Research Corner: Distinguished Research
Lecture Celebrates 100th Birthday of ECG
Barbara J. Drew
delivered the 2002
Distinguished Research
Lecture.
For Barbara
J. Drew, RN, PhD, FAAN, a positive and
interesting first-job experience in a
coronary care unit led to an impressive
career in which she has not only saved
lives, but also helped improve medical
technology and traveled around the world.
Today, the nationally known researcher is
professor and vice chair of academic
programs in the Department of Physiological
Nursing at the University of California, San
Francisco, School of Nursing.
As recipient
of the 2002 Distinguished Research Lecture
Award, Drew shared her experiences and
discussed advancements she hopes will be
made in cardiac care at AACN�s National
Teaching Institute and Critical Care
Exposition in May 2002 in Atlanta, Ga. Her
Distinguished Research Lecture presentation,
titled �Celebrating the 100th Birthday of
the Electrocardiogram: Lessons Learned From
ECG Monitoring Research,� was sponsored by
Philips Medical Systems. (See the July issue
of the American Journal of Critical Care for
an article by Drew on this research topic.)
Drew has
made cardiac care her life�s work, after
being disappointed at the important clinical
problems she saw being missed by doctors and
nurses. She turned to research to identify
ways to improve cardiac monitoring
technology for better patient diagnosis. As
a result of her findings, many manufacturers
made improvements to their cardiac monitors.
Drew has
been studying reduced lead-set technology
that will allow for monitoring multiple
views of the heart without the need to place
electrodes in different anatomical
locations. Under the standard method of
recording ECGs, patients who require
continuous monitoring must suffer the
impediments of wearing 10 electrodes and 10
lead wires. These wires and electrodes not
only interfere with sleep and resuscitation
and lead to skin breakdown, but also are
cumbersome for the nurses to maintain. To
improve the ECG recording system, Drew has
been working with engineers to develop a
five-lead ECG technique.
Drew also
hopes to help improve cardiac monitoring in
the prehospital phase of acute myocardial
infarction. Plans are to equip ambulances in
Santa Cruz County, Calif., with a new system
that will continuously monitor patients en
route to the hospital, automatically dial up
the destination hospital via a cell phone
and print out an ECG in the emergency
department whenever a significant change in
cardiac activity is noted. This new
technology will allow physicians and nurses
to be better prepared when a heart attack
patient is on the way.
�Hopefully,
this new technology will reduce treatment
time and save patients from more heart
damage,� Drew said. �We hope to prove that
this machine results in better outcomes by
earlier detection and treatment.�
Drew also
educates other nurses on the correct
anatomical placement of electrodes.
Inaccurate electrode placement can change a
patient�s diagnosis and result in
inappropriate treatment, she noted. In 1990,
she surveyed AACN members regarding
electrode placement. The 350 responses she
received showed that most inaccurately place
electrodes.
The impact
of her work has spread, with the technology
that she has been helping to develop being
used to monitor astronauts at the
international space station. She also is the
only nurse invited to speak in the
Netherlands at the Willem Einthoven
Foundation�s celebration of the 100th
birthday of the ECG.
Grants: Apply for Research Funding
Oct. 1,
2002, is the deadline to apply for three
nursing research grants that are available
through AACN:
AACN
Clinical Practice Grant�This grant awards up
to $6,000 to support research focused on one
or more of AACN�s research priorities.
AACN-Sigma
Theta Tau Critical Care Grant�Cosponsored by
Sigma Theta Tau, this grant awards up to
$10,000. Recipients must be members of
either AACN or Sigma Theta Tau.
Evidence-Based Clinical Practice Grant�This
grant awards up to $1,000 for studies that
include research utilization studies, CQI
projects or outcome evaluation studies.
Collaborative research teams are encouraged.
To find out
more about AACN�s research priorities and
grant opportunities, visit the AACN Web site
at
http://www.aacn.org.
The grants handbook is also available from
AACN Fax-on-Demand at (800) 222-6329.
Request Document #1013.
Individual Beliefs Must Be Respected:
Cultural Diversity Presents Healthcare
Challenges
By Nancy
Seymour, RN, BSN, CCRN
Ethics
Work Group
Cultural
diversity has created significant gray areas
in the daily challenges of healthcare. In
healthcare, cultural diversity is a concept
describing professional care that is
culturally sensitive, culturally appropriate
and culturally competent.
