AACN News—August 2007—Practice

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Vol. 24, No. 8, AUGUST 2007

New Guide From ECRI Institute Gives ICU Staff Tools to Put Safety Into Practice

Critical Care Safety: Essentials for ICU Patient Care and Technology provides a road map for implementing ICU risk management and quality improvement plans that include patient safety as a core value. ECRI Institute’s new 150-page guide includes advice to help you:

• Assess the ICU environment to identify improvement priorities
• Use research findings on clinical “bundles” that improve ICU patient outcomes
• Emphasize safe selection and use of ICU medical devices and technology
• Comply with Joint Commission goals and other national initiatives
The guide accompanying the CD-ROM provides more than 30 tools such as checklists, self-assessment questionnaires, and education aids to save you time and help ensure a high-quality ICU safety program.

Visit www.ecri.org/criticalcare to learn more and preview the guide’s table of contents and resource list.

A special thanks to the following AACN members who were content reviewers for the guide.

Karen Cuipylo, RN, MS, CCRN, CCNS
Critical Care Clinical Nurse Specialist
Winchester Hospital, Winchester, Mass.

John F. Dixon Jr., RN, MSN, CNA-BC
Nurse Researcher
Baylor University Medical Center, Dallas, Texas
Debra Furtado, RN-BC, BSN, MA
Clinical Director, Critical Care Unit/ Catheterization
Lab/Cardiac Rehabilitation
William W. Backus Hospital, Norwich, Conn.

Joyce C. Hall, RN, MSN
Clinical Practice Specialist
AACN, Aliso Viejo, Calif.

Mary E. Holtschneider, RN-BC, BSN, MPA, NREMT-P
Assistant Clinical Professor
Director, Center for Nursing Discovery
Duke University School of Nursing, Durham, N.C.

Mary Wyckoff, Ph.D., APRN, BC, CCNS, CCRN
Jackson Health System, Miami, Fla.i
Practice Resource Network

Q: I am a nurse in a cardiothoracic surgical ICU, a very specialized critical care area. When I arrived at work the other day, I discovered I had been reassigned to the Pediatric Intensive Care Unit. I immediately contacted the nursing supervisor and explained that I did not have any experience caring for pediatric patients, I did not have the required PALS certification and I felt it was not safe. She told me I would be assigned to an 8-month-old on a ventilator and that other nurses from my unit and the other adult ICUs had been taking care of the patient all week long. When I arrived on the unit, the charge nurse gave me my assignment which included the 8-month-old and a 4-year-old who was also on a ventilator and had a very involved and concerned family. I shared with her what I had been told by the supervisor and after some grumbling, she reluctantly reassigned the 4-year-old to another nurse. After I received report, I discovered that the infant had several drips I was unfamiliar with, a ventilator I had not seen or used before and different IV pumps and monitors. The other nurses in the unit were busy with their assignments but anytime I asked they were helpful. The assistant nurse manager came in and I spoke with her. I explained to her that I was very uncomfortable with the assignment and I did not feel at all safe. She asked me if I wanted to leave and after some calling around, she was able to find another nurse to work. I am grateful that she did that but I should never have been put in that situation. I felt guilty because I was bothering the already busy staff in the unit and that someone was called in to take my place. After thinking about the situation, I am now angry. I should not have felt bad; I should not have been put in that position by either the nursing supervisor or the hospital policy. The next time, I will refuse to go no matter how many other adult ICU nurses have done it.

No nurse should feel unsafe because a hospital decides it is OK to reassign. The saying “a nurse is a nurse” is unsafe in our profession. I am wondering what AACN’s position on this is.

A You are to be congratulated for standing up for yourself, the profession, and most importantly, the patients. This is a very complex issue that unfortunately is seen more frequently than is acceptable. As nurses we have a professional obligation to protect the patients entrusted to our care. Part of this obligation is to understand the boundaries of our competence and only take patient assignments that match this competence.

