Spring 2005

Fall 2005
Volume 16,
Number 3
Index:
Critical thinking .......................................................4
University of Alberta students wrote the lyrics,
CACCN Board of Directors call the tune..............10
ISMP Canada –
Dangerous abbreviations:
“U” can make a difference! ...................................11
Exemplary care of the palliative patient:
The journey shared ................................................16
Family perceptions of
end-of-life care in an urban ICU ...........................22
Improving pain management
for critically ill and injured patients ......................26
IN THIS ISSUE:
Awards available for CACCN members
.................................................................page 33-34
2
16 • 3 • Fall 2005
CACCN
Volume Sixteen, Number Three
Fall 2005
DYNAMICS
The Official Journal of
the Canadian Association
of Critical Care Nurses
is a refereed journal
published four times
annually by Pappin
Communications,
Pembroke, Ontario.
Printed in Canada.
ISSN 1497-3715.
Copyright 2005 by the
Canadian Association of
Critical Care Nurses,
P.O. Box 25322,
London, Ontario, N6C 6B1.
No part of this journal may
be reproduced in any
manner without written
permission from CACCN.
The editors, the association
and the publisher do not
guarantee, warrant or
endorse any product or
service mentioned in this
publication.
For information on
advertising, contact
Heather Coughlin,
Pappin Communications,
The Victoria Centre,
84 Isabella St., Pembroke,
Ontario, K8A 5S5,
telephone (613) 735-0952,
fax (613) 735-7983, e-mail
[email protected],
website: www.pappin.com
Send manuscript enquiries
or submissions to Paula
Price, ACCN Program,
Faculty of Health and
Community Studies, Mount
Royal College, 4825 Mount
Royal Gate S.W., Calgary,
Alberta T3E 6K6
DYNAMICS
The Official Journal of
the Canadian Association
of Critical Care Nurses
is indexed in the
Cumulative Index to
Nursing and Allied Health
Literature, EBSCO, the
International Nursing Index,
MEDLINE, and RNdex Top
100: Silver Platter.
CACCN
DYNAMICS
The Official Journal of the Canadian
Association of Critical Care Nurses
Clinical Editor:
Paula Price, RN, PhD, Instructor,
ACCN Program, Department of Advanced
Specialty Health Studies, Mount Royal
College, 4825 Mount Royal Gate S.W.,
Calgary, AB, T3E 6K6,
Telephone: (403) 440-6553,
Fax: (403) 440-6555,
e-mail: [email protected]
Publications Chairperson:
Asha Pereira, RN, BA, BN,
CNCC(C), CINA(C), Winnipeg, MB
Editorial Review Board:
Adult Consultants:
Janice Beitel, RN, MSc,
CNCC(C), CNN(C), Toronto, ON
Kathleen Graham, RN, MScN,
Ottawa, ON
Martha Mackay, RN, MSN, CNCC(C),
CCN(C), Vancouver, BC
Pediatric Consultants:
Franco Carnevale,
RN, MSA, MEd, PhD,
Kirkland, PQ
Judy Rashotte, RN, MScN, CNCC(C),
Ottawa, ON
Neonatal Consultant:
Debbie Fraser Askin, RNC, MN,
Winnipeg, MB
Dynamics, the Official Journal of the
Canadian Association of Critical Care
Nurses, is printed on recycled paper.
Canadian Association
of Critical Care Nurses
Board of Directors
President:
Patricia Hynes, RN, MA,
CNCC(C), Toronto, ON
Vice-President:
Asha Pereira, RN, BA, BN,
CNCC(C), CINA(C), Winnipeg, MB
Treasurer:
Glenda Roy, RN, BN, CNCC(C),
CCN(C), Grand Falls-Windsor, NFLD
Directors at Large:
Grace MacConnell, RN, BScN, MN,
CNCCP(C), Dartmouth, NS
Joy Mintenko, RN, CNCC(C),
Regina, SK
Susan Williams, RN, BScN,
CNCC(C), St. Thomas, ON
CACCN National Office
Administrator:
Tracy Porchak
P.O. Box 25322,
London, Ontario N6C 6B1
www.caccn.ca
e-mail: [email protected]
phone: (519) 649-5284
phone (toll-free) (866) 477-9077
fax: (519) 649-1458
2005 Subscription Rates: Dynamics, the Official Journal
of the Canadian Association of Critical Care Nurses, is
published four times annually, Spring, Summer, Fall and
Winter - Four Issues - $60 / Eight issues - $120 (plus 7%
GST). Payment should be made by cheque, money order or
by VISA only. International and institutional subscription rate
is $75 per year or $150 for two years.
Article reprints: Photocopies of articles appearing in
Dynamics, the Official Journal of the Canadian
Association of Critical Care Nurses, are available from the
CACCN National Office, P.O. Box 25322, London, Ontario,
N6C 6B1, at a cost of $5 per article. Back issues can be
purchased for $18.
16 • 3 • Fall 2005
3
Critical Thinking
I am sure many among us are looking forward to our
annual fall conference, Dynamics, held this year at
Ottawa’s Chateau Laurier in October. The theme is
Capitalizing on Technology with a Human Touch. Sue
Williams of the CACCN board of directors, along with her
committee, has prepared a fantastic program filled with
opportunities for education, professional development and,
of course, entertainment. For as long as I can remember,
Dynamics has been well-attended, enjoyable and overall
excellent in the provision of education, professional
development and networking opportunities. This year will
be no exception.
The human touch in critical care is gaining ground in the
practice setting and, as a result, the landscape of our day-today work is changing as we speak. Much of this change is
attributable to the presence of patients’ families and
significant others who have been able to gain consistent
access in spite of a system that does not always facilitate their
involvement. We are indebted to those who have shown
persistence because they are now teaching us how we can do
this better.
At the national level, we have demonstrated our support
for family presence (CACCN Standards for Critical Care
Nursing Practice, 2004) and we acknowledge family as
being “who they say they are” (Wright & Leahey, 2000,
p. 70). We are pleased to release our new position
statement called Family Presence During Resuscitation,
a project led by Grace MacConnell of the CACCN board
of directors. Grace illuminates key published points on
family-centred care (FCC) that are useful in
resuscitative situations and also helpful in our
understanding of family partnerships in care delivery.
For example, a requirement for policies that are
comprehensive to meet the needs of families as well as
a system that is flexible, accessible, and responsive is
important. The participation of families who can assist
in guiding the development of the policies would likely
enhance the education and comfort of health care
professionals. We can no longer ignore reports from, for
example, adult patients who have undergone invasive
procedures or survived cardio-pulmonary resuscitation
and found the presence of a family member comforting
and a source of strength throughout the ordeal
(Eichhorn, Meyers, Guzzetta, Clark, Klein, Taliaferro, et
al., 2001).
4
During Nursing Week 2005, we invited a former patient
and his partner, Jim O’Neill and Patrick Conlon, to our
ICU Nursing Council meeting. Jim was a patient for eight
weeks in two ICUs, including ours, and hospitalized for
15 weeks in total. They told a story about fear and
uncertainty and the many things the nurses did to keep
them in a safe place. Nurses give hope to patients and
families when they need it most was one of their
messages. This event was without question the highlight
of the Nursing Week activities we had planned for our
ICU.
While Jim and Patrick provided touching examples of
excellence in nursing care, they also told us what they
needed in order to feel that they were a part of it and not
apart from it, as Patrick said. Allowing that this is
difficult to achieve even within a framework of FCC, he
claims it is still possible to “win a place on the team,
gradually”. The following are excerpts from our
communication:
Q: How do you see FCC?
A: Like a photo. Your training conditions you to focus on the
patient – a close-up. FCC is a group photo, with the patient
still at the centre. It’s like a wide shot, compelling you to
see more. Begin by thinking of those people to either side
as potential assets, allies.
Q: How do you respond to claims that we are already doing
FCC?
A: Some may be already practising FCC, but think
about it. You’re not if you’re just being nice to
family, if some families are welcome and others
aren’t and if you feel you must always be in charge.
The hardest test of all: do you feel comfortable
asking families how’s he/she doing? And being open
to clues from each patient’s family about subtle daily
changes that might affect care decisions. It’s
teamwork. It requires give and take, with mutual
respect for the skills at the table. Families know stuff
you don’t and vice-versa.
Q: Is there anything else you would like to add?
A: FCC has to be positioned for what it is: an invitation to
expand the team around every patient. It’s not a campaign
to save money or replace anyone. At its best, it’s
16 • 3 • Fall 2005
CACCN
community at work. Will all families respond? Of course
not. But if you get 10% who join in a useful and productive
way, I’d call that a win.
In closing, I will ask you to reflect on the possibilities
for FCC within your ICU and for partnering with those
who have experienced the care you provide. If our
experience is in any way typical, there is much to be
gained.
Respectfully,
Patrick Conlon is an author and journalist who has written a
series of columns about FCC for The Toronto Star. I am
grateful to him and his partner, Jim O’Neill, for adding to our
insights on FCC in the ICU.
References
Eichhorn, D., Meyers, T., Guzzetta, C., Clark, A., Klein, J.,
Taliaferro, E., & Calvin, A. (2001). During invasive
procedures and resuscitation: Hearing the voice of the
patient. American Journal of Nursing, 101(5), 4855.
Wright, L., & Leahey, M. (2000). Nurses and families: A guide
to family assessment and intervention (3rd ed.).
Philadelphia: F.A. Davis Co.
It’s finally here!
Check it out
at www.caccn.ca
and let us know
what you think!
CACCN
Proxy votes may be mailed/faxed to: Canadian Association
of Critical Care Nurses, P.O. Box 25322, London, Ontario
N6C 6B1 (Fax) 519-649-1458
The following shall be a sufficient form of proxy:
I, _____________________, of _____________________,
an active member of the Canadian Association of Critical
Care Nurses hereby appoint
_____________________ of ______________________,
or failing her/him,
_____________________ of ______________________,
as my proxy to vote for me and on my behalf at the
meeting of members of the association to be held on the
3rd day of October, 2005, and at any adjournment thereof.
Dated at ____________________, this _____ day
CACCN’s new website
A new up-to-date look
An easy-to-use menu
Current information regarding:
• Membership information
• CACCN Position Statements
• CACCN’s Constitution and by-laws
• Your local chapter information
• Online membership application
• National conference information
• Online registration for the conference
• Contact information
• Awards
Every active member may, by means of proxy, appoint a
person (not necessarily a member of the association), as
his/her nominee to attend and act at the annual general
meeting in the manner and to the extent and with the power
conferred by the proxy. The proxy shall be in writing under
the hand of the member or his/her attorney, authorized in
writing, and shall cease to be valid after the expiration of one
(1) year from the date thereof.