Culturally
appropriate means that the healthcare
provider applies the underlying background
knowledge necessary to provide the best
possible care for a patient. Culturally
competent means that the healthcare provider
understands and attends to the patient�s
total situation, including awareness of
immigration status, stress factors and
cultural differences. Culturally sensitive
means that the healthcare professional
possesses some knowledge of and constructive
attitudes toward the diverse cultural groups
found in the setting in which they are
practicing.
By
determining how the patient defines
healthcare, we can establish a foundation
for understanding how to balance his or her
care within spiritual, physical, mental and
cultural boundaries. However, upon
admission, healthcare providers do not
usually ask patients how they define
healthcare, though they may ask patients
about their religious belief or concerns.
Although
religious beliefs are a testament to
individual spirituality and free will, they
can present a barrier between a nurse and
his or her role as a healthcare provider.
Medical decisions that arise amid religious
conflicts for patients and their families
during end-of-life situations are especially
difficult.
Respecting
individual diversity allows us to understand
a patient�s spiritual needs and the
traditions that mandate them, even when they
are counter to established and accepted
healthcare procedures.
But, what if
they do not have a defined religion or
concern? Or, what if they have exclusive
religious beliefs that they fail to share
until a crisis arises?
Here is an
example:
Mrs. D., who
was scheduled as an outpatient for a urology
procedure, had signed blood consent and
denied any particular religious beliefs,
special needs or concerns. After she became
unstable during the procedure, she was
admitted to the critical care unit for
anemia, hypertension and pregnancy of 34
weeks. She had other children at home and
had been under medical care for this
pregnancy.
Fluid
resuscitation, lab testing, certain
treatments and physical assessments were
performed, but her hemoglobin was 3.1. The
primary physician ordered blood transfusions
to reverse the anemia. The other physicians
on the case had agreed on the plan of care.
When the
physician met with the patient to discuss
her care, she declared that she was a
Jehovah�s Witness, a religion adverse to
blood transfusions at any time. She stated
that she signed the blood consent �to
cooperate,� because she was certain that
there would be no need for a blood
transfusion. At this point, the patient�s
condition in relationship to the Synergy
Model was highly vulnerable and minimally
resilient. Her anemia, spiritual beliefs and
34-week pregnancy made her minimally stable
and highly complex.
A dilemma
manifested between the medical need for
blood transfusions and Mrs. D.�s spiritual
beliefs. The difficulties at this juncture
were the medical needs not only of the
patient but also of the unborn fetus.
As critical
care nurses, we must comply with the wishes
of the patient to refuse medical treatment,
unless ordered otherwise by a court of law.
As was done in this case, when a hospital
has elected to override a patient�s right to
refuse medical treatment, it must provide
immediate notice to the court.
This case
went to the hospital ethics committee, which
debated the patient�s spiritual needs and
the vital interests of her unborn fetus, as
well as the significant burden that rested
with the hospital.
Jehovah�s
Witnesses can make informed refusals for
accepting autologous or homologous whole
blood, packed red blood cells, platelets or
white blood cell transfusions. In this case,
the ethical questions centered on the wishes
of an unborn baby. Mrs. D. was given
multiple blood transfusions. Soon after, a
viable baby girl was born. Within the first
year after the child�s birth, the mother
appealed the circuit court order, stating
that she could not be compelled to undergo a
transfusion for the benefit of her viable
fetus. The decision of the court-appointed
guardian, who was acting in the alleged
interest of the fetus, was reversed.
This
complex, ethical case involved many members
of the healthcare team. Throughout, the
critical care nurses were at Mrs. D.�s
bedside to provide comfort, give support,
allow her to verbalize and provide
professional care. Expressing and following
patients� needs while providing the best
care available is not always easy for the
patient or for the healthcare team. As long
as we continue to work together, we will
continue to improve as nurses and continue
to learn how best to protect the rights of
our patients.
Bibliography
Choices for
blood transfusions. JAMA.
1981;246:2471-2472.
Andrews MM,
Boyle JS. Transcultural Concepts in Nursing
Care, 2nd edition. Philadelphia, Pa: JB
Lippincott; 1995.
I Know Why
the Caged Bird Sings. New York, NY. Random
House;1970.
Knowing My
Neighbor, Religious Beliefs and Traditions
at Times of Illness and Health. Springfield,
Mass: Council of Churches Visiting Nurse
Hospice of Pioneer Valley;1995.
Dresser N.
