AACN News—March 2001—Practice

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Vol. 18, No. 3, MARCH 2001

Practice Resource Network: Frequently Asked Questions

Q:I am a critical care director who is interested in using propofol for mechanically ventilated patients in my unit. Do you have any information on propofol, its indications and its possible problems or side effects?

A:There are several sources of information on this topic.

An article titled “Use of Propofol for Sedation in the ICU,” which appeared in the August 1998 issue of Critical Care Nurse, provides an excellent overview of the indications, pharmacokinetics, potential side effects and nursing implications related to propofol use. An extensive reference list of articles and research studies on this topic is also included. This article is available for continuing education units. The CE test can be obtained either from our Web site at http://www.aacn.org (Click on “Education,” then “continuing education”) or via Fax on Demand at (800) 222-6329. When prompted, enter Document #1106.

Another resource is AACN’s “Protocols for Practice: Care of the Mechanically Ventilated Patient.” This easy-to-understand series of seven protocols is an excellent example of a best-practice-based protocol. It includes a chapter on the concepts and implications of sedation use, with an extensive, annotated bibliography of recent studies on sedation and ventilation. The complete series can be ordered online at http://www.aacn.org (click on “Bookstore”) or by calling (800) 899-2226. Request Item #CC170720. The price is $75 for AACN members ($94 for nonmembers). Individual protocols are also available.

For medical guidelines, check out the “Practice Parameters For: Systemic Intravenous Analgesia and Sedation for Adult Patients in the Intensive Care Unit; Sustained Neuromuscular Blockade in the Adult Critically Ill Patient.” This is available from the Society of Critical Care Medicine’s Bookstore at http://www.sccm.org.

Finally, try a literature search via CINAHL, which is free to AACN members via the AACN Web site. Search for “sedation” AND “mechanical ventilation.” You can also check the drug’s properties by using the Gen RX link on the AACN Web site. Click on “Clinical Practice,” then “Databases.”

Q:We are planning a new ICU and I am seeking resources that can help in developing the best environment for healing. When I attended AACN’s National Teaching Institute, I learned about research related to considerations such as the best colors to use and the need for windows. Now, I need to access this information. Can you help?

A:We recommend two excellent resources.
First, the AACN “Protocols for Practice: Creating a Healing Environment” discusses different modalities that can be used to decrease patients’ stress and anxiety; promote sleep and control pain; and provide for family visits and support. This five-protocol series is available from the AACN Bookstore online at http://www.aacn.org or by calling (800) 899-2226. Request Item #CC170710. The price for the complete set is $52 for AACN members or $64 for nonmembers.

Also highly recommended is “Critical Care Unit Design & Furnishing,” a compilation of information submitted in connection with the annual ICU Design Award presented by the Society of Critical Care Medicine (SCCM), the American Institute of Architects (AIA)—Health Facilities Research Project and AACN. Edited by Maurene A. Harvey, RN, MPH, CCRN, FCCM, this resource details factors necessary to design functional, efficient and comfortable ICU units. Chapters include “Building A Successful Team”; “Unit Size and Design”; “Bedside Design, Work Area and Central Stations”; “Storage Options”; “Floor, Wall and Ceiling Coverings”; “Meeting the Needs of Caregivers”; “Meeting the Needs of Families and Visitors”; “Impact of the Environment”; “Furniture and Furnishings”; and “Noise Control.” A variety of design layouts and floor plans, as well as equipment specifications, are also presented. “Critical Care Unit Design & Furnishing” is available from SCCM at (877) 291-7226 or the SCCM Web site bookstore at http://www.sccm.org.

Do you have a practice-related question? Call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or visit the “Clinical Practice” area of the AACN Web site at http://www.aacn.org. Click on “FAQs.”

Individual Rights Must be Respected and Protected

By Mary Garman, RN, MS, CNAA
Member, Ethics Work Group

Editor’s note: The following article focuses on individual rights and the sources that define patient and staff rights in healthcare. In addition to the case study presented, the Synergy Model is used in describing the patient and nurse characteristics.

Challenges in healthcare today often involve individual rights issues. Although Americans have been confident since the signing of the U.S. Constitution that they have rights, when defining rights at the bedside, critical care nurses are not always cognizant of either their own rights or the rights of the individuals for whom they provide nursing care. The new millennium is an ideal time for professional nurses to better understand and apply their own rights, as well as the rights of their patients.

The headline read “Six Weeks and Counting.” The story of the complex and hopeless battle over the question of surgery to separate conjoined twins captured the attention of many. The twins shared a heart and a set of lungs, which meant that physiological resources were scarce.

