AACN News—November 2001—Practice

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Vol. 18, No. 11, NOVEMBER 2001


AP Work Group Focuses on Enhancing Resources

Members of the Advanced Practice Work Group for 2001-02
are (from left, seated) Kathleen McCauley (AACN board
liaison), Patricia Gonce-Morton and Alice Davis and (from
left, standing) Julie Marcum, Sheila Melander, Deborah Gree
law, Sarah Martin, Sandra Cagle, Linda Bell (staff liaison)
and Julie Stanik-Hutt.


By Alice Davis, RN, PhD, CNRN
Chair, Advanced Practice Work Group

Supporting advanced practice nurses through enhanced resources is the charge before the 2002 Advanced Practice Work Group, which began tackling its initiatives at a two-day meeting in August in Costa Mesa, Calif.
These efforts focus on three primary areas:

• Reviewing the final Acute and Critical Care CNS Scope and Standards document developed by the 2001 Advanced Practice Work Group
• Recommending topics for the 2002 Advanced Practice Institute, which will be held in conjunction with AACN’s National Teaching Institute and Critical Care Exposition, May 4 through 9 in Atlanta, Ga.
• Developing educational resources to support advanced practice roles

AACN staff and volunteers collaborate to operationalize initiatives within the AACN strategic plan and share insights about acute and critical care nursing issues that may shape future initiatives related to advanced practice. In preparation for its work, the group reviewed AACN’s operational and strategic plans with representatives of AACN’s national leadership and national office team. Kathleen McCauley, RN, PhD, CS, FAAN, who is the AACN board liaison to the work group, and Linda Bell, RN, MSN, clinical practice specialist at the AACN National Office, presented activities currently under way. AACN President Michael Williams, RN, MSN, CCRN, President-elect Connie Barden, RN, MSN, CCNS, CCRN, and CEO Wanda Johanson, RN, MN, addressed the priorities for AACN, including AACN’s response to the nursing shortage.

Through the volunteer work group model, AACN has a special link to all members. All members of the Advanced Practice Work Group are involved in some aspect of acute or critical care nursing, and inviting members who represent a broad scope of advanced practice nurses was a priority. The work group members include clinical nurse specialists and nurse practitioners who work in hospitals, as faculty or in private practice.

The number of highly qualified AACN members who responded to the annual Call for Volunteers was exciting, though it made the process of choosing only five new members for this year a challenge. Because the work group would be continuing the dialogue around issues discussed by the previous year’s work group, two members of the 2001 Advanced Practice Work Group were invited to continue as members of the 2002 group.

For me, serving as chair of the Advanced Practice Work Group is an honor. As a former member of the AACN Board of Directors, I do not take this role lightly. I know the importance of the work done by this group as it guides AACN’s initiatives related to advanced practice nursing—a vital priority to our organization. I believe that being appointed chair by AACN President Michael Williams is an acknowledgment of my many years as an advanced practice nurse, educator and AACN volunteer.

Other members of the Advanced Practice Work Group for 2002 are Sandra Cagle, RN, MSN, CCRN, ACNP, Patricia Gonce-Morton, RN, PhD, NP, ACNP, FAAN, Deborah Greenlaw, RNC, MS, CCRN, NP, Julie Marcum, RN, MS, CCRN, CS, Sarah Martin, RN, MS, CCRN, PCCNP, CPNP, Sheila Melander, RN, DSN, ACNP, FCCM, and Julie Stanik-Hutt, RN, PhD, CCRN, ACNP.

At the August meeting, there was great enthusiasm, serious debate, lively dialogue and thoughtful deliberation, all resulting in excellent feedback for the AACN leadership team. In the end, the group had a sense of accomplishment and ownership in AACN because their ideas were heard and their contributions were recognized.

Even as a veteran volunteer, I always feel a sense of pride after leaving an AACN meeting. I am truly proud to be a member of an organization that continually seeks input from those of us who it’s committed to support. AACN is our organization, to shape, to serve and to support.