Multicultural Celebrations. New York, NY.
Three Rivers Press;1999.
Spector RE.
Cultural Diversity in Health and Illness,
5th edition.
Internet
sources:
http://www.ajwrb.org
and
http://www.cms.org.
Viewpoint: When Does Aggressive Care Become
Futile Care?
By Debbie
Brinker, RN, MSN, CCNS, CCRN,
and
Kathleen McCauley, RN, PhD, CS, FAAN
The ethical
dilemma of determining when aggressive care
of the critically ill has transitioned into
�futile� care is of concern to nurses,
physicians, patients and families. In an
effort to clarify this complex issue, we
talked with two experts whose practices
center on helping providers, patients and
families with these difficult decisions.
Mimi Mahon,
RN, PhD, FAAN, clinical nurse specialist for
end-of-life care and ethics at the Hospital
of the University of Pennsylvania,
Philadelphia, defines futility as not being
able to meet the goals of care. The same
disease may or may not be �futile� when
experienced by different patients. Johnny
Cox, RN, PhD, vice president of theology and
ethics at St. Joseph�s Regional Health
System, Orange, Calif., states that he
avoids using the term �futility� because it
has different meanings to different people.
Professional
nurses and physicians share the goal of
providing care and treatment to prevent
disability, aid recovery and relieve
suffering. Life support in critical care
units is designed to restore or sustain
survival that carries meaning and value for
the patient. These principles guide
clinicians in decisions to withhold or
withdraw treatment and provide the context
for many of Mahon�s and Cox�s consultations.
Conflicts
often arise because we do not clearly define
the goals of treatment up front and are not
honest with ourselves as clinicians about
the likelihood of success. Too often in
healthcare, we have difficulty reaching an
accurate prognosis. This is complicated by a
tendency to err on the side of
optimism�sometimes based on inaccurate
data�in our communications with patients and
families.
Mahon
emphasized that care decisions are made with
the best intentions, often driven by a
belief that living is better than dying
regardless of quality of life. In the case
of a deteriorating patient, this culminates
too frequently with a healthcare team asking
the family, �What do you want us to do?� Cox
suggested that the approach to decision
making with patients and families should
focus on the outcomes that the treatment
might or might not produce with respect to
what the patient evaluates as worth the
burden he or she would have to shoulder.
To
illustrate the point, Mahon said: �When your
mother came to the hospital, our goal was to
make her better. She had surgery for the
problem with her intestine. She was on a
breathing machine and received many drugs to
give her body every chance to heal. When we
first spoke, we thought that her body would
respond within five days or so. It has now
been six weeks and your mother�s body has
been unable to heal. Her kidneys and liver
are no longer working normally and our
efforts to get them to work properly have
failed. What we need to do now is change our
focus from curing your mother to making sure
that she is comfortable.�
When you ask
family members what they want you to do, the
probable answers are �Everything� or
�Nothing.� A more optimal question is: �If
your mother were able to participate in this
conversation, what would she tell us to do?�
This approach unburdens the family so that
they are guided to make decisions based on
what they know the patient would want.
Mahon points
out that our language about care can
interfere with this process. We talk about a
patient �failing� therapy. As a healthcare
system, we have arrived at the conclusion
that to be unable to cure is to fail. She
notes that in the last year of our lives,
80% of us will suffer heart failure, chronic
lung disease, cancer, stroke or dementia.
When faced with illnesses that cannot be
cured, we must provide better symptom
management. In Mahon�s clinical experience,
the three major symptoms that patients face
in the last days of life are pain, anxiety
and dyspnea. Relieving these symptoms
clearly benefits patients. However, because
the death is more peaceful and less symptom
ridden, it also helps with family
bereavement.
Cox agrees,
saying that a key is to �address the systems
of treatment/care that perpetuate our
struggles to shift from curative attempts to
comfort only.�
�We practice
in an extraordinarily vitalist field where
death is considered a failure of a
professional duty rather than the completion
of a personal journey,� Cox said. �Until
this fundamental attitude is rectified, we
will only be doing damage control.�
Cox, who
helped found the Hospice of Spokane (Wash.)
in 1976, has committed his practice to
strengthening organizational structures that
support physicians, nurses, patients and
families in decision making regarding end of
life.