The battle was staged in Great Britain’s highest court, where the parents of the conjoined twins expressed their right to informed participation in the care of their children. Because personal privacy and confidentiality were carefully maintained throughout the court hearings, the identity of the parents was not released until the bitter end.

In expressing their rights, the parents refused to have the twins separated, because separation would inevitably result in the death, or what some considered murder, of the weaker baby. The parents, who were described as devoted Catholics, asked that their wishes to allow “God to decide whether and for how long the twins should live” be followed. However, the courts ruled that the twins should be separated to increase the chances of survival for the stronger of the two. After public and private scrutiny of the ruling, the parents chose not to appeal, even though they would soon experience the death of their baby girl.

Although this account is simplified, it captures the complexity of dealing with “patient and human rights.” Critics of the ruling have said that the fundamental rights of the parents were ignored in this case, that no consideration or respect was given to the parents’ personal values and spiritual beliefs. Others contended that separating the twins was the only choice to give the stronger of the two a better chance to survive. They argued that not separating the twins would interfere with the rights and well being of the viable infant.

Unquestionably, this case not only has polarized the medical profession and religious leaders, but also has presented judges with an unprecedented and harrowing ethical quandary, according to reporter John O’Callaghan.1 This case has created confusion and concern for many. Obviously, there are no winners in this case, only survivors.

Acting as an advocate for consumers of healthcare, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), devotes an entire chapter of standards to “patient rights.” The chapter begins by stating that patients have “a fundamental right to considerate care that safeguards their personal dignity and respects their cultural, psychosocial and spiritual values.”
In providing care, healthcare organizations are expected to demonstrate ongoing support of patient rights. Policies, procedures and practices must consider patient rights and organizational ethics.

JCAHO standards require not only that respect and dignity be given to patients, but also that patients are informed about and given the opportunity to participate in decision making. Applying this at the bedside means that patients or their guardians have the right to discuss plans of care, read medical records and ask questions when indicated. They also have the right to expect security, privacy and confidentiality of their medical information. When dilemmas about care decisions occur, the family has the right to second opinions and due process. JCAHO mandates that patients be involved in all aspects of their care.

Critical care nurses can help patients understand the rights they have legally and under regulatory standards. We can act as moral agents by focusing on honesty and informing patients of their rights. We can advocate for the patient by helping them to understand all aspects of their care. We can comfort them when making difficult decisions by applying caring practices.
In addition to defining patient rights, JCAHO standards address the hospital’s responsibility for respecting staff members’ cultural values, ethics and religious beliefs. The hospital must make every effort to excuse staff members from participating in an aspect of care on the grounds of conflicting cultural values, ethics or religious beliefs. JCAHO is committed to the rights of all individuals.

In conclusion, it is imperative that critical care nurses take time in every patient relationship to determine if the rights of all individuals have been respected. It is through recognition of rights and the “power of one” that critical care nurses make a difference.

1. O’Callaghan, J. Parents end UK fight against siamese separation. Reuters. Sept. 29, 2000.
2. Joint Commission on the Accreditation Healthcare Organizations standards, 1999.
3. Curley, MAQ. Patient-nurse synergy: optimizing patients’ outcome. Am J Crit Care. 1998;(7)1:64-72.

Mary E. Garman, RN, MS, CNAA, is the director of critical care at Children’s Medical Center, Dayton, Ohio. She is an active member of the hospital Ethics Committee, and has done extensive work related to the application of the JCAHO standards.

May 1 Deadline to Submit Proposals for AACN-Sponsored ANF Grant

May 1, 2001, is the deadline to submit proposals for the $5,000 American Nurses Foundation (ANF) grant, sponsored by AACN. Available to both beginning and advanced nurse research, this grant requires that the principal investigator be an RN who has obtained at least a baccalaureate degree in nursing. Principal investigators who have received previous ANF funding are eligible to reapply three (3) years from the date when the last grant was completed.

For more information about this grant, contact ANF at 600 Maryland Ave., SW, Suite 100W, Washington, DC 20024-2571; phone, 202-651-7298; e-mail, anf@ana.org.

Clinical Practice Guidelines and Protocols Guide Decisions

By Lisa Kohr, RN, MSN, CCRN, CPNP,
and Marilyn Hravnak, RN, PhD, CCRN, ACNP-CS, FCCM
Members, Advanced Practice Work Group

A hot issue facing advanced practice nurses (APNs) is the development of clinical practice guidelines. For even seasoned APNs, this task can seem daunting. APNs who are just beginning their roles may have many questions about the content, rationale and development of these documents. In this article, we hope to unravel some of the confusion and dispel myths surrounding clinical guideline development.

