AACN News—March 2005—Practice

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Vol. 22, No. 3, MARCH 2005


Beacon and Magnet Recognition
What Is the APN’s Role in Meeting Criteria?


By Carolyn Diane Byrum, RN, MSN, CCRN, CCNS,
and John Whitcomb, RN, MSN, CCRN (Chair)
Advanced Practice Work Group

In the 1980s, the American Academy of Nursing conducted a study that identified qualities or characteristics of hospitals that were able to attract and retain nurses. The original Magnet Hospitals shared initiatives that “promoted and sustained professional nursing practice, unit-based decision-making processes, influential nurse executives and investments in the education and expertise of nurses.”1
Subsequent research shows that these original “magnet” characteristics have endured. In addition, several studies have shown a relationship between decreased mortality and the elements of a healthy work environment, such as decentralized decision making, standardization of nursing processes, increased staffing ratios and collaborative relationships between nurses and physicians.2

The Awards
The American Nurses Association, in conjunction with the American Nurses Credentialing Center, developed the magnet Nursing Services Recognition Program to formally recognize Magnet organizations. Hospitals now have a vehicle to voluntarily apply for magnet recognition. This requires that the hospital meet 14 standards of nursing care through a formal written application, as well as an on-site visit to evaluate the magnet standards in practice. In addition, ANCC requires a recertification every four years.

AACN established a new award, which was presented to four critical care units for the first time in 2004. Unlike the Magnet Hospital recognition, the Beacon Award for Critical Care Excellence focuses not on an entire nursing department, but on units that exemplify excellence. The Beacon Award requires the unit to show evidence of how it centers on the patient-family environment and outcomes, as well as how it utilizes multidisciplinary teams to drive decision making.

The APN’s Role
Both awards identify the importance of creating environments where patients and families believe care is delivered safely; where multiple disciplines, including nurses, physicians, dieticians and pharmacists, collaborate and communicate to reach patient care decisions based on evidence-based research; and where the resources and processes are available to provide quality patient care. The advanced practice nurse can be instrumental in creating these environments.

Patient outcomes are dependent upon the decisions that are made regarding care while in the critical care unit. For effective, collaborative interaction to take place, there must be mutual respect for the information each discipline brings to the decision making process. The marginalization of relationships and the human dimensions of care may be the greatest obstacles to creating conditions of work where nurses can find fulfillment in the path of service they have chosen.3

Facilitating Dialogue
The APN can facilitate the dialogue among multiple disciplines. One opportunity to facilitate this dialogue is multidisciplinary patient-care rounds where the focus is on daily, targeted goals for each patient. The nurse uses these goals to direct the care of the patient and family. In addition, the APN can facilitate the integration of new information and ensure patient-care decisions are based on evidence.

With the focus of JCAHO on patient safety, nursing can no longer waste time with outdated work flow processes. These time-wasting workarounds involve activities such as filling in for secretaries, chasing equipment or forms and incorporating several different practice protocols to accommodate physician preferences. The APN can play a pivotal role in identifying workflow processes or workarounds that are tiring and frustrating and facilitating solutions. Nurses are a hospital’s most precious resource, and the one in the shortest supply.4 Improving work flow allows more time for nurses to provide nursing care. Patient outcomes improve because nurses are at the bedside directing the care of the patient.

Identifying Opportunities
With more of a global view of the patient care environment, the APN is in a position to identify opportunities for improvement that increase overall excellence in practice. These opportunities include:

• Identifying orientation or educational needs of staff and providing educational activities to meet those needs.
• Encouraging nurses to join and participate in local and national AACN and other nursing organization activities.
• Encouraging and facilitating certification in critical care nursing (CCRN), as a clinical nurse specialist in acute and critical care (CCNS), as a progressive care nurse (PCCN) or in other areas of nursing practice.
• Encouraging changes in practice to reflect evidence-based nursing and medicine.
• Encouraging nurses to participate in the identification of nursing problems, then facilitating these same nurses to conduct research to find new solutions.
• Encouraging true collaborative practice with physicians and other colleagues.

By creating an environment of excellence, the APN assists in showcasing the type of excellent nursing practice that the Beacon Award for a unit or Magnet designation for a facility rewards.