He pointed
out that, when the patient is a child, we
tend to provide curative treatment until it
causes significant suffering for the child
with little possibility of benefit. Although
older people can consider dying as the final
chapter in a personal autobiography, a
child�s death evokes a deep sense of
untimely tragedy. Whenever children can
convey evaluations of the benefits and
burdens of treatment options, we should
listen attentively and take them seriously.
The
literature on the experiences of children at
end of life shows that many die in
hospitals, often in critical care units
after withdrawing life-sustaining
technologies. In a recent study, though 76%
of children were treated for pain, treatment
was successful in only 26%. Similarly, 65%
were treated for dyspnea, but effective
management occurred in only 16% (Wolfe J,
Grier HE, Klar N, Levin S, Ellenbogen JM,
Salem-Shatz S, Emanuel EJ, Weeks JC.
Symptoms and suffering at the end of life in
children with cancer. New England Journal of
Medicine. 2000;342:326-33.)
Determining
whether continuing aggressive critical care
is appropriate or futile requires a
multidisciplinary practice knowledge base.
Knowledge and skill are needed to negotiate
the transition from a cure to care focus
that is consistent with the patient�s wishes
and values and is based on realistic
prognostic outcomes.
�Families
and patients feel well supported when they
sense we have heard their stories,
appreciate their fears and concerns, and
encourage them to use their strengths in
working through their decisions,� Cox said.
Our goal is
to provide easily understandable information
regarding their condition and treatment
alternatives, comfort measures and assurance
that we will not abandon them as they
progress on their journey, he added.
In the
Circle: Award Honors Outstanding Clinical
Practice
Following
are excerpts from exemplars submitted in
connection with the 3M Health Care-AACN
Excellence in Clinical Practice Award for
2002, sponsored by 3M Health Care. Part of
the AACN Circle of Excellence recognition
program, this award is presented to acute
and critical care nurses who embody,
exemplify and excel at the clinical skills
and principles that are required in their
practice. The recipients were provided
complimentary registration, airfare and
hotel accommodations for NTI 2002.
Capt.
Erica Spillane, RNC, MHR, CCRN
Landstuhl,
Germany
Landstuhl
Regional Medical Center
At age 40,
Theresa would not recover from severe liver
disease brought on by years of alcohol and
intravenous drug use. She was a challenging
patient, but I consider myself lucky to have
been able to work with her and her family
during this difficult time. I regularly
heard about Theresa�s tirades of fighting
and swearing and noncompliance with her
treatments. However, I was always able to
provide Theresa with the nursing care that
she had previously refused. At shift�s end,
Theresa would smile and say that I had made
her feel like a queen.
Soon,
Theresa required ventilatory and vasopressor
support. Despite our best efforts, her
systems were shutting down, and I spoke with
Theresa�s family members about her
end-of-life wishes. They recalled her
telling them that she did not want to be
kept alive on life support if her condition
was terminal. However, spiritually, they
were having difficulty with this decision.
I called the
chaplain, who spent time offering spiritual
support. I spent the remainder of the shift
talking with the family about Theresa and
her life. That day, the family decided to
withdraw Theresa�s life support.
Theresa was
surrounded by love when she passed away. Her
family later thanked me for what I had done
for them and Theresa. One brother called me
his sister�s angel, which made me feel
extremely humble. It was then that I truly
realized the power of nursing in caring for
the terminally ill.
Steven
Savant, RN, BSN, CCRN
Lafayette, La.
Lafayette
General Medical Center
My
82-year-old patient, Genevieve, was in
respiratory failure secondary to chronic CHF.
She was on a ventilator, awake, cooperative
and obviously concerned after being admitted
to the medical ICU.
Genevieve�s
prognosis was poor. Her right heart
pressures were elevated, and her ejection
fraction on echo was 40%. The stress of
being hospitalized was taking its toll on
her morale, and she seemed to be fading
psychologically. The goal was to support
Genevieve with inotropic therapy and
diuresis in the hope of moving her to the
coronary care unit and possibly to an
outpatient status for control of her CHF.
I learned
that Genevieve had been recently widowed
after a 60-year union. She and her husband
had no children, but had shared the last 15
years with Max, a mixed breed dog, and a
housekeeper named Eleanor. Although I know
the relationships that can evolve between
pets and their owners and I have been both a
pet owner and a pet enthusiast, I had never
considered the relationship between the two
roles.