Proxy votes must be received in the national office
no later than midnight, Friday, September 30, 2005.
Patricia Hynes, RN, MA, CNCC(C)
CACCN President 2004-2006
The updates include:
Annual General Meeting
Proxy Vote 2005
of ____________________, 2005.
Signature of Member: ____________________
CACCN Membership Number: ____________________
Awards Available
to CACCN
members
Criteria for awards available to
members of the Canadian
Association of Critical
Care Nurses are
published on pages
33-34 of this issue of
Dynamics.
16 • 3 • Fall 2005
5
CACCN Board nominee profile
It has been an honour to serve as your board
member for the past 18 months in the capacity of
treasurer. The learning curve has been steep and
I am very pleased to have accepted the
challenge. It has been rewarding to work with a
dedicated team of critical care nurses who have
your interests as their focus, and the betterment
of the patient as the pivot of their care.
This past year has been a great learning experience for me. I
have gained knowledge in areas of national nursing, the
functions of a board of directors and even some computer
skills.
I am asking for the privilege to be your representative on the
board of directors for a second term. I feel the knowledge that
I have acquired will enable me to be a more informed team
player as we endeavour to promote CACCN to all critical care
nurses across our vast country.
I have enjoyed my first year on the board of directors and look
forward to contributing at a higher level this second year. I
wish to apply for another two-year term on the board so that I
can continue to work with this dedicated group of
individuals. I feel that CACCN is the voice of
critical care nurses across our country.
Canada will be facing more challenges in
the nursing profession over the next few
years as the availability of practising nurses
decrease. I hope to be a part of this voice
that will guide Canada through this time of
crisis.
I have worked in a nine-bed critical care unit for
approximately 12 years as a staff nurse. The challenges of
working in critical care in a smaller hospital are endless with
the increase of patient acuity, new technology to master and
the advent of newer and more virulent bugs.
Glenda Roy
Chapter Recruitment
and Retention
Chapters that have recruited between 25 and 49 new
members:
London Regional Chapter
42
Manitoba Chapter
39
B.C. Lower Mainland Chapter
37
Saskatchewan Chapter
36
Calgary Chapter
31
I have worked in critical care for more than 20 years. I am
currently employed at the Regina General Hospital, working at
the bedside in the surgical ICU, the medical pediatric ICU, and
the PACU. I have been a member of CACCN since 1984,
when I graduated from the St. Boniface Adult Intensive Care
Course in Winnipeg, MB. I have just finished studying for and
writing the CNA Critical Care Certification exam. This
certainly reminded me of how much nursing practice and
technology has changed over the past 20 years.
Joy Mintenko
Future sites of
Dynamics
conferences
Chapters that have recruited between 50 and 100 new
members:
Toronto Chapter
127
Greater Edmonton Chapter
71
The following chapters retained greater than 80% of their
previous year’s members:
NONE
The following chapters retained greater than 60% of their
previous year’s members:
Saskatchewan Chapter
76%
B.C. Lower Mainland Chapter
70%
Toronto Chapter
63%
Manitoba Chapter
60%
Dynamics 2006
Dynamics 2007
Dynamics 2008
St. John’s Newfoundland,
Delta St. John’s Hotel and
Conference Centre,
September 24-26, 2006
Regina, Saskatchewan
Montreal, Quebec
NOTICE OF ANNUAL GENERAL MEETING
The national board of directors of the Canadian Association of Critical Care Nurses (CACCN) would like to extend
an invitation to the membership to attend the 2005 annual general meeting of the CACCN. The CACCN annual
general meeting will be held on Monday, October 3, 2005, at 1630-1730 hrs, at the Fairmont Chateau Laurier Hotel,
Canadian Room, in Ottawa, Ontario. Members unable to attend the annual general meeting are reminded that their
proxy vote must be received in CACCN national office by 2400 hrs, Friday, September 30, 2005. The proxy vote
form is printed at right, and can also be obtained from your chapter president or CACCN national office.
6
16 • 3 • Fall 2005
CACCN
From the clinical editor
In this issue of Dynamics: The Official Journal of the
Canadian Association of Critical Care Nurses we are
pleased to publish three original articles and our regular ISMP
Canada column. The column this issue focuses on
abbreviations and the errors that can result from them.
Serendipitously, the articles all focus on a central theme
in critical care – that of comforting patients and family
while in the ICU. The first article is a report of a study
Beth Perry conducted looking at what constitutes
exemplary care. Dr. Perry presented these findings at
Dynamics in Niagara Falls. I will always recall the
emotions Dr. Perry evoked among the audience during her
presentations.
Chapter Highlights
Montreal Chapter
We are a small and humble group with fewer than 30 members,
but our commitment to critical care nursing is immeasurable.
The Montreal chapter organized two eight-hour workshops for
2004 (Cardiac Arrhythmias, May 2004 and IABP, October
2004).
The CNA certification exam was held on April 2, 2005. Five
study group sessions were organized by Renee Chauvin and
facilitated by McGill-affiliated educators and clinical nurse
specialists. The sessions were held from January to March
2005, and were spread throughout three major McGill centres
in Montreal with an average attendance of 21 critical care
nurses.
The Montreal chapter will be organizing a summer meet-andgreet barbecue and an eight-hour Cardiac Pacemaker workshop in the fall.
Montreal chapter members are provided with our semi-annual “e-newsletter”. While Montreal, like most regions, faces
continuous struggles with staffing shortages, critical care
nurses remain interested in CACCN links and educational
events.
Renee Chauvin, President
Ottawa Chapter
Hello from the Ottawa regional chapter of CACCN!
Our chapter encompasses eastern Ontario, which includes
the cities of Cornwall, Pembroke and Kingston and, at the
moment, we have about 60 members. Last fall we offered
a workshop with three guest speakers. Rosemary Zvonar,
Pharmacist, presented on “Bugs and Drugs”, Andrea
CACCN
In the second article, Maria Kjerulf and colleagues present the
findings of their research looking at the factors that determined
levels of satisfaction with care among families who had a
loved one die in the critical care area. Their findings hold
many implications for us in the clinical area.
Since unrelieved pain causes many physiological and
psychological consequences, Heather Ead reviews these
negative outcomes and provides strategies for us to overcome
the barriers of under-treatment of pain.
Finally, I would like to acknowledge and thank Joy Kramarich
for her many years on the editorial board. Joy recently left the
editorial board to pursue other career activities and, on behalf
of the board, I want to thank her and wish her well in all of her
future endeavours.
Paula Price, RN, PhD
Clinical Editor
Fisher, Advanced Practice Nurse, presented on Acute
Stroke and Joanne O’Brien, Trauma Co-coordinator,
presented on the “Trauma Patient’s Experience”. The
session was well attended and we would like to thank
Virginia Steele from Lilly for her generous support of our
day. We were also able to sponsor a Hemodynamics
Workshop held at the Ottawa Hospital this spring. Plans
are underway for a fall learning session and for our
Spring 2006 conference “Horizons”. We’ve kept in touch
with our local members with a quarterly newsletter and
are madly recruiting volunteers for Dynamics in Ottawa
this fall.
After a gentle sell job, we had a great new crew join our
executive committee! Marg Lenny is now education chair,
Leesa Blakeley is our treasurer and Laura St. Pierre has taken
on membership. Janice Bissonette and Sue Bubb continue on
with the executive. We are very excited to have an energetic
dedicated group get involved in promoting critical care
nursing in eastern Ontario. Our ICUs in the area are
expanding and there is an ever-increasing need to promote our
specialty.
Have you been to Ottawa? It’s a great place to visit. Why
not come to Dynamics this fall, October 2-4, at the
Chateau Laurier! The venue for this great conference is
right downtown in the heart of Ottawa, next to Parliament
Hill. You will be within walking distance of the Market
area that offers a bustling market atmosphere with lots of
shopping and amazing bistros and clubs. Our conference
theme “Capitalizing on Technology with a Human Touch”
has guided the selection of a great line-up of presenters.
You will have a challenge picking the sessions you want to
attend, lots of diverse choices for content – from
technology to the human touch. Hope to see you in
Ottawa!
Best wishes to critical care nurses across Canada!
Abbie Hain, President
16 • 3 • Fall 2005
7
Congratulations to the following CACCN members
Congratulations to the following
CACCN members who successfully wrote the
CNA certification exam in pediatric critical care:
Louise Donnelly-Paniaq
Wendy A. Draisey
Michael D. Erhardt
Tracy L. Lake
Jennifer Lewis
Paula R. Mahon
Brigitte Martel
Donna E. McAnallen
Christine V. Palmer
Susan M. Peters
Claudine L. Theriault
Jennifer L. Watson
ON
ON
ON
N.S.
N.S.
B.C.
QC
ON
ON
ON
QC
ON
The following CACCN members successfully
re-certified in pediatric critical care:
Grace A. MacConnell
Cecilia St. George-Hyslop
Margot S. Thomas
N.S.
ON
ON
Congratulations to the following
CACCN members who successfully wrote the
CNA adult critical care certification exam:
Rosalee E. Aguinaldo
Natalie L. Allen
Ruby P. Ang
Melissa Astrologo
Leslie Atkins
Martie J. Atkins
Lynn P. Barry
Cecilia C. Baylon
Caroline Beaudet
Nicole J. Bender
Christine Bernard
Lucia Bernucci
Isabelle M. Bilodeau
Brenda S. Bjerkseth
Debra A. Bosley
Sue D. Brace
Karen J. Brown
Sue Brown
Barbara E. Burkhart
Milijana Buzanin
Leilanie Cardenas
Cornelia Cathelin-Castle
Wanmy Chang
Mary-Lou A. Chatterson
Fay Cherepuschak
Maxine E. Collins
Kathryn Copeland
Hedda Coronado Contrevida
Sarah L. Dawson
Maude Dessureault
Lorelei J. Driver
Crystal L. Emery
Paddee A. Forsey
Anne P. Fu
8
ON
ON
ON
ON
B.C.
N.S.
ON
ON
QC
AB
ON
QC
QC
ON
AB
B.C.
AB
ON
ON
ON
ON
B.C.
ON
ON
AB
ON
ON
QC
ON
QC
B.C.
