort. However, the surroundings were certainly different! Instead of institutional walls, sterile lighting and monitors, I was greeted by brightly colored wallpaper and a mobile over the bed. Sleeping in the crib was C.U., a typical 8-month-old. But things were not so typical with this little boy. He had a trach, a ventilator and a colostomy. This was how my adventure into the nontraditional critical care setting began. Although this was a second job to help out my family financially, I have received much more than financial security.

Applying critical care knowledge and skills to this nontraditional setting was a challenge. The ICU has constant monitors, emergency equipment and staff to help solve problems. In the home setting, you are on your own to determine the best way to solve any problems. My critical care knowledge and skills have made a difference for C.U. and his parents, but they have also taught me many lessons, including trust in my knowledge and skills; increased confidence when caring for pediatric patients; increased clinical knowledge; an understanding of networking and family support; recognition of the need for quality time; and the importance of communication.

I would not give up a minute of my “adventures” with C.U. I have learned the science of nursing, but also what goes into 24/7 care for someone with highly specialized needs in the home. We are so close that I often have been referred to as “C.U.’s second mom.”

In the Circle
Award Recognizes Excellence in Education

Editor’s note: Part of the AACN Circle of Excellence recognition program, this award recognizes nurse educators who facilitate the acquisition and advancement of the knowledge and skills required for competent practice and positive patient outcomes in the care of acutely and critically ill patients and their families. Following are excerpts from the exemplars submitted in connection with this award for 2004.

Barry M. Barnhill, RN, BA, CNRN
Aliso Viejo, Calif.
Integra NeuroSciences
“You are going to miss the bedside when you leave it.” I had heard that as a nurse in the ICU. I was convinced I would never leave the bedside, because that is where the difference is made for patients. Being a bedside nurse felt heroic.

In the ICU, I took an active role in precepting nurses. In teaching my peers, I enjoyed the process of finding our common ground of experience and passion, then working alongside the nurse to promote understanding. Precepting led to lecturing, and I created slides with images, video and computer graphics to reveal the wonder of the brain. My goal was to get the nurses to first love the brain; caring for neurosurgical patients would naturally follow. When Integra NeuroSciences asked me to help “save the neuro patients of the world,” I was intrigued. I started saving patients by teaching their caregivers across the country.

For Integra, I’m on call 24/7. One day, I was called to consult on the brain oxygen monitor that had been placed on a 17-month-old boy whose head had been run over by an SUV. The scene at the pediatric ICU was of devastation and hopelessness. Discussing the monitor’s reading with the ICU team, I supported the nurses by helping them use their own knowledge and skills in caring for the patient. Throughout the night, the nurses integrated new information into their own knowledge of caring.

As a result of the caring of the nurses and doctors, the patient made a miraculous recovery. Teaching keeps me on the road. I do miss the bedside. Now I work toward helping others be heroes.

Jeanette Pickrell, RN, BSN
Indianapolis, Ind.
Clarian Health Partners
I was a new graduate when I started working in cardiovascular critical care 15 years ago, frightened but excited about the challenges before me. Working with cardiovascular patients is fascinating and demanding, especially as technology advances. I have always enjoyed teaching others. However, I had never sought out a formal educator position, instead focusing my energies on the more informal precepting and mentoring roles.

To meet the increasing educational demands of the technologies we use, management developed the new position of device educator. Seeing an opportunity for personal and professional growth, I stepped into that position and continue in that role today. My responsibilities include educating the cardiovascular critical care and step-down unit staffs about the five different ventricular assist devices we utilize. Because many patients will go home with their devices, I also provide extensive education to the patients and their caregivers. In addition, I developed and implemented a program to safely transport patients with VADs from smaller hospitals to our facility via the hospital’s flight program.

I took a great deal of pride as I watched the training come together with a young woman flown in with a biventricular VAD. She spent time in both of the units. One VAD was explanted and another was implanted. She was becoming more independent in preparation for discharge when she received her heart transplant. She is doing well today.

When I began, I never thought I would incorporate the knowledge base and skills I apply in my work today. I continue to grow professionally. I promote critical thinking and create the most productive learning environment for my staff. Perhaps that will enable another frightened new nurse to become energized about entering the profession of nursing.

Jane Willis, RN-BC, MSN
Indianapolis, Ind.
Indiana University Hospital of Clarian Health Partners
She was bursting to tell me more about her mother. “We worried she had brain damage and were nervous as we watched the nurses wean her from the ventilator. We thought she might die. But then Mom opened her eyes! We told her that it was her granddaughter’s birthday, and she remembered to say, “Don’t forget to wrap the red purse for her!”

I don’t know how nurses choose this kind of nursing and learn everything they need to, but what a gift they give! I reflected on the questions she posed: How do nurses choose critical care, and what are we doing to help them learn and be prepared for everything they need to know?