Sharing the Experience: Wyeth-Ayerst Mentors and Fellows Are Connected

Editor’s Note: In celebration of the 10th anniversary of the AACN Wyeth-Ayerst Nursing Fellows Program, AACN invited alumni mentors and fellows to share their thoughts about and experiences with the program. These accounts will be published in AACN News throughout this anniversary year.

By Judy Verger, RN, MSN, CCRN, CS, NP
Wyeth-Ayerst Mentor

While serving on the NTI Work Group for 2000, I met Melissa Hutchinson, RN, CCRN, an enthusiastic critical care nurse who had a strong commitment to clinical nursing and an interest in becoming more involved professionally. I was very impressed by the leadership skills she had already developed.

As our friendship grew, we began looking for other opportunities to work together professionally. The Wyeth-Ayerst Nursing Fellows program presented an excellent avenue to pursue.

The fact that we came from distinct specialty areas of expertise, mine in pediatric critical care and Melissa’s in adult cardiovascular nursing, enriched and expanded our ability to produce a quality manuscript. We felt we could offer the program a unique perspective.

Although the application process required careful thought, it was not overburdening. As the fellow, Melissa prepared the plan to develop one of three manuscripts for publication in the supplement to the American Journal of Nursing. As the mentor, I completed the section of the application addressing previous authorship and mentoring experiences.

We were fortunate to be chosen by the awards panel to develop our manuscript, titled “Immunomodulary Nutrition and ARDS.” During the nine-month program, we collaborated to build a clinically focused article. Melissa did most of the writing, and I did the editing.

We faced the usual struggles during the writing stages. The long distance nature of our work communication was, at times, challenging. Having access to the Internet made the process possible.

The pride we felt when the product was finished was incredible. I knew my fellow was bright and enthusiastic, but to see her flourish was an extraordinary experience.

At the NTI, I felt the strong professional support and financial commitment of the leadership of AACN, AJN and Wyeth-Ayerst Pharmaceuticals. The connectedness of the current and past Wyeth-Ayerst mentors and fellows was evident. I was honored to hear their stories and be affiliated with their work.

Practice Resource Network: Data Related to In-Hospital Resuscitation Outcomes

Q: Do you have information on collecting and analyzing data related to in-hospital resuscitation outcomes or benchmarks? We are seeking direction as we review the new guidelines from the Joint Commission on Accreditation of Healthcare Organizations guidelines regarding this issue.

A: The American Heart Association has done an excellent job of developing guidelines for measuring in-hospital resuscitation outcomes. These “AHA Recommended Guidelines for Reviewing, Reporting and Conducting Research in Hospital Resuscitation,” which appeared in Circulation (1997;95:2213- 2239), can be accessed online via the AACN Web site at http://www.aacn.org. Click on “Clinical Practice,” “General Practice Information,” “Clinical Practice Links” and “Cardiovascular” to locate the AHA guidelines link. These comprehensive guidelines include extensive evidence-based information on benchmarking, recommendation for measures and tools, as well as a variety of other related topics. This information should help you meet the JCAHO requirements. Topics covered include Introduction, Background, In-Hospital Utstein Variables, Utstein Template for Reporting on In-Hospital Resuscitation, Data to Collect on Individual Patients, Gold Standard for Outcome Comparisons, Process Gold Standard, In-Hospital “Chain of Survival,” Resuscitation Quality: Standard Reporting of In-Hospital CPR, Resuscitation Quality During Resuscitations, Ethical Issues, Conclusions and References. The American Heart Association also has the National Registry for CPR (NRCPR), which will be used to develop benchmark data. It has been designed and developed to specifically address the needs of hospitals to meet JCAHO guidelines and improve benchmarking and resuscitation process and outcomes CQI. More than 220 hospitals are enrolled. The association is actively seeking hospitals to contribute data and get reports back to benchmark and improve resuscitation outcome to meet the intent, spirit and content of the JCAHO regulations. For more information, visit the NRCPR Web site at www.nrcpr.org. Sample reports and the standard recommended NRCPR Code Record form can be downloaded from this site. Questions can be e-mailed to info@nrcpr.org.