What are clinical practice guidelines?
Clinical practice guidelines help to guide management decisions about appropriate care in specific circumstances. They direct the diagnosis or management of specific symptoms or health problems, based on scientific evidence and expert consensus.1 How practice guidelines are presented varies. Some are set up in the form of outlines, following the process of assessment, planning, diagnosis, intervention and evaluation. Others are set up as decision-making trees, whose foundation begins with the presenting complaint and clinical findings, which then lead the practitioner to potential differential diagnoses and recommended diagnostic studies. Based upon the results of these studies, the practitioner is guided toward a suggested treatment plan. Some clinical practice guidelines include medication lists and indications for consultation. They may also detail age-appropriate, anticipatory guidance; health promotion; and health protection practices for well and/or at-risk populations.

What was the impetus for clinical practice guideline development?
The forces driving the development of clinical practice guidelines were increased patient complexity, managed care and the demand for optimal patient outcomes. The history of clinical practice guidelines dates back to the early 1970s, when outcome studies identified extensive differences among practitioner management strategies for patients who had the same healthcare problem. The development of clinical practice guidelines assists in standardizing the management of certain diseases by using the consensus of current evidence-based management strategies.

Do all APNs need to develop clinical practice guidelines?
Many states require APNs to follow guidelines or protocols for clinical practice and prescriptive privileges, where granted by state legislation. When this is the case, these clinical practice guidelines should be developed in conjunction with the collaborating physician and reflect the role responsibilities of the APN, based upon their scope of practice and patient population.2 There are two types: guidelines and protocols. The decision to use one instead of the other is primarily influenced by the expectations of the collaborating physician, the employer and the state practice act regarding the recommended format. The APN should be aware of the potential legal ramifications associated with the type of practice document used.3

What is the difference between a guideline and protocol?
Both guidelines and protocols are based upon clinical standards that define the minimal acceptable practice. Guidelines are flexible, easily modified depending on the needs of the individual patient and utilized when multiple but equally acceptable management plans exist for the specific healthcare problem. Protocols are more rigid, define a specific management plan and are intended to be followed in a step-by-step fashion to achieve the desired outcome. Protocols leave little room for interpretation or adjustment for individual patient needs. Guidelines, because of their flexibility, tend to be more adaptable within a large variety of settings or institutions, whereas protocols, because they are more specific, tend to reflect regional or institutional practices.

What is the process for clinical practice guideline development?
APNs may choose to use existing clinical practice guidelines or develop their own, though both must meet specific criteria. The documents must be research-based, timely, easily followed, applicable to the practice setting and “bear scrutiny over time.”4 They must also cover a variety of diseases that are encompassed in the APNs scope of practice. The management strategies must also reflect high quality and cost-effective outcomes. APNs may adapt established guidelines to fit the specific needs of their practice population. If an APN decides to develop his or her own guidelines, data should be pooled from multiple resources that reflect best practices. The ultimate goal for guideline development should be streamlining care and optimizing patient outcomes. Guidelines must have eight attributes: validity, reliability, flexibility, clarity, a multidisciplinary approach, a built-in compliance review mechanism and documentation of the process.5 Upon completion of the development stage, the clinical practice guide

line must be approved, implemented and then evaluated. The clinical practice guideline should be critiqued for percent compliance and the rationale for noncompliance should be investigated. Initiatives addressing these problems should be developed and implemented to ensure correct application of the guideline. Revisions of the guideline should occur, based on input from the multidisciplinary team members, and reflect the trends in management of the specific healthcare issues.

How do you access established clinical practice guidelines?
Clinical practice guidelines are available from many professional nursing and medical organizations, as well as from government agencies and insurance companies. Access can be obtained through journal publications, books, policy statements and the Internet. Combining resources for general guidelines with those generated by specialty organizations may assist the APN in addressing the needs of the majority of patients seen in the APN’s practice setting.

Following is a list of publications and online resources that some advanced practice AACN members use to assist in developing clinical practice guidelines.
Paul S. Developing practice protocols for advanced practice nursing. AACN Clin Issues. 1999;10:343-355.
Pearson LJ. Annual update of how each state stands on legislative issues affecting advanced nursing practice. Nurse Pract. 2000;25:16-68.
Moniz DM. The legal danger of written protocols and standards of practice. Nurse Pract. 1992;17:558-60.
Callender D. Pediatric practice guidelines: Implications for nurse practitioners. J Pediatr Health Care. 1999;13:105-111.
Field M, Lohr K (eds). Clinical Practice Guidelines: Directions for a New Program. Washington, DC.