I recently participated in two progressive programs to meet this challenge. The first was an online critical care course developed by a partnership of AACN, the Indiana University School of Nursing and Clarian Health Partners. I provided content review and course photography, and as project liaison, I helped define the mechanisms of this innovative online course for our units.

The second program to help recruit, teach and advance nursing practice was our implementation of the AACN Synergy Model. Serving on the Curriculum Design Committee for our differentiated practice model, I was challenged by Martha Curley’s probing question: “Once you define your continuum of practice, how will you grow that practice?” We studied curriculum design and analyzed “what” nurses need to know to practice at different levels. Curriculum and learning methodologies are being planned, based on the defined progressive knowledge and skill sets identified for advancing practice.

Nadia Boulanger said, “The essential conditions of everything you do must be choice, love and passion.” As an educator I am also driven by a fourth element, commitment. I share the AACN mission to “commit to providing the highest quality resources to maximize nurses’ contribution….” As educators I believe that our efforts need to include synergistic relationships to finding new ways to acquire knowledge, catalyze personal growth and inspire lifelong learning.

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Applications Open for ICU Design Citation

Applications are now being accepted for the ICU Design Citation Award to recognize a critical care unit that demonstrates attention to functional and humanitarian issues in a complementary manner.

Cosponsored by AACN, the Society of Critical Care Medicine and the American Institute of Architects, this award focuses on planning and design. Aug. 15 is the deadline to apply. For more information, e-mail cprendergast@sccm.org or call (847) 827-6826.

In the Circle
Award Honors Excellent Preceptors

Editor’s note: Sponsored by Eli Lilly & Company, the Excellent Preceptor Award recognizes preceptors who demonstrate the key components of the preceptor role, including teacher, clinical role model, consultant and friend/advocate. Following are excerpts from exemplars submitted in connection with this award for 2004.

Denise De Rosa, RN, BSN, CCRN
Bosque Farms, N.M.
University of New Mexico Health Sciences Center
Throughout my nursing education and career, numerous people, especially nurses, have encouraged, mentored, guided, touched and inspired me to be the nurse I am today. Both the good and bad experiences have shown me the nurse I aspired to be and the nurse I did not ever want to be. This has been the driving force behind my strong and passionate commitment to learning and teaching and my desire to share my knowledge and experience with others.

My encounters in nursing school taught me that, as preceptors, we are patient, insightful, available and attentive to individual learning needs and styles. My first nursing position and orientation showed me that we learn as much as our preceptees, because there is a constant exchange of dialogue and information. We see the words “I don’t know” as an open door to a new learning experience.

My continued journey in clinical nursing allowed me to see that, as preceptors, we facilitate learning relationships with all members of the healthcare team. In addition, we understand that learning and teaching can effectively occur in both formal and informal settings.

My orientation to the medical ICU provided me with the insight that, as preceptors, we make a commitment to our preceptee to provide the best learning and educational experiences. We also recognize and utilize the strengths of others to enhance this process. Because we are nurses, caregivers and patient advocates, we are learners and we are teachers.

Simply stated, to precept is to impart knowledge and share experiences. We all precept; we just differ in our degree of commitment and the way in which we do it. Just as nursing is both an art and a science, so is precepting.

Diane M. Krieger, RN, BS
West Hartford, Conn.
Connecticut Children’s Medical Center
A few days prior to my first day in the pediatric ICU, I learned I would be orienting with a nurse who had been in the pediatric critical care field for more than 10 years. Not only was I starting as a new graduate nurse, I was going to be precepted by one of the most respected and experienced nurses on the unit. Every assessment, drug calculation, medication administration and linen change was done with Diane. No question was too irrelevant, no mistake judged.

Although Diane was patient as I learned every task, she had enough left for the families and the patients themselves. Instead of telling me the answer to every problem, she had a way of making me find the answer within myself. Diane knew that even she didn’t know everything. She stressed that even more than 10 years of critical care experience could not have prepared her for every situation.

During my months in the ICU, important issues arose, including termination of life support and patient advocacy. Diane taught me some of the most important lessons about nursing—that it wasn’t an exact science, but rather an art. Diane made sure I was aware of even the simplest aspects of human nature.

Nancy Elaine Martin, RN, BSN
Muncie, Ind.
Ball Memorial Hospital
My son, the young would-be rock climber, tugged at his harness and gazed up apprehensively. Where had I seen that look before? I remembered. Just the evening before, I had shaken hands with my newest orientee, her eyes wide, face blanched. I was JoAnna’s sixth preceptor in 10 days. I assured her, “I’m your last preceptor, and I’m not going to let you fall.”