If you have a practice-related question, call AACN’s Practice Resource Network at (800) 394-5995, ext. 217, or post your question online at http://www.aacn.org.

Make a Difference, One Patient at a Time

As the old man walked the beach at dawn, he noticed a young man picking up starfish and flinging them into the sea. Catching up to the youth, he asked why he was doing this. The answer was that the stranded starfish would die if left until the morning sun. “But the beach goes on for miles and there are millions of starfish,” countered the other. “How can your effort make any difference?” The young man looked at the starfish in his hand and threw it to safety in the waves. “It makes a difference to this one,” he said.
Loren C. Eiseley
The Star Thrower

By Natalie Correll-Yoder, RN, MN, CCRN
Chair, Ethics Work Group

Assisting members to look inward and assess their own ethical decision making and values will help them develop the skills to reach out and be available to patients and families. We work with one patient and family at a time and, like the starfish, the impact we have can support them through very difficult situations. We can make a difference.

Thus, AACN’s 2002 Ethics Work Group will continue to build on the theme of “Making a difference, one patient at a time.”

The work group, which is chaired by Natalie Correll-Yoder, RN, MN, CCRN, met in August 2001 in Costa Mesa, Calif. Other members of the group are Benny J. Bolin, RN, ADN, MS, Kate E. Sullivan Collopy, RN, PhD, CCNS, CCRN, Julie A. McNulty, RN, BSN, CCRN, Pamela K. Popplewell, RN, BSN, CCRN, Nancy L. Seymour, RN, BSN, CCRN, and Christine G. Westphal, RN, MSN, CCRN. Carol Puz, RN, BSN, CCRN, is the liaison for the AACN Board of Directors. AACN National Office liaisons are Practice Director Justine Medina, RN, MS, and Clinical Practice Specialist, Katie Schatz, RN, MSN, NP.

Identifying current issues facing AACN members with respect to clinical ethics topped the agenda. The list included clinical issues such as informed consent, advance directives, patient and family decision making, advocacy, current economic and demographic trends, cultural diversity, organ donation and brain death, genetic research and medical error reporting.

In addition, the ethics of the current workplace environment was identified as an issue that needed to be addressed. The work group members explored the question of how critical care nurses are managing to care for patients when they are faced not only with a staffing shortage but also with increased expectations from patients and family members. Much of the discussion focused on the availability of tools to help critical care nurses deal with these ethical situations as they arise.

Goals for the year were developed in response to requests by members for expanded resources and education on dealing with difficult ethical issues that arise when providing care for critically ill patients. Following are some of the goals for the coming year:

• Continue the ethical case study articles for use as teaching tools in AACN News.
• Increase AACN members’ awareness of currently available ethics resources.
• Develop tools to assist critical care nurses with self-assessment of their values and ethical decision making.
• Develop tools to assist critical care nurses when working with the patient or family trying to make decisions about appropriate treatment options.
• Ensure that a thread of ethics is incorporated throughout AACN educational programming.
• Continue to evaluate needs and opinions of AACN members regarding current ethical issues, including workplace environment, as well as the tools required to meet these needs.

Work group members saw a need to further increase awareness of available AACN resources and provide or create more tools for dealing with ethical issues. Critical care nurses assist patients and families when it is time to make the appropriate treatment decisions. By tapping into available resources and having the right tools, we can help guide patients and families through some of the ethical issues they come across and the decisions they have to make.

Research Corner: Identifying Research Problems in Critical Care

By Jane M. Kurz, RN, PhD

Every critical care nurse who wants to improve the quality of patient care can have a role within the research process. This could be by participating in data collection, developing
a research proposal or evaluating nurse colleagues’ research proposals or studies.
Identifying the research problem is the most important step in the research process. What is being studied? Who is being studied? Why is this issue being studied? Once the problem is clarified, you can move forward to generate the research purpose and research questions.

Recognizing Problems
The research process usually starts with a question prompted by a problem or unusual situation in practice that needs to be explored.

All nurses can identify clinical situations where the outcomes are unsatisfactory. For example, certain types of patient wounds do not heal as well or as quickly as expected. Certain patients respond differently to different types of analgesia. Positioning makes a difference in recovery for some patients. These are situations that need further examination and improvement.