Genevieve
was mourning her husband and worrying about
her dog. A special visit by Max was the
obvious solution to motivating her. Within
48 hours of Max�s visit, Genevieve was
extubated and moved to the coronary care
unit. Two days later, she went home. Because
of the positive outcomes that resulted from
Max�s visit, our hospital has started a pet
therapy program. Although it is still in its
infancy, the program is being supported by
enthusiastic staff and the administration.
Debra
Pronitis-Ruotolo, RN, BSN, CCRN
Dallas,
Texas
Presbyterian Hospital Dallas
�You�re
getting this patient from Spain at about 10
p.m,� was the assignment I received when I
came on shift. Upon B.�s arrival, I took
report from the French transport team.
Except for the fact that she had no
discernable neurological response, the
patient was stable. The disconcerting
findings were a decreased level of
consciousness and the lack of reflexes in
the absence of sedation or paralytic agents.
What she needed now was close observation.
Turning my
attention to her family, I described what
they would see in the room and encouraged
them to hold B.�s hand and speak to her.
Although our ICU visiting times are open, we
encourage family members to get some rest
after 10 p.m. However, because this family
could not bear to be away from the patient�s
side, I agreed to let one family member at a
time sit quietly at her bedside the first
night.
B.�s brother
called me to the room and said, �She
squeezed my hand! B., do it again for the
nurse!� Soon, a crowd had gathered around
B.�s bed. Although I finished my shift
without experiencing a hand squeeze from B.,
her family did not give up hope.
Ten months
after the crash, B. and her husband hosted a
thank-you party for everyone who had cared
for B. We all rejoiced! Recently, B. and her
husband visited my unit. As I hugged both of
them, I remembered what I had thought when I
first saw B. I had recoiled at the prospect
of guiding yet another family through the
grieving process. Instead, I had been given
this incredible gift, a reminder that
sometimes miracles do happen.
Kate
McCarthy, RN, BSN, CCRN
Tallahassee, Fla.
Tallahassee Memorial Hospital
In 1987, I
entered the world of critical care nursing.
I had spent more than 10 years in nursing
practice, working in the emergency
department, surgery and obstetrics. However,
after a move from Ohio to Florida, I entered
the highly technical and stressful arena of
acute, critical care.
As I
familiarized myself with the equipment, I
comforted myself with the thought, �If I
really care and pay close attention, things
will be OK until I learn everything I need
to know.� As I tried to keep a balance
between seeking knowledge and giving care, I
found solace in caring for my patients and
focusing on their perception of what was
happening to them. The privilege of my role
was apparent. What some saw as sadness or
stress presented itself to me as an
invitation into an intimate human exchange.
Hearts were laid bare, relationships were
illuminated, and basic human needs were the
true patient call bells.
One evening,
an older woman with a ruptured septal wall
was heading to surgery. Prior to her
transport, I asked if there was family to be
called. This frail woman simply smiled and
said, �Yes, there�s Albert. He�s my nephew.
I never married, never had children. My
sister�s boy always took an interest in me.
He�s the only one here tonight with his
wife. I wonder if you would do me a favor,
dear. I don�t suspect I�ll be coming back
here tonight. If that should happen, I want
you to tell Albert �thanks� for me. Tell him
I went to surgery for him. He insisted I
couldn�t just lay here. I had to try to lick
this. Tell Albert it was a nice way for him
to say goodbye after all these years. Give
him my love.�
Dea Ann
Martin, RN, BSN, CCRN
Allen,
Texas
Presbyterian Hospital of Dallas
As I entered
Amy�s room, I noticed her husband Scott was
still in the same �labor coach� scrubs from
the previous night. He appeared lost,
distraught and alone. Amy was admitted to
our unit after a difficult delivery followed
by an emergency hysterectomy. This was her
first and last baby.
Amy arrived
ventilated, with severe hypotension and on
multiple intravenous medications. She had an
amniotic emboli to the lung, which resulted
in disseminated intravascular coagulation.
She was also in acute renal failure and
continued to hemorrhage. The only option was
to return to the operating room to find the
source.
Although the
bleeding had stopped, her condition
worsened, and, after surgery, she was
severely edematous because she had received
30 liters of fluid and blood. Scott would
not leave her side. Because the airports
were still closed because of the Sept. 11
tragedy, Amy�s mother, who lived out of
state, could not get a flight in. My goal
was to keep Amy hemodynamically stable while
providing emotional support to Scott and her
distraught mother.