AB
ON
ON
Mohanie M. Ganesh
Charlaine M. Garvey
Jennifer L. Giesbrecht
Mary Grace Griffin
E. Dalton Grizzard
Vicky N. Groulx Marris
Sonia A. Hill
Cheryl D. Hodgdon
Nazira Inshan
Zdravka I. Iolova
Anne Jarcew
Glory Joji
Geethamma Mani Kattumattathil
Joanne Kavelman
Susan N. Kean
Linda M. Klein
Eva Klein
Jennifer Kryworuchko
Lyne Landry
Alvin Lee
Susan M.A.S. Leonard
Ian D. Lindsay
Gillian C. Lockwood
Karen A. Lodato
Kari K. Logan
Edward A. Louvaris
Nuru Saleh Lushpay
Christina M. MacDonald
Joanne L. Magnan
Andrew P. Mardell
Geneviève J. Martin
Sylvianne Martineau
Laurel A. Matthies
Francesca A. Mileto
Joy W. Mintenko
Diane E. Mlynaryk
Sivagadhachum Moonsamy
Michele A. Myrah
Laurie A. Oliver
Coreena J. Padgett
Louise H. Paquet
Trevor Pedley
Stéphanie Pelletier
Marlene M. Penney
Lee Pétrin
Leanne N. Proveau
Toni Rogers
Paula J. Rose-Sharman
Marci D. Rosin
Carolina C. Ross
Donna Rothery
Lanei Samis
Tania Louise Sampson
Alison R. Saunders
Jennifer L. Seeley
Anne E. Sinclair
Diane Smith
Patricia Diane Stoddard
Barbara A. Stone
Janet D. Stone
Judith W. Strachan
16 • 3 • Fall 2005
ON
ON
AB
QC
ON
ON
ON
ON
ON
ON
ON
ON
ON
ON
AB
B.C.
ON
ON
QC
ON
MB
B.C.
AB
ON
AB
QC
N.S.
QC
QC
AB
QC
QC
B.C.
QC
SK
QC
QC
SK
PE
B.C.
ON
ON
QC
NL
ON
ON
ON
AB
AB
ON
ON
AB
B.C.
ON
ON
ON
B.C.
ON
B.C.
N.S.
MB
CACCN
Barbara S. Stumm
Jeanette S. Suurdt
Allen Trevor Swinden
Samantha Sierra Taylor
Nancy A. Teskey
Tessieram B. Tesoro
Christine E. Thomas
Jessy Thomas
Carla M. Tilley
Corina Tiriba
Amy L.Y. Tong
Shawn R. Toovey
Meneleo D. Torres
Kenneth J. Tucker
Sylvie Vandale
Nathalie Veillette
Valerie E.D. Veinot
Jane Ann Waddell
Cheryle E. Wade Lee
Anita P. Waldron
Karen M. Wannamaker
Shauna C.S. Weinreich
Kristina M. Wenzler
Erica M. White-Ryan
Denise C. Wilson
Wone L. Woo
Shelley Wood
Helen Yang
Nola P. Young
Claudia T. Zanchetta
Carol Zanette
Johanna A. Zantinge
ON
ON
B.C.
AB
ON
ON
B.C.
ON
B.C.
ON
ON
SK
ON
B.C.
QC
ON
N.S.
ON
ON
ON
ON
B.C.
NT
ON
ON
N.S.
ON
ON
QC
ON
B.C.
ON
The following CACCN members
successfully re-certified in critical care nursing:
Laurie A. Angle
Valerie A. Banfield
Janice L. Beitel
Carmela-Defelice Bianca
Marina Bitton
Elsie C. Boomer
Mary E. Brousseau
Susan E. Bubb
Bernice Budz
Donna M. Burko
Mona L. Burrows
Susan L. Chapman
Lynn M. Childs
Mary Lynn L. Clarke
Jo-Anne E. Costello
Elaine F. Cox
Jacqueline A. Croft
Dorothy A. Davisson
Marie T. Dennis
Lorraine M. Dougan
Sandra E. Eisenkrein
Dana M. Evans
Lynne A. Fenerty
Doriana A. Frassetto Meakin
Sue-Ellyn J. Gaterell
Denise M.L. Geroux
Nancy L. Giles
Sandra J. Goldsworthy
France T. Goudreau
CACCN
ON
N.S.
ON
ON
ON
AB
ON
ON
B.C.
SK
ON
ON
N.B.
N.B.
ON
ON
N.S.
SK
ON
PE
AB
ON
N.S.
SK
ON
ON
ON
ON
AB
Suzanne J. Graab
Linda D. Harris
Carrie L. Homuth
Robin L. Horodyski (Arnold)
Geraldine M. Hubble
Shirley L. Ireland
Angela R. Jeffs
Joanne M. Kelly-Nichols
Sue E. Kennedy
Judith E. Kojlak
Jocelyne Legault
Margaret A. Lenny
Cheryl A. Levi-Woods
Francis D. Loos
Lisa L. Lowther
Gerald M. Macdonald
Gwynne E. MacDonald
Donna M. Mackinnon
Alanna D. Major
Sandra D. Matheson
Charlotte McCallum
Rachelle K. McCready
Eileen C. McDonald Karcz
Beverley R. McFarlane
Janice Melchiorre
Brenda L. Morgan
Susan G. Morris
Eleanor A. Ng
Linda M. Oliver
Gaetane M. Parps
Rosemary A. Pedder
Céline Pelletier
Stephen A. Penticost
Kathy A. Perrin
Patrick S. Pfefferle
Tracy M. Porcina
Elaine T. Potvin
Robin E.A. Rankin
Lynn A. Reid
Darren F. Rideout
Sonia P. Rivera
Marilyn L. Schmidt
Elaine M. Selby
Jason L. Shand
Heather M. Shephard
Rhonda C. Sheppard
Gail Y. Siracky
Betty A. Skarpinsky
Heather A.M. Stoyles
Teddie A. Tanguay
Melanie Z. Thibeau
Benoit Y. Thibodeau
Wilma Catherine Thomson
Diane M. Tyrer
Dawna M. Van Boxmeer
Jane M.L. Van Nes
Nancy J. Vandenbergh
Suzanne M. Vanderlip
Kathy G. VanDine
Lynn C. Voelzing
Beverly A. Waite
Linda G. White
Erin M. White
Susan M.C. Williams
16 • 3 • Fall 2005
ON
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AB
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N.B.
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9
University of Alberta students wrote the lyrics,
CACCN Board of Directors call the tune
Dear Provost Amrhein and Medical School Dean Marrie:
We represent the Canadian Association of Critical Care
Nurses (CACCN), a professional organization that speaks to
and for Critical Care Nurses, both male and female, from
across Canada. A sense of humour is a formidable defence
mechanism in our highly stressful workplace. We believe that
our sense of humour is well developed, and widely
encompassing. However, it is with shock and dismay that we
have learned of the “humorous” song performed by your
medical students at their “Medshow” this past spring.
The incident generates a number of questions:
• Does the University of Alberta deliberately foster this
abusive attitude toward women? If not, and this is a naturally
occurring attitude born by Alberta med students, has the
University made any attempt to educate the med students
regarding equality of gender, professionalism, abuse...?
• Does the medical program at the University of Alberta
cause med students to have such a poor self-image that
they feel the need to strike out in frustration at another
segment of the health community?
• Are there no female students at the University of Alberta?
If there are, how could they possibly condone this type of
gender abuse? What indeed do they think of themselves?
• If the University of Alberta med students (judging from the
“song”, one would assume that they are predominantly
male) treat fellow professionals (predominantly female) in
this manner, how will they treat female patients (should
they ever be allowed to become doctors)?
• Based on the fact that this incident happened in the spring
and we have yet to see any action taken by the University
of Alberta despite a loud reaction from the professional
community, should we assume that the university condones
and supports this behaviour?
The University of Alberta must make it clear to all and
sundry that it does not tolerate, nor will it condone, such
aberrant behaviour on the part of its students.
We urge you to take the following actions:
• publish the names of those directly responsible for the
“song”, both those who wrote it and those who performed
it, and remove them from the program. Even with a doctor
shortage in Canada, we don’t need or deserve doctors who
have such a low opinion of 51% of the population.
• discipline those who were supposedly in charge of
presenting the “Medshow” yet who allowed this to occur.
• send a personal letter of apology to each University of Alberta
nursing student, complete with details of what disciplinary
measures the university has taken and an outline of what steps
the university will take to ensure that this will not be repeated.
• publish a public apology from the University of Alberta to
all nurses in Canada in The Canadian Nurse and
Dynamics: The Official Journal of The Canadian
Association of Critical Care Nurses.
10
• provide a clear outline of what measures the university will
take to ensure that this behaviour will not recur (i.e., cancel
the “Medshow”, provide sensitivity and awareness training
for medical professionals, initiate job-shadowing between
the different disciplines of the medical profession).
There is a shortage of nurses across Canada, which will get
worse in the coming years as many nurses become eligible for
retirement. Efforts are being made to improve nursing’s image
and the working conditions for nurses in order to encourage
nurses to stay in nursing rather than take early retirement as
well as to attract young people into the nursing profession.
The attitudes and behaviours of the medical students at the
University of Alberta, not only demoralize those in the
profession, they are a deterrent to anyone considering nursing
as a career. A clear and decisive message must be sent out to
say that these attitudes and behaviours will not be tolerated.
We urge you to deliver this message without further delay.
Written on behalf of the CACCN Board of Directors:
Patricia Hynes, RN, MA, CNCC(C), President
Asha Pereira, RN, BA, BN, CNCC(C), Vice-President
Sue Williams, RN, BScN, CNCC(C), Secretary,
Glenda Roy, RN, BN, CNCC(C), Treasurer
Joy Mintenko, BN, CNCC(C), Director
Grace MacConnell, RN, MN, CNCCP(C), Director
Thank you,
Susan Williams, RN, BScN, CNCC(C)
http://www.nursingadvocacy.org/news/2005jul/
08_edmonton_j.html
CACCN calendar of events
DATES TO REMEMBER!
September 1, 2005
September 29-30, 2005
October 1, 2005
October 2-4, 2005
January 15, 2006
January 31, 2006
February 15, 2006
16 • 3 • Fall 2005
Deadline for Educational
Award Submission
CACCN Board of
Directors’ face to face
meeting, Ottawa, Ontario
Chapter Connections Day,
Ottawa, Ontario
Dynamics of Critical
Care 2005 Conference,
Ottawa, Ontario
Spacelabs Innovative Project
Awards Application Deadline
Deadline for
abstract submissions for
Dynamics 2006
CACCN Research Grant
Application Deadline
CACCN
ISMP Canada
Dangerous abbreviations:
“U” can make a difference!