Conversely, nurses often relate stories about specific patients who experienced better outcomes than expected. Some patients were able to sit out of bed longer and earlier after surgery. Some patients and families learned a specific procedure more easily than others. These, too, are situations that a nurse might want to explore in greater depth.

The critical care environment also lends itself to scrutiny, whether related to staffing, patient workload, leadership and management issues. For how many ventilator patients can a nurse safely provide care? How does the managerial style of nurse managers affect functioning of the unit? What are the characteristics of nurses or units successfully using self-scheduling strategies? What is the best and most appropriate way for critical care nurses to
delegate nonnursing tasks?

Identifying Research Problems
Identifying research problems in critical care begins with the nurse describing situations or concerns regarding problems in the everyday workplace or practice area. What is happening? Why is this situation different from the ideal? You must be aware of current standards and practices. Has there been a practice change? You should brainstorm with colleagues about the problem. Are others noticing this issue? What have others read about this problem?

The focus does not always need to be negative outcomes. You can also be interested in factors associated with positive results. Do some patients who listen to music while being weaned return to breathing room air faster than others who follow the usual protocols? Why do some units have less absenteeism rates than others? Conferring with others in your unit or hospital will help to focus on what should be examined.

Critical care nurses can also become aware of research problems by reading journal articles. Be aware that published studies usually include a section addressing limitations. Authors might state that the sample was too small or did not include some population, such as women. You might question using the findings with your group of patients. This could serve as a source of a research question for you. Would the results be the same if the study setting was like your unit or hospital or included your typical patient or nurse? Some authors give suggestions for future studies. When several nurse researchers identify the same area that deserves further attention, legitimacy for exploring a research problem is established.

In addition, professional organizations and funding agencies establish research priorities that identify and address important gaps in knowledge topics. The list of AACN research priorities is available on the AACN Web site at http://www.aacn.org

If your initial focus is on work force, patient care advocacy or technology issues, visit the Web site of the American Organization of Nurse Executives at www.aone.org/practiceresearch/research_priorities.htm. Details about the National Institute of Nursing Research priorities and areas of funding can be accessed at its Web site at http://www.nih.gov/ninr) as well.

Information presented at conferences is another way to identify findings that warrant further investigation. Speakers speculate about creative implementation strategies or outcome measurement methods. The presentations could be at national gatherings, local chapter conferences or specialty conferences that focus on specific systems. Many units conduct multidisciplinary “grand rounds” that offer discussions of global and unit trends. How many times have you heard, “We don’t have the answer to that question. Someone should look into that.” There are many areas that offer research problems, but the critical care nurse needs to be curious, astute and imaginative to use these sources effectively.1

Refining the Problem
Once the research problem or area of interest has been identified, it needs to be refined. By asking questions about the problem, the critical care nurse develops a clearer view as to what is really of interest. Typical questions are:2

• What is unusual with this situation?
• Does this happen often?
• What are the factors involved here?
• Who is involved?
• What happens if … occurs?
• What causes …?
• Is this important to patients and/or nurses?
• What do others know about this problem or situation?

To answer these questions, you must use your personal resources, such as critical-thinking skills, problem-solving abilities, creativity and clinical knowledge.3 Writing responses to these questions and keeping related materials in a personal folder or binder improves organization, prevents duplication of efforts, prevents loss of important notes or articles, tracks sources of information and makes retrieval, when needed, efficient.

Start by seeking the support of colleagues, who can critique your ideas and direct you to other sources. A preliminary review of the literature, starting with a computerized search of such resources as CINAHL and MEDLINE will provide timely information related to the research problem. You will find out what is known and what gaps exist. As new information is discovered, you can alter the research problem.