References
1. Aiken LH, Havens DS, Sloane DM. The magnet services recognition program: a comparison of two groups of magnet hospitals. Am J Nurs. 2000;100(3):26-36.
2. Barden C. Bold Voices Fearless and Essential. 2003 Presidential Address. San Antonio, Tex: American Association of Critical-Care Nurses National Teaching Institute; 2003.
3. Block P. Creating healthy conditions for service: a time to heal. Reflect Nurs Leadersh. 2004;30(4):20-22.
4. Fontaine D. Rising Above. 2004 Presidential Address. Orlando, Fla: American Association of Critical-Care Nurses National Teaching Institute; 2004.

ANA Code of Ethics: Provision 1: Compassion, Respect and the AACN Synergy Model

Editor’s note: In today’s healthcare environment, nurses are constantly challenged to apply clinically competent “state-of-the art” practice. They are also obligated to practice within an ethical framework. The ANA Code of Ethics for Nurses provides that ethical framework and the foundation of professional nursing practice. Awareness of the code and its provision is the responsibility of every nurse. Following is the first in a series of articles applying the provisions of the ANA Code of Ethics to critical care nursing practice. This article highlights the first provision and its underlying principles.

By Teresa A. Wavra, RN, MSN, CCRN, CCNS
National Office Liaison
and Cynda Rushton, RN, DNS, PhD, FAAN
Chair, AACN Ethics Work Group

Provision 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.1

Respect is fundamental to nursing care. This provision reminds nurses of the underlying fundamental principles of respect for the inherent worth, dignity and human rights of their patients. Respect requires exquisite attention to relationships, communication and behavioral awareness.
Acute and critical care nurses work within a highly technical and sometimes hectic environment. The AACN Synergy Model for Patient Care states that the needs and characteristics of a patient, clinical unit or system should be matched with a nurse’s competencies.2 Nurses must always be aware of the patient’s values, beliefs and preferences, even when the environment is not conducive to maintaining patient dignity, shared decision making or interprofessional collaboration.

The primary focus of nursing care is meeting the comprehensive needs of patients and their families across the continuum of care.1 Nurses use specialized knowledge and skills to promote and restore health and prevent illness. To achieve these objectives, nurses develop relationships with patients during some of the most vulnerable times in their lives.

Response to diversity, one of the competencies in the Synergy Model, states that the nurse must be sensitive to and recognize, appreciate and incorporate differences into the provision of care.2 To provide comprehensive care, nurses must explore patients’ and families’ basic beliefs and values regarding health, illness and death, as well as take into consideration their cultural, religious and ethnic backgrounds. It is the nurse’s ethical responsibility to deliver nursing services without prejudice and irrespective of the nature of the health problem.

Unlike physicians, nurses rarely engage in a contractual relationship with patients. This provision of the code appeals to broad principles of justice to ensure nondiscriminatory or unfair treatment for all persons who are in need of critical care services. Nurses may be challenged to uphold this value in an environment of constrained resources, and fiscal and institutional pressures. Advocacy and moral agency, another competency in the Synergy Model, states that the nurse works on behalf of and represents the concerns of the patient and family to help identify and resolve ethical and clinical concerns.2

Autonomy is a principle that ensures individuals the freedom of choice or free will to determine what happens to them, as long as these decisions do not seriously harm them or others. This principle is grounded in respect, which means that each individual is treated as a person of moral worth and moral agency.3 Autonomy implies that people have an inherent right to make treatment decisions and should be active participants in their own care.4

To support informed decision making, patients with decision-making capacity or their surrogates must have access to all information relevant to a particular decision.3 Within the informed consent process, it is important to provide technically accurate information that discusses the benefits and burdens of all alternatives to allow the person to make an informed decision about their healthcare and to engage in a process of verifying understanding. The goal of an informed consent process is to ensure that the patient or surrogate has an opportunity to accept or reject the recommended treatment without coercion. If this does not occur, his or her autonomy and dignity are compromised.4 Based on the principle of autonomy, healthcare professionals should respect patients’ and clients’ choices concerning their own lives and not let their personal values or morals influence treatment decisions.5

The principle of respect can also be extended to collegial relationships. Nurses must adhere to a standard of conduct when working in collaboration with other healthcare professionals. These standards preclude prejudicial actions, any form of harassment or threatening behavior, or disregard for the effect of an action on others. The nurse is ethically responsible to treat others fairly and respect the distinctive contribution of the individual or group. Such behaviors contribute to creating a respectful and trustworthy practice environment.