By Christine Koczmara, RN, BScPsy, Valentina Jelincic,
RPh, BScPhm, and Carol Dueck, RN, BScN
Abstract
Dangerous abbreviations are also known as “error-prone
abbreviations”. They are referred to as “dangerous” or
“error-prone” because they can lead to misinterpretation of
orders and other communications, resulting in patient harm or
death. Selected medication errors arising from the use of
dangerous abbreviations are highlighted in this article, along
with examples of such abbreviations and strategies to
eliminate their use. This column is intended to enhance the
awareness of practitioners who treat and care for critical care
patients of the problems associated with using ambiguous
abbreviations and to provide suggestions for associated safe
practices.
The use of dangerous abbreviations was one of the first
medication safety issues highlighted by the Institute for Safe
Medication Practices (ISMP) more than 25 years ago (ISMP,
2001). Since then, other safety and quality organizations have
emphasized this problem as a safety issue, including the Joint
Commission on Accreditation of Healthcare Organizations
(JCAHO) in the United States (JCAHO, 2001; USP, 2004).
Starting in 2006, the Canadian Council on Health Services
Accreditation (CCHSA) will require facilities to meet goals
that “Ensure the safe use of high-risk medications” and
“Ensure the safe administration of parenteral medications”
(CCHSA, 2005, p. 104). Although the elimination of
dangerous abbreviations is not yet a required practice, it is
noted in a CCHSA worksheet for assessment of strategies for
preventing medication errors (CCHSA, 2005). Eliminating
these abbreviations can improve communication throughout
the medication use process — prescribing, transcribing,
dispensing and administration.
The use of dangerous abbreviations can result in what is
known as confirmation bias. In this situation, errors can
occur because practitioners “see” the information they
expect (i.e., confirming their expectations) rather than
seeing the information that is actually present (which might
contradict what they expect). Depending on the frame of
reference, the “U” in the title of this column can be
interpreted as “you” or “units”. Confirmation bias involving
the abbreviation “U” can also occur in the medication use
process: the letter U being misread as a zero (0) resulting in
a ten-fold overdose. For example, an order for insulin
written as “7U” was interpreted as “70 units”; the overdose
caused permanent harm to a patient (ISMP Canada, 2003).
Confirmation bias is often more pronounced when people
are stressed or fatigued.
Although technically the “naked decimal point” is not an
abbreviation, this dose designation can lead to serious
medication errors. The problem occurs when a fractional
amount of medication is ordered (e.g., 0.2 mg), but is
expressed without a preceding zero (i.e., .2 mg). Without the
leading zero, the decimal point might be overlooked, with a
resultant ten-fold overdose. This practice, and associated
misinterpretations have led to serious patient harm, including
the death of a nine-month-old baby girl. “The baby’s
physician had prescribed morphine ‘.5 mg’ IV for the
management of post-operative pain. However, a unit secretary
did not see the decimal point and transcribed the order by
hand onto a medication administration record (MAR) as ‘5
mg.’ An experienced nurse followed the directions on the
MAR without question and gave the baby 5 mg of IV
Table One: “Minimum list” of dangerous abbreviations, acronyms and symbols*
Abbreviation
Potential Problem
IU (for international units)
Mistaken as IV (intravenous) or 10 (ten)
U (for units)
QD, QOD, (for once daily
and every other day)
Trailing zero (X.0 mg), lack
of leading zero (.X mg)
MS, MSO4, MgSO4
Mistaken as the numeral 0 (zero), the number 4
(four) or the unit cc (mL)
Mistaken for each other; a period after the Q
can be mistaken for the letter I and the letter O
can also be mistaken for the letter I
Decimal point is overlooked
Confused for one another. Can mean morphine
sulfate or magnesium sulfate
Preferred Term
Write “units”
Write “international units”
Write “daily”, write “every other day”
Never write a zero by itself after a
decimal point (use X mg), and always
use a zero before a decimal point for a
fractional amount (0.X mg)
Write “morphine sulfate” or
“magnesium sulfate” depending on
what is intended
Adapted by ISMP Canada from http://www.jcaho.org/accredited+organizations/patient+safety/06_dnu_list.pdf
*Used with permission from ISMP Canada.
CACCN
16 • 3 • Fall 2005
11
morphine initially and another 5 mg dose two hours later.
About four hours after the second dose, the baby stopped
breathing and suffered a cardiac arrest (ISMP, 2001). This
death was a particular tragedy, since a similar case, in which
another infant died, had been reported the previous year
(ISMP, 2000).
Ten-fold medication dosage errors can also occur with
trailing zeros. The presence of a zero after a decimal point
can lead practitioners to overlook the decimal point. For
example, oral risperidone 1 mg twice a day was ordered for
an elderly patient, but the order was transcribed onto the
MAR with a trailing zero, as “1.0 mg”. A nurse
misinterpreted the dose and administered 10 mg. The
Table Two: “Extended list” of dangerous abbreviations, acronyms and symbols*
Abbreviation
µg (for microgram)
hs or HS (for half-strength or
Latin abbreviation for bedtime)
T.I.W. (for three times a week)
SC or SQ (for subcutaneous)
D/C (for discharge)
Cc (for cubic centimetre)
AS, AD, AU (Latin
abbreviations for left ear,
right ear, both ears)
Potential Problem
Preferred Term
Intended meanings may be mistaken for each
other; qhs or qHS may be mistaken for “every
hour”; all can result in a dosing error
Write out “half-strength” or
“at bedtime”
Mistaken for SL (sublingual) or “5 every”
Write “subcut” or “subcutaneously”
Mistaken for mg (milligrams), resulting in
thousand-fold dosing overdose
Write “mcg”
Mistaken for three times a day or twice weekly,
resulting in overdose
Write “3 times weekly” or
“three times weekly”
Interpreted as an order to discontinue
whatever medications follow
Write “discharge”
Mistaken for U (units) when poorly written
Mistaken for OS, OD, OU (Latin abbreviations
for left eye, right eye, both eyes)
Write “mL” for millilitres
Write: “left ear”, “right ear” or
“both ears”; “left eye”, “right eye”
or “both eyes”
Adapted by ISMP Canada from: http://www.jcaho.org/accredited+organizations/patient+safety/06_dnu_list.pdf
*Used with permission from ISMP Canada.
Table Three: Examples of strategies to
eliminate the use of dangerous abbreviations*
Nursing Staff:
• Avoid use of dangerous or ambiguous abbreviations when:
■ transcribing medical orders (e.g., medication administration records, patient care plans);
■ taking telephone orders;
■ completing medication-related forms (e.g., pharmacy medication discrepancy forms; admission and discharge forms,
which are often used in the medication reconciliation process); and
■ documenting information in patients’ progress notes.
• Familiarize yourself with abbreviations that are considered dangerous.
• Alert appropriate departments or individuals when dangerous abbreviations are found (e.g., prescriber for order
clarification, pharmacist for product packaging and labelling, nursing management for preprinted orders).
• Report all errors and near misses, including those that occur as a result of dangerous abbreviations. Consider reporting
these problems to ISMP Canada.
• Model ideal behaviour when mentoring or preceptoring new staff by avoiding use of dangerous or ambiguous
abbreviations.
Critical Care Units (and other patient care areas):
• Post a list of dangerous abbreviations in locations where orders are written and transcribed (e.g., by telephones, in health
records dictation areas, in medication rooms, on medication carts, in a central location for access during unit rounds).
• Consider distributing the list to all staff in a variety of formats, such as a pocket card, a laminated card that can be placed
with identification badge, an e-mail message.
• Ensure that drafts of preprinted order forms are reviewed before they are finalized for the purpose of eliminating
dangerous and ambiguous abbreviations. Include a pharmacist in the review process of any forms that include
medications.
continued on page 13…
12
16 • 3 • Fall 2005
CACCN
continued from page 12…
• Systematically review and revise all preprinted orders and care pathways to ensure appropriate use of abbreviations.
• Hold brief, regularly scheduled education sessions on patient safety for staff, and highlight this issue. (These education
sessions can be multidisciplinary.) Outline expectations and include discussions on how to effectively deal with dangerous
abbreviations and other unclear orders.
• Include this safety topic in orientation for new staff members. A presentation can be created and shared throughout the
organization.
• Make patient safety a standing agenda item at staff meetings, and solicit staff feedback regarding hazardous conditions,
including the use of dangerous, ambiguous, inappropriate or unapproved abbreviations.
• Share learning throughout the organization, i.e., successes and difficulties encountered.
Pharmacists and Pharmacy Staff:
• Avoid purchasing pharmaceutical products that are labelled with dangerous or ambiguous abbreviations. Report
dangerous abbreviations that appear on pharmaceutical packages and labels to the manufacturer and to your buying group,
if applicable. (Buying groups or group purchasing organizations, to which hospital pharmacies commonly belong, can
often influence pharmaceutical manufacturers to make changes in packaging, labelling and product format.) Consider
reporting packaging and labelling problems to ISMP Canada.
• Eliminate use of dangerous abbreviations from all computerized and automated systems in the pharmacy, both on-screen
and for generation of labels. If the abbreviations are hard coded into the software, work with vendors to eliminate their
use. Consider the following:
■ Create a forcing function, whereby computers do not use or accept input of dangerous abbreviations.
■ Eliminate use of dangerous abbreviations on all pharmacy-generated labels and forms, e.g., centralized intravenous
admixture, total parenteral nutrition, unit dose dispensing, repackaging of bulk products, medication administration
records, patient medication histories and summaries.
• Avoid use of dangerous or ambiguous abbreviations when:
■ transcribing medication orders into patient profiles, progress notes, care plans;
■ transcribing telephone order clarification;
■ completing medication-related forms (e.g., medication reconciliation forms); and
■ documenting information in patients’ progress notes.
• Require order clarification when dangerous abbreviations are used by prescribers.
• Create a standard alert letter and send it when prescribers use dangerous abbreviations.
• Refer to sections above (nursing staff, critical care units) for education and feedback that can also be applied for
pharmacy staff.
Hospital Leaders:
• Build and actively cultivate a “culture of safety” so that patient safety is a priority at all levels of the organization.
Organizational culture is the foundation on which successful patient safety initiatives are built. Patient safety must be
viewed as everyone’s ongoing responsibility.
• Make the elimination of dangerous abbreviations an organization-wide initiative that incorporates interdisciplinary
collaboration. Identify champions from the various disciplines and departments to create momentum.
• Develop and widely distribute a list of dangerous abbreviations that must not be used. Consider starting with a few
ambiguous and problematic abbreviations, and build on the list over time. In addition, consider a grace period followed
by a “go live” date, after which the abbreviations will not be accepted.
• Use a variety of communication strategies, e.g., hospital publications; agenda items at committee meetings, such as
pharmacy and therapeutics committee and medical advisory board; laminated lists used as a divider for the “orders”
section of the patient’s chart; posters; screen savers.