Watching my son glance nervously at his coach, I thought that my preceptor role was quite similar to that of a coach in protecting from novice judgments, finding footholds and expressing encouragement. JoAnna gradually adjusted to our unit’s culture and began to climb. We debriefed after work, occasionally at each other’s homes. Although we shared few life commonalities, we intentionally developed a friendly, rewarding relationship.

Several months later, on JoAnna’s last night of orientation, she chose an unstable trauma patient. As she tightened an imaginary waist belt and looked up, I winked. However, despite her consistently flawless decisions and skills, her patient could not survive. Bravely declining my help, JoAnna gathered the family as I paced uselessly, knowing that her words would be adequate, if not exceptional. Post mortem care completed, the end-of-orientation party commenced somberly. We reflected that the measure of good nursing is not always a living patient.

Finally, the time had come to uncurl my fingers and let go. Now, we would be climbing side by side. With a hug, JoAnna assured me that she too would soon pick up the rope and calmly assure other new nurses that she would not let them fall.

Congratulations to AACN Nursing Research Grant Recipients!


2004 Medtronic Physio-Control AACN Small Projects Grant
Kay Luft, RN, MN, CCRN
Olathe, Kan.
The Lived Experience of Women With an Implantable Cardioverter Defibrillator

2004 AACN Clinical Inquiry Grant
Judith Bartz, RN, MSN, BC, CCRN
Kalamazoo, Mich.
Nursing Students and Their Lifestyle Habits

Kathryn Fay, RN, MSN
Reston, Va.
A Comparison of Patient Outcomes in Relation to Patient Characteristics and Oral Endotracheal Tube Securing Methods

Shawn McCabe, RN, MSN APN
Bloomfield, N.J.
Patient Perceptions of Oral Care

Barbara Pfaff, RN-C, MSN, CCRN, ACNP
Staten Island, N.Y.
Comparison of Noninvasive Cardiac Output Measurement by Bioimpedance and Invasive Measurement by Intermittent Bolus Thermodilution Technique in Critically Ill Medical and Surgical Patients

Jo Voss, RN, PhD, CNS
Sturgis, S.D.
Nursing Students’ Use of Personal Data Assistants to Improve Timeliness, Medication Preparedness, and Critical Thinking in Critical Care

2005 AACN Critical Care Grant
Sandra Swoboda, RN, MS
Baltimore, Md.
Does Isolation for Infection Control Increase Adverse Events and Decrease Patient Satisfaction in an Intermediate Care Unit

2004 AACN Clinical Practice Grant
Alexa Doig, RN, MS
Salt Lake City, Utah
Graphical CV Display for Hemodynamic Monitoring

2004 Evidence-Based Clinical Practice Grant
Susan Isaacs
Coeur d Alene, Idaho
A Collaborative Approach to Improve the Delivery of Care to Critically Ill Patients

2005 Evidence-Based Clinical Practice Grant
Ellen Sorensen, RN, CNS, MS, MSN, CCRN
Neptune, N.J.
Thromboelastography: Developing an Evidence-Based Post-Operative Protocol

Mary Beth Makic, RN, CNS, MS, CCRN, CCNS
Arvada, Colo.
Nursing Directed Interventions to Reduce Ventilator-Associated Pneumonia in the ICU

Donna DeLise, RN, MS, MSN
Norman, Okla.
Reducing Ventilator Associated Pneumonia Rates Through Evidence Based Best Practice Through Continuous Quality Improvement

Bradi Granger, RN, CNS, ND, PhD, FAHA
Bahama, N.C.
A Unit-Based Intervention for Effective Evidence-Based Practice

Bronwynne Carpico, RN, BS, BSN, CCRN
Pittsburgh, Pa.
Noise Reduction Using Education Based on an Organizational Change Model

Annette Gee-Monahan, RN, BS, BSN, CCRN
Middletown, N.J.
Evidenced-Based Practice for Nursing Care of Chest Drains

2005 AACN–Sigma Theta Tau Critical Care Grant
Maher El-Masri, RN, PhD
Windsor, Ontario, Canada
Examining the Effectiveness of 0.12% Chlorhexidine Gluconate Oral Rinse in Reducing the Rate of Ventilator Associated Pneumonia in ICU Patients: A Controlled, Randomized, Double-Blind Study

2005 End of Life/Palliative Care Small Projects Grant
Elizabeth Later
Idaho Falls, Idaho
Advance Directive Community Education Project

Cynthia Susan Scott, RN
Houston, Texas
Determining Parental Satisfaction With End-of-Life Care in Pediatric Intensive Care Units

2005 AACN Mentorship Grant
Lauren Broyles
Pittsburgh, Pa.
Clinicians’ Evaluation and Management of Pre-existing Substance Use, Chronic Pain, and Psychiatric Conditions in Long-Term ICU Patients