Evaluating the problem
Before finalizing the research problem, critically evaluate it. Ask: Is this a researchable problem? Problems that pose a philosophical or ethical question are not directly answerable by research. Is this an important research problem to you and to nursing? If the examination of the problem does not result in information that can be used to improve patient care or the nursing environment, it may not be an appropriate research problem. Is this a problem that will hold interest? All research problems are initially exciting. As other problems develop and time passes, motivation needs to fuel continued interest for the duration of the project. Consider personal time and energy constraints. Are there resources available to explore the problem? Verify that the equipment, specialists or administrative support needed are available. If other staff nurses believe that critically ill patients and families are too stressed to participate in a survey, the needed support to address the problem may not be available.

Jane M. Kurz, RN, PhD, is chair of the Division on Research at Temple University, Philadelphia, Pa. She is a member of AACN and of the Delaware Nurses Association.

References
1. Burns, N. Grove, S. The Practice of Nursing Research: Conduct, Critique, & Utilization, 4th ed. Philadelphia, PA: W.B. Saunders Co, 2001.
2. Norwood, S. Research Strategies for Advanced Practice Nurses. Upper Saddle River, NJ: Prentice Hall Health, 2000.
3. Schira, M. Mateo, M. Exploring innovative ways of giving care. In M. Mateo, K. Kirchhoff, Using and Conducting Nursing Research in the Clinical Setting, 2nd ed. Philadelphia, PA: W.B. Saunders Co., 1999.
4. Cormack, D. An overview of the research process. In D. Cormack, The Research Process in Nursing, 4th ed. Oxford,:England: Blackwell Sciences Ltd., 2000.


For Those Who Wait: A Guide to Critical Care for Patients, Families and Friends


This new, 21-page booklet is a great resource for patients, families and friends. It focuses on what to expect from admission through discharge, including visiting the patient and the need for a family spokesperson. It reviews the critical care team, advance directives and the types of equipment that might be used in the critical care unit. The information is appropriate for both pediatric and adult ICU patients and families and provides a helpful glossary in easy-to-understand terms.

Price: $1.50 for AACN members ($1.75 for nonmembers)
(Quantity discounts available)
Item #120630

To order, call (800) 899-2226.


Grants

AACN awards several grants to fund studies that are relevant to critical care nursing practice. The deadlines to apply for some of these grants are approaching. Read on for more information about these grants:

Due Jan. 15, 2002

AACN Clinical Inquiry Grant
This grant awards up to $500 to support research that focuses on one or more of AACN’s research priorities. Funds may be applied to new projects or projects in progress. Interdisciplinary projects are especially invited.

Due Feb. 1, 2002

AACN Datex-Ohmeda Grant
This grant funds up to $5,000 to support research related to nutritional assessment of the critically ill patient. Suggested topics include the impact of continuous metabolic monitoring, assessment of the nutritional and metabolic condition, current practices of nutritional assessment, use of the Harris-Benedict Equation vs. indirect calorimetry in nutritional assessment, and evaluation of the accuracy or efficacy of continuous metabolic monitoring.

AACN Certification Corporation Research Grant

This grant awards up to $10,000 for up to four studies related to certified practice. Examples of eligible projects are studies that focus on continued competency, the Synergy Model, the value of certification as it relates to patient care or nursing practice and credentialing concepts.

AACN Critical Care Grant
This grant awards up to $15,000 to support research that focuses on one or more of AACN’s research priorities.

AACN Mentorship Grant
This grant awards up to $10,000 to provide support for a novice researcher, who will be directed by a mentor experienced in the area of proposed investigation.

To obtain grant application materials, call (800) 899-2226 and request Item #1013, or visit the “Clinical Practice” area of the AACN Web site at http://www.aacn.org. Click on “Research.”


In the Circle: Award Honors Excellent Preceptors


The following excerpts are from exemplars submitted in connection with the Eli Lilly & Company Excellent Preceptor Award for 2001, sponsored by Eli Lilly & Company. This award, which is part of AACN’s Circle of Excellence recognition program, honors preceptors who demonstrate the key components of the preceptor role, including teacher, clinical role model, consultant and friend/advocate. Recipients were provided complimentary registration, airfare and hotel accommodations for NTI 2001 in Anaheim, Calif.