• Update current list of acceptable abbreviations to eliminate those that are dangerous and ambiguous.
• Ensure that new technology and software does not use dangerous abbreviations or ambiguous terminology, e.g., physician
order entry applications.
• Ensure that all new staff who are expected to deal with any aspect of the medication use process — e.g., nurses,
physicians, pharmacists, respiratory therapists and respiratory care practitioners, unit secretaries (if transcribing),
pharmacy technicians, purchasing staff, risk management staff, all front-line managers — receive formal orientation on
patient safety that includes eliminating the use of dangerous abbreviations. Include internal and external errors to
highlight the issues.
• Include the elimination of dangerous abbreviations as a criterion for product purchasing decisions, e.g., pharmaceuticals,
infusion pumps.
• Include the elimination of dangerous abbreviations in the approval process for all hospital forms.
• Perform frequent random chart audits to determine if unapproved or inappropriate abbreviations are being used. Widely
distribute and present results of these audits to staff.
CACCN
16 • 3 • Fall 2005
13
patient required admission to ICU. “After a couple of
excessive doses, the patient developed hypoxia and
required the establishment of an airway and subsequent
ventilation” (Hicks, Santell, Cousins, & Williams, 2004,
p.33).
Latin abbreviations are often the norm in medicine, yet they
can be problematic. Figure One illustrates an order for digoxin
0.125 mg with an abbreviated frequency that could be
interpreted as “qod”, “qid”, or “q.d.” The prescriber intended
the dose to be given “qod” (every other day), but the
abbreviation was understood to mean “qid”, or four times a
day.
Abbreviations that are common in everyday use have also
found their way into health care communication. One
example is the “at” sign (@) which can be misread as the
numeral two or five, which would cause over-infusion of
IV solutions and overdosing of medications. The
examples in Figures Two and Three show that
misinterpretation of abbreviations and symbols is not
limited to handwritten orders and that such notations
should be avoided throughout the medication use process:
in labelling and packaging, preprinted orders,
computerized physician order entry, electronic MARs,
automated dispensing cabinets, and the screens of
infusion pumps. Furthermore, the use of abbreviations
needs to be carefully considered for all functions within
health care facilities. For example, when new
technologies and software are being purchased, safety
requirements, such as hard coding or avoidance of
unacceptable abbreviations, must be stipulated before a
vendor is selected.
Two lists of dangerous abbreviations are provided in Tables
One and Two. A more complete list is available from ISMP
(ISMP, 2003). Of particular interest is that greater successes
are achieved by organizations that begin by focusing on just a
few abbreviations, those identified as most likely to cause
harm, and building on these successes over time rather than
trying to implement changes on the basis of a long or
exhaustive list. Examples of additional strategies for the
elimination of dangerous abbreviations are provided in Table
Three.
Critical care staff often cares for seriously compromised
patients, who have minimal physical reserves to recover
from medication or fluid-related errors. The use of
Figure One: A doctor’s handwritten
order. The abbreviation “qod” was
interpreted as “qid”. The digoxin was
given four times daily, rather than the
intended “every other day”. (Used with
permission from ISMP Canada.)
14
dangerous abbreviations in order communication —
prescribing, transcribing, dispensing, administration and
associated processes (e.g., medication reconciliation) — can
be perceived as saving time; however, the potential for harm
to patients, as well as to patients’ families, the practitioners
involved, and the health care organization as a whole reveals
the need to eliminate their use. Health care organizations
must become preoccupied with systemic reasons for failure,
learn about common human limitations and continuously
apply system-based improvements if they are to become
“high reliability organizations”:
“High reliability organizations refer to organizations
or systems that operate in hazardous conditions, but
have fewer than their fair share of adverse events…
Commonly discussed examples include air traffic
control systems, nuclear power plants, and naval
aircraft carriers… It is worth noting that, in the patient
safety literature, HROs are considered to operate with
nearly failure-free performance records, not simply
better than average ones. This shift in meaning is
somewhat understandable given that the “failure
rates” in these other industries are so much lower than
rates of errors and adverse events in health care. The
point remains, however, that some organizations
achieve consistently safe and effective performance
records despite unpredictable operating environments
or intrinsically hazardous endeavours” (AHRQ, 2005).
Eliminating the use of dangerous abbreviations is one type
of proactive system-based change that critical care staff
(nurses, physicians, pharmacists, respiratory therapists) can
make by collaborating and setting an example in an
organization’s efforts to enhance patient safety and quality
of care.
If in doubt, spell it out!
Report an error to the Institute for Safe Medication Practices
Canada (ISMP Canada):
i) through the website, www.ismp-canada.org;
ii) by e-mail to [email protected]; or
iii) by phone at (416) 480-4099 or 1-866-54-ISMPC [47672].
ISMP Canada guarantees confidentiality and security of
information received. ISMP Canada respects the wishes of
the reporter as to the level of detail to be included in
publications.
Figure Three: Label on an octreotide
infusion. The text “run @5ML/H” was
Figure Two: A doctor’s handwritten
misinterpreted as “run 25ML/H”.
order. The symbol @ was interpreted
(Used with permission from ISMP
as the numeral 2. The intravenous
Canada.)
bicaronate solution was infused at 250
mL/hour, rather than the intended
“@ 50 cc/r”. (Used with permission
from ISMP Canada.)
16 • 3 • Fall 2005
CACCN
About the authors
Christine Koczmara, RN, BScPsy, is a staff member at
ISMP Canada. She also holds a casual position as a
bedside nurse in the Intensive Care Unit (ICU) at St.
Joseph’s Health Centre, Toronto. Valentina Jelincic, RPh,
BScPhm, is a pharmacy and management consultant and
medical writer, with varied experience in the private and
public sectors and with professional and non-profit
associations. Carol Dueck, RN, BScN, is Project Leader
with ISMP Canada supporting the software for medication
error tracking and analysis reporting. She is also a Patient
Care Coordinator at West Lincoln Memorial Hospital, with
a background in critical care and clinical informatics
management.
References
Agency for Healthcare Research and Quality. (2005).
Glossary: High reliability organizations (HROs).
Retrieved July 2, 2005, from http://psnet.ahrq.gov/
glossary.aspx#H.
Canadian Council on Health Services Accreditation. (2005).
CCHSA Education. Improving Patient Safety through
Accreditation. Workshop handout. Author.
Hicks, R.W., Santell, J.P., Cousins, D.D., & Williams, R.L.
(2004). MEDMARXSM 5th anniversary data report: A
chartbook of 2003 findings and trends 1999-2003.
Rockville, MD: USP Center for the Advancement of
Patient Safety.
Institute for Safe Medication Practices. (2003, November 27).
ISMP list of error-prone abbreviations, symbols, and dose
designations. ISMP Medication Safety Alert!, 8(24), 3-4.
Retrieved June 30, 2005, from http://www.ismp.org/PDF/
ISMPAbbreviations.pdf.
Institute for Safe Medication Practices. (2001, May 2). Please
don’t sleep through this wake-up call. ISMP Medication
Safety Alert!, 6(9), 1.
Institute for Safe Medication Practices. (2000, November
15). Safety Briefs. ISMP Medication Safety Alert!,
5(23), 1.
Institute for Safe Medication Practices Canada. (2003,
April). Insulin Errors. ISMP Canada Safety
Bulletin, 3(4), 1-2. Retrieved July 1, 2005, from
h t t p : / / w w w. i s m p - c a n a d a . o rg / d o w n l o a d /
ISMPCSB2003-04Insulin.pdf.
Joint Commission on Accreditation of Healthcare
Organizations. (2005). National patient safety goals for
2005 and 2006. Official “Do Not Use” List. Retrieved
July 4, 2005 from http://www.jcaho.org/accredited+
organizations/patient+safety/06_dnu_list.pdf.
Joint Commission on Accreditation of Healthcare Organizations.
(2001, September). Medication errors related to
potentially dangerous abbreviations. Sentinel Event
ALERT, 23, 1-3. Retrieved June 27, 2005, from
http://www.jcaho.org/about+us/news+letters/sentinel+even
t+alert/sea_23.htm.
United States Pharmacopeia. (2004, July). Abbreviations can lead
to medication errors! USP Quality Review, 80, 1-7.
Retrieved June 24, 2005, from http://www.usp.org/
pdf/EN/patientSafety/qr802004-07-01.pdf.
*Used with permission from ISMP Canada.
CACCN
16 • 3 • Fall 2005
15
Exemplary care
of the palliative patient:
The journey shared
By Beth Perry, RN, PhD, Associate Professor, Athabasca
University, Edmonton, Alberta
Abstract
Critical care involves caring for complex and acute needs of
patients with life-threatening conditions. Despite skilful
interventions, there are times when the care needed by
patients and their families is primarily palliative. In this
article, the author focuses on examples of ways nurses can
make the palliative care they provide exemplary. Based on
findings of a research study of outstanding palliative care
nurses, the researcher describes the possible effect providing
excellent palliative care may have on both the patient and the
caregiver.
Critical care nurses are often called to stand in the shadow of
grief that accompanies death. Yet in doing so, these caregivers
can be molded into more caring and compassionate people,
and more exemplary nurses.
Nurses in critical care are challenged daily to meet the
multiple needs of patients and their families. Though state of
the art technology, medications and advanced skills may
save many lives, there are times when the care that is
required is palliative. It is in these instances that a nurse’s
strength and courage may be tested. By taking up this
challenge, and sharing the final journey with patients, a
nurse may learn many lessons. In part, caregivers may come
to see that sometimes death is neither an enemy, nor a
failure. Rather, sometimes death can lead to a more joyous
embracing of life. Sometimes death is the only way that
suffering can be erased.
This article includes a description of key ways critical care
nurses may address the needs of patients who are palliative.
Specifically, the themes of helping people live on,
individualizing care, defending human dignity, sensitive
listening, sharing hope, and keeping the promise to never
abandon are described. These themes all fall under the
overarching theme of simple gestures, which is also described
in this report.
Background
Providing excellent palliative care demands a specific set of
skills and base of knowledge. This article features many
stories that demonstrate the skills and knowledge needed to
provide exemplary palliative nursing in the critical care
setting. Many of the stories are drawn from a study of
exemplary nurses caring for patients with cancer (Perry, 1996).
The participants in this study were nominated by their peers as
those nurses they would want to have care for them, or for
16
their family members, if they were in a palliative care
situation. The researcher conducted interviews with these
exemplary nurses, observed them at work, and asked them to
recount their memories of patient interactions that changed
them, or the way they practised nursing. These interviews,
observations and recollections were analyzed using a
multidimensional analysis derived from the phenomenological
perspective (Perry, 1994).