Support for this is found in the standard for appropriate staffing included within the AACN Standards for Establishing and Sustaining Healthy Work Environments published in 2005 (www.aacn.org > Healthy Work Environments). The standard states:

Appropriate Staffing
Staffing must ensure the effective match between patient needs and nurse competencies
The critical elements for this standard are:

• The healthcare organization has staffing policies in place that are solidly grounded in ethical principles and support the professional obligation of nurses to provide high-quality care.
• Nurses participate in all organizational phases of the staffing process from education and planning–including matching nurses’ competencies with patients’ assessed needs–through evaluation.
• The healthcare organization has formal processes in place to evaluate the effect of staffing decisions on patient and system outcomes. This evaluation includes analysis of when patient needs and nurse competencies are mismatched and how often contingency plans are implemented.
• The healthcare organization has a system in place that facilitates team members’ use of staffing and outcomes data to develop more effective staffing models.
• The healthcare organization provides support services at every level of activity to ensure nurses can optimally focus on the priorities and requirements of patient and family care.
• The healthcare organization adopts technologies that increase the effectiveness of nursing care delivery.
• Nurses are engaged in the selection, adaptation and evaluation of these technologies.

Further, AACN strongly supports the positions stated by several other leading healthcare organizations.
1. The Joint Commission’s HR Standard 3.10 states that “Staff competence to perform job responsibilities is assessed, demonstrated, and maintained.” One of the elements of performance for this standard is that “the hospital assesses and documents staff's ability to carry out assigned responsibilities safely, competently, and in a timely manner upon completion of orientation.”

2. Provision 4 of the ANA Code of Ethics for Nurses states, “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.” This includes the acceptance of accountability and responsibility. The interpretive statement goes on to say: “The nurse must exercise judgment in accepting responsibilities, seeking consultation, and assigning activities to others who carry out nursing care.” Interpretive statement 4.3 addresses a nurses responsibility for nursing judgment and action. It states, “Individual nurses are responsible for assessing their own competence. When the needs of the patient are beyond the qualifications and competencies of the nurse, consultation and collaboration must be sought from qualified nurses, other health professionals, or other appropriate sources.”

3. The ANA has a position statement titled “Right to Accept or Reject an Assignment.” In summary it states, “The American Nurses Association (ANA) believes that nurses should reject any assignment that puts patients or themselves in serious, immediate jeopardy. ANA supports the nurse’s obligation to reject an assignment in these situations even where there is not a specific legal protection for rejecting such an assignment. The professional obligations of the nurse to safeguard clients are grounded in the ethical norms of the profession, the Standards of Clinical Nursing Practice and state nurse practice acts.”

I hope this information helps validate that your actions were in keeping with your professional obligation to ensure that those patients received the most appropriate care. But, what do you do the next time this might come up? There are several actions you can take to assist in a situation such as this.

First, review your hospital’s Chain of Command policy. A Chain of Command policy will help to reduce the confusion that surrounds questionable patient care situations by providing you with a process to resolve administrative, clinical and patient safety issues. It should outline the steps any employee can use to present an issue or concern up the lines of authority until a resolution is reached.

Second, communicate with the hospital Risk Management Department. This is especially important if your hospital does not have a Chain of Command policy. They can guide you in the process to resolve the issue and partner with you to advocate for safe systems.

Third, work with your nursing leadership and Education Department to determine if there are cross training opportunities to expand the number of nurses competent to care for pediatric patients. You may want to work with a collaborative group to look at the floating policy within the hospital and try to work through this complex problem, keeping patient safety in mind.
I would encourage you and your colleagues to look at the work that Connie Barden, AACN past president, did during her year in office. Her theme for that year was Bold Voices. In her Opening Session at the 2003 NTI, she stated, “What is a Bold Voice? A bold voice isn’t a blaming voice or a whining voice. It doesn’t argue about who is right or wrong or about whose fault it is that we are faced with challenges. A bold voice moves past complaints to look for solutions, which will be found if we work with others and take the time, give the thought and have the patience to create the changes needed.” 6 You can find more Bold Voice information, including a full copy of her Opening Session remarks at:

You have used your Bold Voice to raise this issue within your organization. We hope you continue to work toward creating a safer environment for your patients and your colleagues. AACN stands ready to assist and support you in your efforts.