The first provision of the code offers critical care nurses important professional guidance. Respect for people and its derivative principle of autonomy are foundational for creating an ethically sound workplace.

References
1. ANA Code of Ethics for Nursing With Interpretive Statement. Available at: http://www.nursingworld.org/ethics/code/ethicscode150.htm. Accessed on Jan 22, 2005.
2. AACN Synergy Model for Patient Care. Available at: http://www.certcorp.nsf/vwdoc/SynModel. Accessed on Feb 1, 2005.
3. Fowler M, Fry S. Ethical enquiry. In Sarter B, ed. Paths to Knowledge: Innovative Research Methods in Nursing. New York, NY. National League for Nursing; 1988.
4. Ersek M, Kagawa-Singer M, Barnes D, Blackhall L, Koenig B. Multicultural considerations in the use of advance directives. Oncol Nurs Forum. 1998;25:1683-1690.
5. Presented by Joan McGiven Gibson. Summarized by Sara S. Hunt. Applying Ethical Principles to Individual Advocacy.. Accessed January 21, 2005.

Practice Resource Network

Q: In reviewing questions in the Beacon Award application, we realize that we don’t currently track some of these patient outcome indicators. Do we need to establish a track record before we can submit an application?

A: No. Each unit tracks outcome data based on the unique environment, determined by the patient population, patient average length of stay and quality data monitoring. For example, if you are not tracking UTIs per 1,000 device days, tell us why. Is it because the rate of infections was so low that it was decided to no longer continually track this data, or is it because LOS is only 24 hours, and most patients don’t have a catheter? Because the applications are reviewed in the context you provide, providing texture to support the numerical or yes/no response is highly desirable.

To learn more about the AACN Beacon Award for Critical Care Excellence, visit the AACN Web site.

Do you have a practice-related question? Call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or e-mail practice@aacn.org.

Public Policy Update


U.S. House Lineup Takes Shape
U.S. Rep. Nancy Johnson (R-Conn.) will continue to chair the House Ways and Means Health Subcommittee during the 109th congressional session. Most heath-related legislative proposals, including those related to information technology, would need to get through the subcommittee and full Ways and Means Committee before passing the full House. Republican members of the Health Subcommittee are Jim McCrery (La.), Sam Johnson (Texas), David Camp (Mich.), Jim Ramstad (Minn.), Phil English (Pa.), J.D. Hayworth (Ariz.) and Kenny Hulshof (Mo.). Democrat appointments had not been announced at press time. More information is available on the congressional Web site at thomas.loc.gov.

HHS Secretary Says Healthcare Needs Comprehensive Reform
President Bush’s newly appointed Secretary of the Department of Health and Human Services, Michael Leavitt, says the nation’s entire healthcare system needs comprehensive reform.

“The entire system of health care in our country is inefficient. We can dramatically improve it,” the former Utah governor told members of the Senate Finance Committee. “We won’t do it by futzing around the edges. We will have to be bold.”

In particular, Leavitt said, the Medicaid program is not meeting its potential to do good in the lives of the nation’s poor.

Senators praised his record as Utah governor and more recently as administrator of the Environmental Protection Agency. Some Democrats, however, voiced concerns that the federal government might cap Medicaid payments to states, forcing them to drop coverage for the poor. They also pointed to the use of waivers, like Utah received, that could erode coverage to those covered by Medicaid.

While Leavitt was governor, Utah was the first state in the country to receive a Medicaid waiver. The move allowed it to reduce benefits for many of those covered in order to provide basic coverage to 18,000 uninsured in Utah. Since then, more waivers have been granted and $21 billion in Medicaid dollars are now administered by states under waiver arrangements.

The Government Accountability Office, the investigative arm of Congress, said that in some cases those waivers skirt the law by providing less coverage than mandated by law. Leavitt defended the Utah waiver and said governors should have flexibility to find innovative ways to cover their states’ uninsured, as long as those guaranteed coverage by Congress are covered.