Perhaps the narratives in this research report may re-awaken
memories of some of the individuals with whom you have
journeyed. These stories illustrate what the researcher
concludes is the essence of exemplary palliative care. Stories
are especially appropriate in articulating the actions of nurses
caring for the dying because, “stories are the juncture where
facts and feelings meet” (Van Manen, 1990). Further analysis
of the caregiver’s experiences is offered in this article by short
poems, written by the author, that attempt to capture the
essence of the interaction within the limitation of words.
According to Van Manen (1990), poems are the perfect
medium for giving voice to the tacit and unspoken. These
poetic interpretations also come as close as is possible to
capturing the emotion of human interaction.
The major theme addressed in this article is called simple
gestures. From watching nurses who are experts at caring for
the dying, it appeared that it was often the small, seemingly
insignificant nursing actions and acts of human kindness that
made the greatest difference to the patients and their families
when they were close to death. In making the difference, in
helping another, the life of the nurse and that of the person
receiving care became entwined and, for at least a few
moments, the journey was shared. The discussion begins by a
description of the overarching theme of simple gestures.
Simple gestures
Mother Teresa said, “It is not about doing great things, it is
about doing small things with great love” (Mother Teresa,
1997, p. 75). This is especially true in palliative care. In a
world where bigger has often come to symbolize better, where
we seem to value grandeur, opulence, speed and technology,
we may have lost sight of the immense power of a tiny gesture
rendered with sincerity and a compassionate heart.
Certainly critical care nurses need a deep knowledge base and
advanced psychomotor nursing skills, but beyond these, the
small thoughtful actions may make an immense difference in
the lives of palliative patients and their families. Most people
can think of a time in their lives when a single word, a smile,
a touch was a watershed moment, refocusing their thinking,
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making them feel a little better, a little more secure, a little
more hopeful. Too often, we underestimate the power of a
touch, a kind word, a listening ear, the smallest act of caring,
all of which have the potential to make a difference in the
quality of life of another. The simple gestures highlighted in
this paper are some that the exemplary nurses studied found
most helpful to the dying. The first example of a simple
gesture addressed is helping people live on.
Helping people live on. For many of the exemplary nurses who
participated in the study, their most meaningful memories of
patients were those who came into their care facing terminal
events. The nurses spoke about their role in helping these
people and their families come to a point of acceptance of this
transition from life to death. One important element of the care
provided was to help the individuals identify, and sometimes
develop, a way to leave a legacy, a way to be remembered. As
a nurse named Lucy said, “Patients who are close to death may
be facing a sense of despair and hopelessness in part because
they haven’t discovered, or defined, their gift to the world.
Everyone wants to leave some footprints after they have
gone.” As the following story illustrates, the ill individual, if
given the opportunity, may lead the way to their legacy.
Bubble, Bubble…
Elderly and spunky are the two words I would use to describe
Zella. She was about “82 years and six months old” and
although she didn’t have any disease we would call terminal,
in Zella’s words, “all of her organs had just given up the
ghost.” I cared for Zella almost every day, tending to all of her
nursing care.
One day Zella asked shyly if I had a camera. I could tell by the
sparkle in her eye that she had plans for my camera. I nodded
in the affirmative and Zella burst into a huge toothless smile.
“Bring your camera and lots of film” Zella ordered in her
customary way. “Tomorrow we shoot!” Then as a post-script
Zella added, “There’s one more thing. Bring a big bottle of
bubble bath, fruit flavour, maybe watermelon or tangerine. I
love tangerine!”
I complied and the next morning we both giggled as we poured
the tub and added more capfuls of “Mr. Bubble” than the label
recommended. Then, we added Zella, and she glowed as I
snapped several shots of her frolicking in her glory with the
bubbles discreetly covering all of her unmentionables.
I was off the next weekend and when I returned to work the
cold news of Monday morning report stated that Zella had
died – peacefully in her sleep. No one was surprised, but I felt
a sense of loss and sadness at the news. The night charge nurse
paused for a minute that morning on her way out to let me
know that there was a note for me – a note from Zella. The
instructions, writing in frail hand, were in Zella’s voice –
“Give the bubble photos to my granddaughter” was all the
note said. I smiled a little as the message gained clarity. Zella
had planned her legacy. She knew exactly how she wanted to
be remembered; happy, joyful, full of zest and just a little
provocative. As I close my eyes and remember Zella, guess
how I see her, too.
CACCN
Footprints
May I leave
A footprint on
Your heart?
A tiny seal
To permanently
Etch a reminder of
My life on earth.
I have to be more than dust.
Dust is just dust,
And when the wind blows
It scatters and is forever lost.
People, especially those who are dying, seem to long for a
sense of continuity. In one person’s words, “the thing I want
most to know is that the people closest to me will not forget
me, and that I have achieved some things that will count after
I die. Some of my nurses give me that feeling and I love those
nurses dearly.”
Nurses’ simple words can help this remembrance happen for
those in their care. Simply telling dying people that they will
be remembered, helping them think of those people who will
remember them, telling them that you are not the same person
because you have met them, can help that person to know they
will live on.
Individualizing care. Individualizing care could also be
termed finding out what patients really want. This simple
gesture focuses on providing nursing care that addresses the
unique needs of an individual and the theme emerged as
important to proving exemplary care to the dying.
Individualizing care relies heavily on the nurse’s ability to
assess the patient’s situation and determine what is needed.
Many times, this action requires that the nurse maneuver
outside of usual routines and procedures in order to provide
the patients and their families what is needed most. At times,
bureaucratic organizational rules need to be judiciously broken
and nurses may be called to act in an advocacy role in order to
have the patient’s distinctive needs acknowledged and met. In
the following example, the nurse had to rely on her sensitivity
to provide for the needs of grieving parents.
Farewell
Their baby is dead? How could it be? Had they not just sat
together smiling and feeling her kick through Jackie’s
bursting abdomen the week before? They had known for
several months that their baby was a girl and they had named
her Rachel after Jackie’s mother. They had splurged to buy
Rachel a velveteen white sleeper from a European import
store for her to wear home from the hospital. It was her
“debut” outfit they called it. Together they had prepared a
special place in their home, and in their hearts, for their little
girl. Now the grim-faced doctor was saying it again, “the
baby is dead.” They clung to each other just trying to keep
breath in their own lungs.
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Induction followed, the pain of the child’s birth was great for
all of us. I took the waxen child from the doctor’s hands,
bathed and dressed her carefully in her white sleeper. Then, I
wrapped Rachel in the prettiest hospital blanket and gently
asked the parents if they wanted to hold their infant.
Yes, they nodded, but their faces cried, “not here in this cold
confining hospital room.” I understood, they needed to be
alone, to hold their Rachel for the first and the last time in a
beautiful place. I knew the perfect site, the hospital chapel. It
was late at night, no one would disturb them there. Setting two
chairs close together, I laid Rachel in her mother’s arms. From
a distance, I watched as they held their baby, and each other,
and said good-bye.
In your pain and sorrow
Your words and wishes are unclear.
I catch a glimpse
Inside your soul.
And write clearly
The next lines of your life.
Finding out from patients what they need in order to
individualize their care can be as simple as asking them. One
nurse often said to her dying patients and their families, “if I
could do one thing for you right now, what would it be?” This
nurse commented that the answer was often surprising. She said,
“Often I couldn’t have guessed what would bring them comfort.”
Exemplary nurses ask the question and then do what they can to
individualize the care to meet the patient’s real desires.
Defending human dignity. Nurses often felt they made the
biggest difference to their patients’ well-being when they acted
to promote and defend the dignity with those who only had
remnants of dignity left. These actions involved helping the
health team to see the patient as a whole person rather than as
a disease, a bed number or a diagnosis. Respect for the person
for whom they were caring seemed to be the key value that
motivated the care provided. Through their actions and words,
the nurses let their patients know that their lives were of value
no matter what their physical or emotional state.
A major part of maintaining human dignity is encouraging
patients to retain control over their care decision for as long as
possible. As Smith-Stoner (1999) points out, when patients are
fully involved in their treatment plans, making decisions and
evaluating outcomes, their integrity is preserved. Sometimes,
as the following story illustrates, this is a difficult experience
for the caregivers, especially when the patient’s decision may
not be the same choice we would make.
It wasn’t an easy day for any of us. David had come to our
acute medical unit for treatment of a minor infection. “Nothing
serious,” we thought. Even though David was quadriplegic and
ventilator-dependent as a result of an accident two years
earlier, we were confident we could have him back “home” to
his extended care facility in a matter of days.
18
Now we cared for David’s every need. When I asked David
one morning if he wanted anything else, he replied, “What
I really need is to be set free.” In further conversation,
David shared his wish to have his ventilator turned off.
David explained first to me, and then to his doctors, that
he was tired of being less than a husband to his wife, and
less than the father he wanted to be to his two small
children. He explained in a very rational voice that he
wanted to die.
David’s doctor took his repeated pleas seriously and, after
extensive consultation with David, his family, the care team
and the ethics board, he agreed on a cold October day to
comply with David’s wish.
Nurse’s Knowing
David’s decision
David was the kind of patient you connect with instantly. Good
looking, our age, a great sense of humour despite the tragic
turn that life had thrown at him. After his accident, the skilful
paramedics had saved his life, but David had spent each day
thereafter “trapped” in his own body.
I have such a clear image of the moments preceding David’s
death. His doctor, a caring and thoroughly professional man,
came to the nursing unit at the appointed hour. I could tell by
his face, his stance, his gait that he was in great pain at what
he was about to do. He took a deep breath before he entered
David’s room and he did something I have never seen him do
before, he removed his lab coat and hung it in the hallway. He
entered that room and faced David person to person, not
doctor to patient. It was a small gesture, perhaps no one else
even noticed, but to me it was significant, it showed respect
and was perhaps an acknowledgement of our basic human
sameness.
I held David’s hand as his doctor administered sedation
and turned off the machine. As his eyes closed, David
smiled a little and mouthed the word, “peace.” Was it a
wish sent to us, or a statement of his state of being? I hope
it was both.
Equality?
Disguised in jargon
Clocked in power
Clothed in position
We hold all the cards.
You are vulnerable to our decisions.
In all ways we are unequal.
In all ways but one.
Sensitive listening. If there is comfort to be found in talking
about what is bothering us, there is comfort to be offered in
simply listening. Bottoff (1991) describes what it means to be
truly present and to listen with sensitivity. She writes, “When
a nurse is with us, in the sense of being present, we feel the
security of her protective gaze, we feel valued as a
person…there is a kind of hopefulness. For a moment we are
not alone” (p. 241). Julie offered this account of the power of
a simple listening presence.