Slowly,
Amy�s condition improved. We needed to
arrange for Amy to see her baby, Emma Grace,
who was in the neonatal ICU. Emma was crying
when she arrived, but stopped when the NICU
nurse placed her in her mother�s arms. As
the family was reunited, our tears of
sadness turned to joy.
I saw Amy
often during her two weeks in the hospital.
I knew she would not remember the week�s
events, but I would never forget. I was
elated that everything had turned out so
well. It was the most precious success story
of my career.
Practice Resource Network: Withdrawing Blood
From Central Lines
Q:
When drawing blood off central lines, is it
OK to re-inject the initial discard blood
into the patient instead of throwing it
away? In our adult critical care unit, many
labs are drawn from a single patient during
a 24-hour period. Each discard usually
involves approximately 10cc of blood, which
can amount to a significant blood loss over
time. We would like to conserve blood but
are concerned about exposing the patient to
an increased risk of infection. What does
the literature suggest?
A:
The purpose of withdrawing blood from the
central line before obtaining a blood sample
is to clear the catheter and tubing of
material that could contaminate the sample
and affect the test results. Studies have
shown that between 62.6 and 73.9 mL is the
mean range of blood withdrawn per day from
indwelling catheters in adult ICU patients.
One study of cardiothoracic ICU patients
demonstrated a mean daily blood loss of 377
mL, 30% of which was due to blood discard.1
This data
illustrate that frequent blood samplings and
their accompanying discards can present a
significant blood loss over time,
potentially resulting in anemia. This
nosocomial-induced anemia introduces an
additional and unnecessary risk for the ICU
patient, especially in highly vulnerable
populations, such as postoperative,
posthemorrhage and volume-depleted patients.
This is a
particularly significant problem in
pediatric populations. If strict
conservation efforts are not followed,
routine blood draws and discard from the
neonate often exceed 10% of the child�s
circulating blood volume.2 Unfortunately,
the practice of re-instilling the discard
blood via a conventional central line setup
poses a significant risk for contamination
and infection. The use of a well-designed,
inline, closed-loop system will help to
avoid this problem, while conserving
much-needed blood.
A
closed-loop system with a built-in blood
conservation device provides a practical and
relatively low-cost solution to excessive
blood loss due to blood discard.
Dech and
Szaflarski3 define a blood conservatory
system as a device that allows for sampling
of undiluted, heparin-free blood, while
storing the discard volume in a reservoir
placed in the line�s circuit. This allows
the full volume of discard blood to be
maintained in a closed system and then
returned to the patient without risk of
contamination. A variety of commercial
products are available and are illustrated
and discussed at length by Dech and
Szaflarski.
References
1. Henry M,
Gamer W, Fabri P. Iatrogenic anemia. Am J
Surg. 1986;151:362-363
2. Wilson
JR, Gaedeke MK. Blood conservation in
neonatal and pediatric populations. AACN
Clin Issues. 1996;7:229-237.
3. Dech ZF,
Szaflarski NL. Nursing strategies to
minimize blood loss associated with
phlebotomy. AACN Clin Issues.
1996;7:277-287.
Critical Thinking Spans the Continuum
By Diane
Salipante, RN, MSN, MS, CCRN, NP
Progressive Care Task Force
After being
admitted to the progressive care unit with
pneumonia, Mr. J., a 50-year-old diabetic
with hypertension and COPD, tells the nurse
he can�t breathe. He is diaphoretic and
using accessory muscles to breathe. His
vital signs are: RR 40, P 120, BP 88/50, and
oxygen saturation 85%.
While
completing the physical assessment, the
nurse draws upon basic knowledge and past
experience to assess that the problem might
be an MI, a pulmonary embolus, a
pneumothorax or CHF. The nurse starts
oxygen, summons help, calls the medical care
provider and prepares the emergency cart.
Next, the nurse draws labs, including a
blood gas, does an ECG and calls for an
x-ray. By using critical-thinking skills to
anticipate what interventions are needed,
this nurse can prevent delay in diagnosing
and treating Mr. J.�s problem and possibly
avert a more serious situation.
Critical
thinking is a reasoning process in which
individuals analyze their own thoughts,
actions and decisions, as well as those of
others. A critical thinker takes nothing for
granted, considers alternatives and makes an
informed decision by applying reasoning and
logic. A critical thinker then evaluates and
reflects on the decision to determine if it
was the best possible one.1
Unlike the
five-step nursing process, critical thinking
cannot be taught as a competency in a basic
educational program. Critical thinking is a
problem-solving approach that becomes part
of each nurse�s character through the
acquisition of knowledge and experience.2
Although principles of critical thinking are
often introduced in basic nursing education,
they must be nurtured in the individual by
example and fostered in an environment where
they can develop further.