Marilyn Meredith, RN
Mission Viejo, Calif.
Mission Hospital
Preceptors must be sensitive to each new nurse’s individual needs. The orientation program that I developed for nurses new to the surgical-trauma ICU was standardized in content, the process was individualized. Our unit goal is to encourage new nurses to accept their individuality and to foster the collaborative practice of all disciplines within our unit.

Recently, our ideals and goals were challenged when I precepted one of our newest nurses. A single mother, she was a new nursing school graduate who was thrilled to be hired into the surgical-trauma ICU. She had graduated near the top of her class and was highly motivated. However, personal stress had created barriers to her performance.

While trying to study for state board exams and perform well during her orientation, she was told that both of her children faced serious medical and educational difficulties. This stress affected her learning, her self-esteem and her performance.

The ICU managers and I knew she had the ability and desire to become an excellent critical care nurse. We met with her on a regular basis, assisted her with appropriate goal setting and lengthened and altered the hours of her orientation schedule. These individual changes allowed her the time she needed with her family as she adjusted to her new job.

She completed her preceptorship and is now working full time in our unit. She continues to learn and is making continued progress toward fulfilling her goals. On her own, but not left to stand alone, her continued efforts and the support of our staff have made it possible for her to succeed.

Lynn Orser, RN, BSN
Hamden, Conn.
Hospital of Saint Raphael
In today’s healthcare environment, nurses are asked to do more with less, which also applies to the orientation of new staff. However, providing new staff with a comprehensive and concise orientation is more important than ever.
Faced with budget cuts, I recognized the need to find creative ways to assist with orientation in the medical ICU. I developed educational packets on basic ECG interpretation, arterial blood gas interpretation, drug calculations and pulmonary artery catheters, which I use in conjunction with the preceptee’s clinical orientation. I encourage my preceptees to share equally in the responsibility of their orientation. I give each new nurse a copy of a concise, pocket-sized resource book that I created. In addition to precepting in the MICU, I present the lecture on “Care of the Patient with Acute Myocardial Infarction” in the hospital’s critical care course.

Preceptors must be a positive role model. Exposing a preceptee to a preceptor’s own negative attitude reinforces the acceptance of bad behavior and negative attitudes. Preceptors must provide a supportive environment for new staff. Lending an ear and extending friendship is as important as providing new staff with educational information and clinical experiences.

Nursing is a wonderful profession that requires compassion, caring, intelligence, innovative thinking and leadership. We need to extend our gifts to our peers, as well as to our patients. I am proud to be a critical care nurse. Precepting enables me to share my love of nursing with others and make a difference for the future of nursing.

Heidi Radke, RN, ADN
Albuquerque, N.M.
University Hospital
Since beginning my role as a preceptor on a general medicine unit seven years ago, I have embraced the opportunity to teach nursing students, graduate nurses and experienced nurses who are new to critical care, as well as medical students and interns, patients and their families.

Teaching comes easily for me. Precepting, however, is much more than teaching. It means turning a passion for learning into a passion for watching someone else learn. It means being the silent partner, the wind under the wings, the gentle nudge.

My teaching strategy is simple: commitment, communication and compassion. If I model these and provide the best learning opportunities for preceptees, precepting is easy.

For example, I wanted to provide a quick transition for my preceptee from day shift to night shift and support her

in being independent and autonomous. My challenge was to identify and support her strengths, to identify her weaknesses and gently guide her through this learning curve, and to be a role model. However, the greatest challenge was to sit back, be her consultant, her advocate, and eventually her friend.

One evening, when I stepped in to offer help in an acute event, my preceptee was able to observe my behavior, my communication skills and my plan of action to save this patient’s life. She quickly joined me in a team effort to provide immediate care to a bleeding patient. At one point, I looked up and saw sheer terror in her eyes. The next minute, I saw pure intensity. It was at that moment that I knew this nurse was going to be awesome!

AACN Online Quick Poll

Does your hospital provide a pay differential for CCRN certification?

Yes 25%
No 75%

Number of Responses: 930

The AACN Online Quick Poll is a voluntary survey on a variety of topics and is not scientivcally projectable to any other population. AACN presents 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.