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CACCN
I will listen to your heart
He was a tall, good-looking man. At his request there was a
“No Visitors” sign on his door. He drew pictures, he discussed
world politics. He didn’t cry, he didn’t laugh, he just watched.
He gave single-word answers. His patient history report said
he had attempted suicide because he had been diagnosed with
cancer and he didn’t want his family to watch him fade and
die.
I could sense that he was searching for an answer to that
common question, “Why?” I recognized his loneliness and his
fear. How was I going to let him know I was there to help?
Finally, the opportunity arrived one evening when all of a
sudden he said, “Do you believe in God?” I answered
carefully, not wanting to shut the door. I said, “I really don’t
know about God for sure, but I do believe in angels.” The door
was finally opened and, over the next few days, I listened to
him share his beliefs about God, angels, fate and justice and
how unfair his situation was. He talked. I listened.
As the days passed, he told me a lot about his life. He had been
a young family man during the war, an army officer. One day
he and his wife went for groceries, leaving their two boys at
home. While they were gone, their home was bombed, their
family destroyed. As post-war refugees to Canada, his wife
bore another son who died shortly after birth. In an attempt to
gather some semblance of normality after all this heartache,
they adopted an infant. This child was now in his mid thirties
and mentally handicapped.
I think of him often. I was fortunate to be with him in his last
moments. I held his hand. All I could do was stand there and
hope that he was seeing his kids. I prayed, “Please, if there is
a God, this man deserves to see his kids.” I don’t know if it was
just the side effects of the medication or what, but when I said
to him as he was dying, “Your sons are there,” he squeezed my
hand and smiled. He really did. He squeezed my hand and died
and I sobbed.
Listening with Openness
As I listen to you speak,
My ears catch the sound
But my heart absorbs the message
And I allow myself to be changed by your words.
Into my willing heart
You pour your fears, your pain, your guilt.
Now that you are rid of these chains
There is a chance
You may be free.
Sharing of hope. The next simple gesture involves the sharing
of hope. The exceptional nurses shared their hope with patients
who seemingly had none of their own. In doing so, exemplary
nurses helped people see that they did have possibilities for the
future, even in tragic circumstances. Jane, an outstanding
nurse, said, “If patients see no hope, no possibilities for even
their immediate future, they are left with despair. It is part of
my role to help them with this.”
CACCN
In critical care, tragedy is a common reality. Consider this
narrative written by a nurse named Tracy that illustrates how a
nursing intervention rekindled hope in a devastating situation.
Tragedy in our town
It had been a challenging day in our small-town emergency.
But none of us could imagine that the terrible day was about
to get worse. A call came in that there had been an accident on
a rural road. Details were sketchy, but when the ambulance
arrived we quickly realized that the man who was pronounced
DOA was the husband of one of our long-term nurses.
Calling her home was beyond difficult. As she arrived, we
blanketed her in our compassion as we took her to his side.
After 20 years together, how could this moment of reality be
laced with any fragment of hope? We watched, feeling
helpless as she ran her hands over his face, which was
amazingly unmarked by the crash. We listened as she spilled
out her heart and whispered how much his love had meant to
her. After these moments, all of the energy seemed to drain
from our friend and colleague and she collapsed into my
arms. Helping her to a chair in the staff lounge I sat close,
quietly drying each tear as it flowed. Then she asked me, “Do
you think I said good-bye ok?”
“Yes,” I said, a confident and unhesitant “yes.” Later, as I
relived this moment, I knew somehow that my certain
reassurance made a difference in that moment of hopeless
despair. Did it give her hope? I don’t know. But I do know it
didn’t take it away.
Hope is to Life
Hope.
Without it what is life?
Desolate, onerous, unthinkable.
Hope.
With it what is life?
Bearable, promising, possible.
Keeping the promise to never abandon. When nurses stay
with patients through pain, suffering and grief, they keep the
promise to never abandon. In doing so, they share their
shadows with the shadows of people in their care. As a person’s
individual capacity to provide exemplary care for other human
beings grows, that person may experience the overlapping of
their shadow with the shadows of others. Human lives are
inextricably linked and nurses’ capacity to care in an exemplary
way is enhanced as they interact meaningfully with others.
From this research, it is evident that in many effective nursepatient relationships shadows are shared.
The length of the relationship may vary greatly from a few
moments in an ambulatory setting to a long-term relationship
in an intensive care unit. No matter the duration of the time,
shadows are shared. By inviting another to share our shadow,
we are offering them an island of hope, enveloping them with
our strength and offering them a harbour; in a sense, a shelter,
a home.
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19
The extraordinary nurses in this study made an unspoken
commitment to their patients they knew by heart, “to cure
sometimes, to relieve often, to comfort always.” This is a
promise that nurses renewed implicitly each time they
interacted with patients or family members. Nurses told those
in their care, by their presence and simple caring gestures, that
no matter how difficult and unpleasant things became, they
would never abandon them. The fear of being abandoned, of
being given up on, of being left alone to face pain, technical
procedures, or even death, is immense. Promising to stand by
and willingly following through with this promise, is
providing patients with the ultimate comfort measure. As one
of the nurses in the study said regarding her pledge to never
abandon, “I never leave a hurting person without a hand to
hold.”
One young woman in the ER talking about what she needed
from the staff after her 11-year-old sister was killed by a
speeding car said, “all I needed was someone to stay near me,
to stay still and hold my hand. I didn’t want people to turn
away at the sight of my tears.”
The sharing of your shadow is a symbol of the promise that
you will not abandon, that you will not turn away. Consider
this example of maintaining the promise to never abandon,
keeping the pledge to share one’s shadow based on a story by
a nurse named Sue.
The singing of a song
A year or so ago, I was working as a shift manager on nights.
A man of about 35 years of age became increasingly restless
and agitated. He had a progressive brain disease that was
unlike anything I had seen in 25 years or more of nursing. That
night, he required two-to-one nursing care.
Around 0300 hours, Peggy (the other nurse I was working
with) observed that in spite of his verbal lashing out, he had
never once cursed. She remarked that he must not have “bad”
words in his normal vocabulary because usually what is in a
mind comes out in confusion.
The night wore on with our patient experiencing agitation,
yelling and extreme restlessness. He would bite his own hands
and arms and grab on to anything near him. Peggy and I
confided in one another that we were tempted to just leave and
close the door, but our sense of professional responsibility kept
us planted at his bedside.
At one point, I heard him repeat a series of words in a garbled
fashion and recognized the words of an old hymn. I began to
sing the hymn and immediately he became quiet. The change
was instantaneous and profound. Peggy was able to leave for
a break while I sat beside him singing every hymn I could
remember. As long as the hymns were sung, the patient rested.
We later found out that the man had been a lay pastor. He was
loved by many, many people and he died a terrible death that
sucked every bit of dignity from this previously dignified gentle
man.
I loved being his nurse because none of the usual textbook
interventions worked. He required flexible, creative nurses
who were not afraid to try the unconventional and who were
20
willing to stay. Large doses of artificial sedation made no
difference. Somewhere in the deepest levels of this man’s
mind our presence through music and just being near
touched him. It was a profound night because all my years of
training and education came down to the simple singing of a
song.
Simple Presence
I do not claim to take
Your pain away.
Instead through my presence
I express my sincere desire
To be with you.
Conclusion
Caregivers whose work privileges them with the opportunity
to share significant life events with others may move
through various stages as they progress from novice to
exemplary. The first stage is that of the beginner. It brings
with it the experience of dependency. As nurses begin their
careers, they may be dependent on colleagues and others for
guidance, encouragement and support in order to do their
work.
With experience, most nurses gradually reach a phase of
independence. At this level, they may pride themselves in their
ability to confront almost any work situation with confidence.
The independent caregiver is able to work with expedience,
accuracy and efficiency. Benner (1984) labelled the
independent nurse as a proficient caregiver.
The findings of this study suggest that nurses who
become exemplary in palliative practice engage in
interdependence. They entwine themselves in a mutually
dependent way with others, learning and growing
together as they share the journey. Watson (1989) calls
this experience “transpersonal caring”, a situation in
which “both the nurse and the patient are changed by the
actual caring even” (p. 58). This study shows that
through
exceptional
nurse-patient
associations
something remarkable occurs for both the nurse and the
patient. This extraordinary experience is called “joint
transcendence” and it is a common feature in the
exemplary care of the seriously ill and dying (Perry,
1994). The following story illustrates the power and
potential of such encounters.
Heather’s hair
I think the patient I will always remember is a young
woman named Heather. She was a young person, only 34,
and she had flawless olive skin and waist-length, thick,
black hair. Heather was one of the most physically beautiful
people I had ever cared for. Heather had been receiving
chemotherapy with a combination of drugs known to cause
hair loss, immunosuppression and nausea. She came to
emergency one night because of a raging infection. When I
asked her how she was doing, her biggest concern wasn’t
her fever; it was that her hair was starting to fall out. She
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CACCN
confided in me that she had noticed many strands of hair on
her pillow and that she was starting to be able to pull her
hair out by handfuls.
Well into the early morning hours, Heather called me to her
bedside. When I asked how I could help, she simply said,
“Help me with my hair.” Devastated by the loss of her physical
beauty, she couldn’t face these terrible moments alone. So, we
sat together on her stretcher with a green garbage bag
between us stuffing it full of her beautiful hair. I was
speechless. In fact, I remember feeling guilt for having hair
and for being well.
When we were finished, we tied the bag closed. We sat
together quietly for a while and then I turned to Heather,
looked into her eyes, took both of her cold hands in mine and
said, “I think you still look beautiful.” We cried and we
comforted each other and then I took the bag and walked
away.
Beauty
You are a goddess,
A beauty in body and spirit.
No matter how this disease ravishes you,
A beauty you will always be.
The temporary and transient beauty
Of your face,
Your hair,
Your body,
Pale against
The permanent beauty of your soul.
As nurses share their shadows, their journey, with their
patients; they share their humanity with us. If we are open and
receptive, the lessons learned will change us forever and will
move us toward being truly exemplary nurses.
References
Benner, P. (1984). From novice to expert: Excellence and
power in clinical nursing practice. Menlo Park, CA:
Addison-Wesley.
Bottoff, J. (1991). The lived experience of being comforted by a
nurse. Phenomenology and Pedagogy, 9, 237-252.
Mother Teresa. (1997). No greater love. Novato, CA: New World
Library.
Perry, B. (1994). Exceptionally competent nursing practice.
Unpublished doctoral dissertation, University of Alberta,
Edmonton, AB.