Congressional Aides Sharpen Forecasts of Action on Healthcare
With Congress back in session, congressional aides are sharpening their forecasts of likely action on healthcare this year. Speaking at a briefing sponsored by Women in Government Relations, almost all projected that Congress will tie Medicare payments to quality of care and that early action on legislation to reduce medical errors is likely.

Although aides agreed that deficit reduction will require cutting Medicare and Medicaid spending growth, they conceded that doing so would be difficult politically, if not morally. The need to fix doctor payments and to address an expiring moratorium on physician investments in specialty hospitals may generate “intense pressure” for Medicare legislation, a GOP aide said. But a Democratic counterpart suggested that Medicare changes would not occur if the budget committees fail to issue instructions authorizing cuts in Medicare and Medicaid.

In agreement that paying providers for improving quality of care or for meeting certain quality benchmarks is a legislative priority, the aides also indicated there is interest in legislation to foster the spread of information technology in healthcare. However, they acknowledged differences about whether that should be done through up-front federal funding assistance to providers or whether it should be accomplished by paying more for better quality care—making higher payments for infotech contingent on it actually delivering improvements in care.

Public Ranks Malpractice Reform and Drug Importation as Low Priorities
Americans favor reducing jury awards in malpractice lawsuits and drug importation from Canada, but rank them relatively low on a list of 12 healthcare priorities for President Bush and Congress to address this year, according to a new postelection survey conducted by the Kaiser Family Foundation and the Harvard School of Public Health. While supporting both, the public places greater emphasis on limiting the number of lawsuits than on capping awards and generally favors higher caps for noneconomic damages than the $250,000 being discussed by President Bush.

In the survey of almost 1,400 adults, slightly more than 26% ranked reducing malpractice jury awards 11th, just ahead of increasing federal funding for stem cell research (21%). Slightly less than 31% ranked allowing drugs to be imported from Canada eighth on the priority list.

At the top of the list, almost 63% cited lowering the costs of healthcare and health insurance as a top priority, followed by making Medicare more fiscally sound (58%) and increasing the number of Americans with health insurance (57%).

Overall, the respondents ranked healthcare issues third when asked to name the single most important priority for the president and Congress to address. Fewer cited healthcare issues (10%) than the war in Iraq (27%) or economic issues (17%). Terrorism and national security (10%) tied with healthcare as the third-most cited issue.

The complete survey results are available online: www.kff.org/kaiserpolls.

JCAHO Certification Provides Standard for Staffing Firms
Hospitals weighing which staffing firms to use and healthcare professionals who are thinking about going to work for such a firm now have a new factor to consider: Is the staffing company certified by the Joint Commission on Accreditation of Healthcare Organizations?

JCAHO began its certification for staffing companies in response to the ongoing shortages of nurses, pharmacists and other healthcare professionals, which have forced healthcare organizations to increasingly fill positions with temporary workers through contractual arrangements with staffing firms.

To become certified, staffing firms must meet standards in several key functional areas, including processes for verifying the credentials and competence of healthcare staff. Certification standards also address topics such as leadership, managing human resources, performance measurement and improvement, and information management.

NQF Selects Priorities to Improve Healthcare Quality
The National Quality Forum, a coalition of consumer groups, healthcare providers, payers and research organizations, has reached consensus on priorities for improving healthcare in America. The NQF includes the American Medical Association, American Hospital Association, AARP, General Motors, March of Dimes, Kaiser Permanente, American Nurses Association, Leapfrog Group, and many federal agencies. Its report, National Priorities for Healthcare Quality Measurement and Reporting, endorses 23 priorities for healthcare quality measurement and reporting as a starting point for focusing on healthcare quality improvement activities.

In a separate initiative and with a goal for providing uniform measurement of quality in hospitals, the Consumer Purchase Disclosure project issued a set of guidelines urging organizations that provide quality ratings to use measures endorsed by the NQF, federal agencies or national accrediting bodies. Coordination of data collection to minimize burdens to providers is also encouraged. The reports are available online at healthcaredisclosure.org.