Research Corner: Communication: What Is the Patient’s Reality

By Paula Lusardi, RN, PhD, CCNS, CCRN
Member, Research Work Group

Yesterday, Mrs. T., a frail 79-year-old woman, arrived at the emergency department in acute respiratory distress, secondary to myasthenia gravis and pneumonia. Because she was the primary caregiver for her 42-year-old son with cystic fibrosis, she did not want to be admitted to the hospital. However, there was no alternative, and she was admitted to the ICU after being emergently placed on mechanical ventilation.

Today, she has stabilized physiologically, though I find communication with her difficult because of the endotracheal tube placement and her varying levels of consciousness. I ask Mrs. T. questions to assess her orientation and mental status. I explain what is happening in terms of my nursing care and ongoing procedures. I ask if she is having any trouble breathing or has any pain. She shakes her head, indicating that she understands what I am saying and that she is physically comfortable. I am pleased that my communication has gone well. Am I correct in my assumption that I have communicated adequately with this patient?

Myth: Nurses always communicate well with patients.

Reality: A variety of data sources underscore that communication may be the most pressing problem in the ICU and research suggests that patient-healthcare provider interactions range from superb to abysmal. Although empirical data indicate that most nurse-patient communication consists of brief, task-oriented information, commands or questions and are limited to concrete information, patient-driven data indicate that the most effective communication focuses on a patient’s self-focused needs, worries and concerns. In fact, in a series of studies, between 13% and 100% of patients worried about an inability to communicate their concerns. The ability not only to interact but also to be understood appears to be key to a patient’s contentment and confidence in the ICU. Patients emphasize that being understood and having their needs met are the most crucial element for patient satisfaction and security in the ICU.

What should you do?
1. Talk and listen by whatever means works; remember that patients gauge effective communication by having their needs satisfied.
2. Take time to interpret messages.
3. Understand that patients are focused almost exclusively on themselves.
4. Be patient and work with your patients’ frustration, anger and feelings of insecurity at not being able to communicate.
5. Be aware that patients know “good” and “bad” nursing communication.
6. Talk with patients, not at them.
7. Be sure to spend more time with the patient than the equipment.
8. Demonstrate attentive and caring behaviors.
9. Give patients hope and have an “upbeat” attitude.
10. Be willing to listen to patients’ feelings of despair and fear. You don’t need to solve these problems, just listen to them.
11. Provides patients information, reassurance about progress and explanations about events.
12. Ask for a reasonable workload, so that you have time to communicate.
13. Allow patients to choose their nurses, if possible.
14. Try to allow for continuity of care by assigning the same nurse to a patient on successive days.
15. A patient’s relationship with his or her nurse is important and built on a day-to-day basis; maintain these relationships.

Paula Lusardi is a clinical nurse specialist at Baystate Medical Center, Springfield, Mass.

Suggested Reading
Jablonski RS. The experience of being mechanically ventilated. Qual Health Res. 1994;(2):186-207.
Hafsteindottir T. Patient’s experiences of communication during the respirator treatment period. Inten and Crit Care Nrsg. 1996;12(5):261-271.
Leathart, A. Communication and socialisation (1): an exploratory study and explanation for nurse-patient communication in an ITU. Intensive and Critical Care Nursing. 1994;10:93-104.
Logan J, Jenny J. Qualitative analysis of patients’ work during mechanical ventilation and weaning. Heart Lung. 1997;26(2):140-147.
Tanner C, Benner P, Chesla C, Gordon D. The phenomenology of knowing the patient. Image. 1993;23(4):273-280.
Gerteis M., Edgman-Levitan S, Daley J, Delbamco T. Through the patient’s eye: Understanding and promoting patient-centered care. San Francisco: Josey-Bass,Inc. 1993.
Hafsteindottir T. Patient’s experiences of communication during the respirator treatment period. Inten and Crit Care Nrsg. 1996;12(5):261-271.
Green A. An exploratory study of patients’ memory of their stay in an adult intensive therapy unit. Inten and Crit Care Nrsg. 1996;12:131-137.
Johnson M, Sexton D. Distress during Mechanical Ventilation: patient perceptions. Crit Care Nurse. 1990;10(7):48-57.
Ruiz P. The needs of a patients in severe status asthmaticus: experiences of a nurse-patient in an intensive care unit. Inten and Crit Care Nrsg. 1993;9:28-39.

Vox Populi: AACN Online Quick Poll Update

Does your hospital use a needleless intravenous system?
Yes 84%
No 16%

Number of Responses: 2,075

The AACN Online Quick Poll is a voluntary, nonscientific survey on a variety of topics. We present these surveys to give our users an opportunity to share their opinions on particular topics. Participate by visiting the AACN Web site at http://www.aacn.org.
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