1. AACN Standards for Establishing and Sustaining Healthy Work Environments. AACN 2005. Accessed 06/25/07 at: http://www.aacn.org/aacn/pubpolcy.nsf/Files/HWEStandards/$file/HWEStandards.pdf
2. Hospital Accreditation Standards 2007, The Joint Commission, 2007 p. 333.
3. Code of Ethics for Nurses with Interpretive Statements, ANA, Silver Spring, Md 2001. p. 16-17.
4. “Right to Accept or Reject an Assignment,” American Nurses Association. Accessed 6/21/07 at:
5. Navigating today’s healthcare risks and liabilities: Chain of Command. Compass March 2004 Volume 2, Issue 2 accessed 6/25/07 at: http://www.mcneary.com/pdf/consortium_newsletters/Vol2No2Compass.pdf
6. Bold Voices: Fearless and Essential, Opening address at 2003 NTI, Connie Barden. Accessed 6/17/07 at: http://www.aacn.org/AACN/mrkt.nsf/Files/ConnieSpeech/$file/ConnieSpeech.pdf
Gawlinski Receives Distinguished Research Lecture Award for 2008


Anna Gawlinski, RN, DNSc, CS, ACNP, FAAN, adjunct professor at the UCLA School of Nursing and director of evidence-based practice at UCLA Medical Center, has been named the 2008 Distinguished Research Lecturer. As the recipient of this prestigious award, she will present her research at NTI 2008 in Chicago.

Gawlinski’s research focuses on the conduct and dissemination of interventions that improve outcomes in acutely and critically ill patients. For example, her research on hemodynamics and oxygenation has assisted nurses to more accurately monitor and intervene to maximize oxygenation and correct hemodynamic derangement in critically ill patients. In addition, Gawlinski has contributed to the body of knowledge on the therapeutic effects of adjunctive interventions, such as animal-assisted therapy and communication boards for the acutely and critically ill.

As the director of evidence-based practice at UCLA Medical Center, Gawlinski has developed and implemented an infrastructure that supports research and evidence-based practice initiatives in the Department of Nursing. Her mentoring of staff nurses and advanced practice nurses has helped clinicians apply research findings in day-to-day practice situations to improve patient outcomes. Her clinical expertise coupled with her knowledge of research methodology and a pragmatic approach to problem solving has energized clinicians at all levels and increased their commitment to research and evidence-based care. Her ability to clarify difficult research concepts and apply them in a meaningful way has helped clinicians become involved in research studies to test interventions for improving patient care. Few other clinicians or researchers have this ability, which ensures the integration of nursing research into practice.

Her collaboration with the Research and Quality Improvement teams at UCLA has facilitated research-based practice in the care of critically ill patients with advanced heart failure, acute myocardial infarctions and other acute coronary artery syndromes. During the past two decades, UCLA’s Acute MI Quality Improvement Team has developed a program that ensures each patient receives evidence-based care. UCLA is one of the leading users of secondary prevention therapies for acute MI patients. Gawlinski notes that nationally, secondary prevention therapies are underutilized in treating coronary artery disease patients, despite evidence that such therapies reduce mortality and morbidity in this high-risk population. To increase utilization, the UCLA team developed and implemented a protocol that focuses on initiating secondary treatment therapies prior to hospital discharge. Gawlinski said, “Our vision of facilitating research-based practice taps the best of nursing’s potential for ensuring quality patient care and outcomes.”

Part of AACN’s Circle of Excellence Recognition program, the Distinguished Research Lecturer Award honors a nationally known researcher who has made significant contributions to acute and critical care research; is known for publications, presentations and mentorship relevant to acute and critical care; and is viewed as a consultant in his or her area of expertise.
Nominations for 2009 Lecture

Dec. 1, 2007 is the deadline to apply for the 2009 AACN Distinguished Research Lecture Award. The recipient will present the Distinguished Research Lecture at NTI 2009 in New Orleans.

The recipient receives an honorarium of $1,000, an additional $1,000 toward NTI expenses and a crystal replica of the AACN vision icon. Distinguished Research Lecture Award winners are selected based on several criteria: a continued body of research, publications, mentorship in research relevant to acute and critical care, and significant contributions made to acute and critical care research. The award is sponsored by Philips Medical Systems. Those interested in applying may e-mail research@aacn.org.
Research and Creative Solutions Abstracts Invited for NTI 2008

AACN is inviting abstracts to be considered for presentation at the 35th annual National Teaching Institute & Critical Care Exposition, May 3 through 8 in Chicago, Ill.
Selected abstracts will be exhibited as posters. The first author/presenter whose abstract is accepted will receive a $75 reduction in NTI 2008 registration fees as an honorarium.
Four research abstracts will also be selected to receive the Research Abstract Award. This award recognizes individuals whose abstracts reflect outstanding original research, replication research or research utilization. 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.

Oct. 1 is the deadline to submit research abstracts.

The applications, guidelines and resources are available online at www.aacn.org >Research > Research & Creative Solutions Poster Abstracts > NTI Abstracts.
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