Study Finds Disruptive Acts Common Among Hospital Staff
Approximately 86% of nurses and 49% of physicians surveyed said they had witnessed disruptive behavior among healthcare professionals, according to a VHA study published in the January 2004 issue of the American Journal of Nursing. Most respondents said they believed such behavior had an impact on adverse events, medical errors, patient safety, patient mortality, quality of care and patient satisfaction.

Some 68% of nurses and 47% of physicians said they had witnessed disruptive behavior among nurses and by nurses directed at other hospital staff. The report did not provide data specific to disruptive behavior by physicians. VHA defined “disruptive behavior” as any inappropriate behavior, confrontation or conflict, ranging from verbal abuse to physical and sexual harassment. It drew responses from a total of 1,500 nurses and physicians in 12 states.

About 60% of respondents said they were aware of potential adverse events that may have occurred as a result of disruptive behavior.


Around the States

Massachusetts
State Representatives Back Patient Safety Bill
State Reps. Kathi-Anne Reinstein and Robert DeLeo are supporting legislation setting minimum safe nurse and patient ratios for hospitals. The bill would allow state health officials to establish the number of registered nurses who would be assigned to specific numbers of patients in a hospital. Agreeing to adhere to that ratio would be a requirement a hospital would have to meet before being licensed by the state.

New Jersey
Hospitals Required to Disclose Nurse-to-Patient Staffing Levels
New Jersey’s Acting Gov. Richard Codey has signed a groundbreaking law that requires New Jersey hospitals to make daily public disclosures of the ratio of patients to nurses and other healthcare workers who provide direct patient care.

Under the law, every hospital must post on a daily basis in patient care units the number of registered nurses, licensed practical nurses, certified nurse aides and other licensed professionals providing direct care, and the ratio of these healthcare workers to patients.

Pennsylvania
State Nurses Association Calls for Action to Improve Healthcare
The Pennsylvania State Nurses Association, in collaboration with the Alliance of Advanced Practice Nurses, has released a briefing paper, titled “Solving One Piece of the Health Care Delivery Crisis Puzzle: An Action Agenda for the Commonwealth of Pennsylvania,” examining the full scope of nurse practitioners and clinical nurse specialists and their capability to significantly expand the capacity of Pennsylvania’s healthcare system.



Public Policy Snapshot

Studies: CPR Often Performed Inadequately

According to two studies of resuscitation efforts during cardiac arrest, cardiopulmonary resuscitation is often performed inadequately by doctors, paramedics and nurses. Whether a stricken patient is in the hospital or on the way, the guidelines for administering CPR frequently are not followed. Both studies used an experimental monitor that assesses CPR quality, and both received funding from Laerdal Medical Corp., a Norwegian company that developed the device with Philips Medical Systems.

• The combination heart monitor and defibrillator used in the studies includes a small sensor that attaches to the patient’s chest and evaluates depth of chest compressions and other aspects of CPR. The monitor includes an automated voice that provides on-the-spot coaching, telling rescuers when chest compressions are not strong enough or frequent enough. But that feature was not used during the studies.

• In one of the studies, involving 67 adult patients at the University of Chicago, doctors and nurses failed to follow at least one CPR guideline 80% of the time. Failure to follow several guidelines was common.

• The other study involved 176 adults with out-of-hospital cardiac arrest treated by paramedics and nurse anesthetists in Stockholm, Sweden; Akershus, Norway; and London. Chest compressions were done only half the time, and most were too shallow.

• Among the problems commonly cited: Rescuers did not push hard enough or frequently enough on the victim’s chest to restart the heart, and breathed air into the lungs too often—either mouth-to-mouth or through breathing tubes.

The researchers explained that skills learned in the classroom can fall by the wayside in the stress-filled chaos of a real-life emergency. Also, they noted that chest compressions strong enough to break ribs are sometimes required, and rescuers can tire quickly.

Both studies were too small to determine whether using the device saved lives, but the Chicago researchers said it could improve patients’ survival chances. Although other studies have found CPR techniques lacking, these studies are the first using a monitor to evaluate “what’s going on during real cardiac arrests and in real people,” said American Heart Association spokesman Vinay Nadkarni. The studies will be taken up at a medical conference in Dallas that could lead to an update of the CPR guidelines. Additional information about the studies and the conference is available online at www.c2005.org.
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