Critical
thinking parallels professional development,
evolving through three levels: basic,
complex and committed. As nurses gain
experience and knowledge, attitudes and
standards that are basic to decision making
develop. At the basic level, nurses rely on
experts for answers and see each situation
as having a right or wrong solution. As
nurses progress to the complex level, they
analyze and examine situations more
independently, explore alternatives, and
weigh the risks and benefits of each
alternative before making a final decision.
When nurses advance to the commitment level,
they assume accountability for decisions and
choose actions or beliefs based on previous
knowledge and experience.3
To ensure
that safe, efficient and expert care is
delivered across the continuum of critical
care nursing, the development of
critical-thinking skills must be fostered.
An environment in which nurses can develop a
sense of confidence, independence, fairness,
responsibility, risk taking, discipline,
perseverance, creativity, curiosity,
integrity and humility is key to nurturing
critical-thinking skills. In addition, the
environment must support adherence to
professional standards and intellectual
standards, such as logic, accuracy and clear
thinking.3
Although
critical-thinking skills are valuable in all
nursing situations, they are essential for
nurses who function autonomously without the
availability of a large number of support
systems, such as in a progressive care unit.
When critically ill patients are moved from
ICUs to progressive care units, their
characteristics, as defined by the Synergy
Model, have changed from unstable and
vulnerable to more stable and less
vulnerable.4 However, these patients are at
risk of relapsing to the unstable and
vulnerable state at any time.
If safe,
effective, and expert care is to be
delivered in the progressive care setting,
progressive care nurses must have the same
knowledge base, assessment skills and
critical-thinking skills as ICU nurses.
Leadership must acknowledge the importance
of critical-thinking skills for progressive
care nurses and mobilize support systems and
educational resources to support them. They
must promote an environment where
progressive care nurses can acquire the
clinical and critical-thinking skills that
are essential to meeting the needs of their
patients.
References
1. Paul RW,
Heaslip P. Critical thinking and intuition
in the nursing process. J Adv Nurs.
1995;22:40-47.
2. Facione
NC, Facione PA. Externalizing critical
thinking in knowledge development and
clinical judgment. Nurs Outlook.
1996;129-136.
3.
Katako-Yahiro M, Saylor C. A critical
thinking model for nursing judgment. J Nurse
Ed. 1994;33: 351-356.
4. Edward
DF. The Synergy Model: linking patient needs
to nurse competence. Crit Care Nurse.
1999;19:88-97.
NTI
2003 Abstracts Due Sept. 1: Share Your
Research or Creative Solutions
Sept. 1 is
the deadline to submit research and creative
solutions abstracts for AACN�s 2003 National
Teaching Institute and Critical Care
Exposition, scheduled for May 17 through 22
in San Antonio, Texas.
Abstracts
must be relevant to the care of the acute
and critically ill or critical care nursing
and must be noncommercial in nature. The
first author must be a nurse holding current
AACN membership. Only completed research and
finished projects are eligible, and
abstracts must not have been previously
published or presented nationally.
The
designated presenters of accepted abstracts
receive a $75 reduction in NTI registration
fees. All other expenses are the
responsibility of the presenter, who can be
either the first author
or a
designate of the author.
In addition,
four awards will be presented for oral
research abstracts reflecting outstanding
original research, replication research or
research utilization. Each of these awards
provides an additional $1,000 toward NTI
expenses.
Following is
information about the abstracts:
Research
Abstracts
can focus on any aspect of critical care
nursing research, including reports of
research studies or reports of research
utilization. Only abstracts of completed
projects will be accepted. Abstracts
reporting research studies must address the
purpose; background and significance;
methods; results; and conclusions.
Creative
Solutions
Abstracts
should focus on specific strategies and
practice innovations that are used by nurses
to solve difficult, unique or interesting
problems in patient care, nursing practice,
nursing management or nursing education. The
creative solution must have been
implemented, with outcomes evaluated.
Abstracts must address the purpose of the
project and include a description of the
creative solution, as well as evaluation and
outcomes.
To obtain
abstract forms, call (800) 899-AACN (2226)
and request Item #6007, or visit the AACN
Web site at
http://www.aacn.org.
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