2005 AACN Family Presence in the Acute or Critical Care Unit
Mae Ann Pasquale, RN, MNEd, MS, CCRN
Orefield, Pa.
A Prospective Evaluation of Family Presence During Trauma Resuscitation

Janice Mangurten
Coppell, Texas
Family Presence During Resuscitation Interventions and Invasive Procedures in Pediatric Critical Care: Experiences of Family Members and Healthcare Providers

Public Policy Update

New Program to Focus on Emergency Preparedness, Disaster Response
Two new graduate options now offered by the Johns Hopkins University School of Nursing will prepare nurses for pivotal leadership roles during disasters and mass casualty incidents. The Health Systems Management: Emergency Preparedness/Disaster Response options—a clinical nurse specialist track in the master of science in nursing program and a postmaster's certificate option—are designed for nurses seeking strategic skills in planning, managing and responding to large-scale emergencies or disasters.

Associate Professor Marguerite Littleton-Kearney, RN, DNSc, FAAN, a captain in the Navy Nurse Corps reserve component, designed the program in response to concerns following the 9/11 disasters. The new curriculum will provide graduates with the tools to embark on a career path to assume leadership roles for emergency preparedness in hospitals, nursing homes, ambulatory centers, military, government agencies and other settings throughout the healthcare system.

Study Shows RN Shortage Easing
The nursing shortage is easing in hospitals, according to the 2004 National Survey of Registered Nurses. The survey presents the views of a random sample of nurses across the country on a range of issues, including the nursing shortage, work environment, nursing as a career, recruitment and retention of RNs, and Johnson & Johnson’s Campaign for Nursing's Future. Because many of the questions were repeated from the landmark 2002 survey, researchers could detect trends and compare results.

Johnson & Johnson and Nursing Spectrum funded the study, conducted by Harris Interactive from May 11 through July 26, 2004. The first data released from the study concerns RNs’ views of the shortage and nursing as a career. Although a large majority of the RNs surveyed said the shortage still existed, they described some improvements.

• In 2004, nurses observed a reduction in the amount of overtime.
• Fewer nurses perceived a negative work environment or referred to inadequate salary and benefits as the main reasons for the shortage, although they said both were key factors that could contribute to solving the shortage.
• More RNs indicated they had no plans to leave their nursing positions, and fewer reported they planned to leave their nursing positions within the next three years. Of those who planned to leave, the vast majority expected to move into other nursing positions or continue their nursing education.

Despite the improvements, the study reveals that problems persist.

• More than 70% of nurses surveyed who were in direct care positions in acute care facilities responded that the shortage contributed to a reduction in the number of available hospital beds, increased patient wait time for surgery or tests and delayed discharge from the hospital.
• Nurses perceived they had less time to spend with patients, and the quality of patient care and their own work life suffered.
• Despite a narrower gap between nurses’ supply and demand, nearly nine in 10 perceived a shortage where they worked.

The first article on the 2004 NSRN, “Six-Part Series on the State of the RN Workforce in the U.S.” by co-investigator Peter Buerhaus, RN, PhD, FAAN, appears in the March/April 2005 edition of Nursing Economic$.

Public Policy Snapshot

Rising, But Ineffective End-of-Life Costs

Some lawmakers are concerned about the amount of money spent at the end of life when that spending does not result in medically effective care. According to the Johns Hopkins University Bloomberg School of Public Health:

• The United States spends about two-and-a-half times more per capita than Europe on end-of-life care.
• Higher per capita spending results primarily from costly and lengthy stays in hospitals and expensive treatments.
• Most spending in the last six months of life is of very little value to the patient.

RAND Health policy analyst Joanne Lynn says Medicare costs are approximately $30,000 per person in the last year of life; $12,000 in the last month.

Source: Health Issues.com, April 5, 2005

For more information about these and other issues, visit the AACN Web site at ww.aacn.org.

Is Your Unit a Beacon of Excellence? Apply for Award Online

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.

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 at www.aacn.org > Beacon Award for Critical Care Excellence.

Research and Creative Solutions Abstracts Invited for NTI 2006

AACN is inviting abstracts for presentation at its 33rd National Teaching Institute and Critical Care Exposition, May 20 through 25 in Anaheim, Calif.

Selected abstracts will be exhibited as either a poster or oral presentation. Individuals whose abstracts are accepted will receive a $75 reduction in NTI registration fees.

Four research abstracts will be selected to receive the Research Abstract Award. This award recognizes individuals whose abstracts reflect outstanding original research, replication research or research utilization. Each of the award recipients will present their findings at one of the research oral presentation sessions at NTI and will also receive an additional $1,000 toward NTI expenses.

Sept. 1, 2005, is the deadline to submit the abstracts.

The applications, as well as guidelines and resources are available online at www.aacn.org > Research > NTI Abstracts.