Perry, B. (1996). I am a nurse. Canadian Oncology Nursing
Journal, 6(1), 6-13.
Smith-Stoner, M. (1999). How to build your hope skills. Nursing
99, 29(9), 49-51.
Van Manen, M. (1990). Researching lived experience: Human
science for an action sensitive pedagogy. London, ON:
Althouse.
Watson, J. (1989). Human caring and suffering: A subjective
model for health services. In J. Watson & R. Taylor (Eds.),
They shall not hurt: Human suffering and human
caring. Boulder, CO: Colorado Associated University.
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21
Family perceptions
of end-of-life care in
an urban ICU
By Maria Kjerulf, RN, MScN, PhD Candidate,
Faculty of Nursing, McMaster University, Assistant
Professor, School of Nursing. Ryerson University,
Cheryl Regehr, PhD, Associate Professor, Faculty
of Social Work, Faculty Member, Faculty of Law
& Institute for Medical Science, Director, Centre for
Applied Social Research, University of Toronto,
Svelana R. Popova, MD, MPH, PhD Candidate,
Faculty of Social Work, University of Toronto and
Andrew J. Baker, MD, FRCP(C), Associate Professor,
Departments of Anaesthesia and Surgery, University of
Toronto, Director, Cara Phelan Centre for Trauma
Research, St. Michael’s Hospital, Toronto, Ontario
Abstract
Objectives:
As most Canadians die in hospital, the final contact of family
members with their loved ones is frequently in an unknown and
uncomfortable environment. Family members are integral to
the end-of-life decision-making process and are vital
contributors to the comfort of dying patients. A quantitative
study was conducted in three critical care areas where the
stated goals were to provide not only quality care to patients,
but also support to families. The researchers sought to
determine levels of satisfaction with care, visitation, support,
comfort and pain measures.
Method:
Three hundred surveys were mailed to next of kin who had a
loved one die in the critical care areas of an urban tertiary
care centre within the prior three years. Survey questions
covered such issues as perceptions regarding the decision to
stop life supports, access to the patient, access to physicians
and nurses and information regarding the patient’s status,
support provided by the hospital, and organ donation
attitudes.
Findings:
Multiple regression analysis revealed that three factors
predicted perceptions of overall quality of care: 1) being
informed by nurses and physicians of any changes, 2) having
the same group of nurses provide care, and 3) having one
individual act as the family contact. Together these factors
accounted for 52% of the variance in perceptions of care. Two
factors accounted for 59% of the variance in dissatisfaction
with the information received: 1) the perception that
physicians did not spend enough time answering family
questions, and 2) that the family was not present when the
patient died.
22
Implications:
Consistency in nursing care and provision of information to
family members may be difficult in the fast pace of an ICU,
but are reasonable program objectives considering the
positive influence this has on perceptions of care. Further,
flexible visitation policies which maximize access between
family members and both their dying loved one and health
care professionals appear to have a beneficial effect on
satisfaction.
Despite policy shifts towards increased community care of
individuals with health problems, most Canadians die in
hospital. In a study reviewing 1997 registry data, Heyland,
Lavery, Tranmer, Shortt, and Taylor (2000) revealed that
73% of all Canadians dying in that year died in hospital,
with provincial averages ranging from 87% in Quebec to
52% in the Northwest Territories. This reflects a gradual
increase from 45% of deaths occurring in hospitals in 1950
to 73% in 1996 and 1997. Of those dying in hospital, 19%
or 13,069 people died in special care units, such as
intensive care (ICU) and cardiac intensive care (Heyland et
al., 2000). These statistics parallel those in the United
States (Lynn et al., 1997; Sager, Easterling, Kindig, &
Anderson, 1989), England (Seals & Cartwright, 1994) and
Australia (Hunt, Bond, Groth, & King, 1991). Clearly
hospitals in general, and ICU’s in particular, have a vital
role in providing end-of-life support to patients and
families.
Unlike deaths in chronic and extended care units, deaths in
ICU are often relatively sudden following a decision to
withdraw life support. Hall and Rocker’s (2000) study
reviewing deaths in an ICU over a one-year period in Halifax,
Nova Scotia, revealed that 174 patients died in the ICU,
representing 13% of those admitted to the unit. Of those dying
in ICU, in 79% of the cases this was as a result of the removal
of life supports. Once life support had been withdrawn,
patients were typically treated with larger doses of sedatives
and analgesics than actively treated patients and died within a
few hours (Hall & Rocker, 2000).
Similarly, McLean, Tarshis, Mazer, and Szalai (2000)
demonstrated an increase in the withdrawal of life support in
two Canadian hospitals from 43% and 46% in 1988 to 66%
and 80% in 1993. Likewise in a U.S. study, recommendations
to withhold or withdraw life support increased from 51% in
1987/1988 to 90% in 1992/1993 (Prendergast, Claessens, &
Luce, 1998). This, then, suggests that medical professionals
are increasingly placed in the position of deciding to withdraw
treatment and discussing their decisions with family members
of the patient.
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CACCN
A study by Malacrida et al. (1998) indicates that families
were satisfied with the care their loved one received in the
ICU prior to the patient’s death and with the information they
received, although families were less satisfied when they did
not have face-to-face discussions with those making the
decisions. Factors which patients’ families felt led to quality
of end-of-life care were adequate pain and symptom control,
avoiding inappropriate prolongation of dying through
aggressive interventions, and achieving a sense of control
through input into the decision-making process (Hanson,
Danis, & Garrett, 1997; Lynn et al., 1997; Singer, Martin, &
Keiner, 1999). Additionally, research has indicated that
families of patients at the end of life wish to feel there is
hope, be informed about treatment decisions, be reassured
that the patient is receiving the best possible care and be
reassured of the patient’s comfort (Danis, 1998; Malacrida et
al., 1998).
One of the major issues of concern for caregivers and
family regarding end-of-life care is the relationship
between health care providers, primarily physicians,
nurses, patients and their families. Several studies point to
concerns regarding lack of communication between health
care providers and families and, in particular, lack of
access to physicians (Fins & Solomon, 2001; Hanson et al.,
1997; Malacrida et al., 1998). Hall and Rocker (2000)
noted that the process of life support withdrawal frequently
involves several discussions with family as treatment goals
are re-established and the likelihood of survival
diminishes. However, in their study, there was
considerable variability considering the documented
presence of the physician in these discussions (ranging
from 54% to 94% of cases). They indicate that this may be
the result of discomfort that some physicians feel in having
these discussions. Kollef (2000) suggests that some of the
factors that influence a physician’s difficulty in
approaching and discussing these important issues with
families are demands on time, reimbursement strategies
that favour more aggressive levels of care, and societal
expectations of medical cures. Others have suggested that
physicians may experience a patient’s death as a personal
failure that they are reluctant to share with others (Glazer,
2000), or that the nature of the ICU intervention in which
intensivists meet the family for the first time under
difficult circumstances adds to difficulty in communication
(Bowman, 2000; Fins, & Solomon, 2001; Rushton &
Scanlon, 1998). Similarly, the discomfort of nurses in
discussing end-of-life issues with families and in
supporting people during their anticipated bereavement has
been attributed to training that focuses on problem-solving
and, consequently, results in feelings of helplessness when
someone is dying (McKissock & McKissock, 1996).
Nurses also express frustration with family members who
they perceive to be at times angry, demanding and
unrealistic (Kirchhoff & Beckstrand, 2000; Kirchhoff,
Spuhler, Walker, Hutton, Cole, & Clemmer, 2000).
The purpose of this study was to determine the level of
satisfaction with comfort, support, visitation, availability of
information and access to their loved one experienced by
CACCN
families of patients who died in the ICU of a large urban
teaching hospital. The philosophy of the critical care program
when someone is dying is to ensure that patients’ needs are
met and families are supported during this difficult time.
Family care becomes more pronounced at this time, when the
goals of care for the patient change from cure to palliation.
Families are integral to the decision-making process as they
bring the patient’s story and offer unique perspectives into
ongoing care. This study attempted to determine whether the
goals of care as perceived by the next of kin were adequately
met.
Method
In this study, surveys were mailed to 300 next of kin, including
siblings, parents, and partners who had a loved one die in one
of three adult critical care areas (medical surgical, cardiac, and
trauma & neurosurgery) of an urban tertiary care centre within
the prior three years. This survey was adapted from a survey
developed by Kirchhoff & Beckstrand (2000). A set of survey
statements (Figure One) covered such issues as perceptions
regarding the decision to stop life supports, access to the
patient, access to physicians and nurses and information
regarding the patient’s status, support provided by the hospital,
and organ donation attitudes. All questions were accompanied
by a five-point likert-type scale. One hundred and fifty surveys
were returned unopened and 51 surveys were received,
resulting in a 34% response rate. As this was a single-item
scale, reliability and validity data are not available. Ethics
approval was granted by the research ethics board of this
tertiary urban care centre.
Findings
Perceptions of care: Overall, families endorsed the statement
“Your family member received the best possible care at x
hospital” with 87% of families selecting three to five on a
likert-type scale of zero to five, and 61% of families selecting
the top score of five. Sixty-eight per cent of respondents
believed that their family member was comfortable and 76%
Figure One: Family perceptions
of end-of-life care survey statements
• Physicians were too hopeful about your loved one
surviving
• Your family disagreed with each other about whether to
continue or stop life support
• Unit visiting hours were too limited
• You believe that your loved one experienced pain that
was difficult to control
• The cultural needs of your family were not met
• Treatment was provided for your loved one that he/she
did not want
• You experienced difficulty getting updated information
• Your family members experienced anger related to your
loved one dying
• Your family was not with the patient when he/she was
dying
16 • 3 • Fall 2005
23
indicated that the same team of nurses worked with the patient
and they found this to be helpful or very helpful. Some
respondents did indicate some concerns with care provided.
Six per cent indicated that they found it very problematic that
various physicians differed about the care required. Others
indicated that it was very problematic that treatment was
continued despite the fact that it caused pain to the patient
(6%), and one person indicated that treatment was imposed on
their loved one to which the patient would have objected if
they were capable. Twelve per cent indicated that the nurses
were too busy.
Correlational analyses revealed several factors associated
with the perception of care. The perception that physicians did
not spend enough time with family answering questions was
negatively associated with perceptions of care (r=-0.37, p ≤
0.01). Other information factors associated with perceptions
of care included feeling the nurses were open and honest (r=
0.49, p ≤ 0.01), and believing that they were informed of
changes (r=0.45, p ≤ 0.01). A t-test was conducted on the
following survey statement, “having the physician do the
death notification” yielding a statistically significant p value
(p ≤ 0.01). Having one individual at the hospital act as the
contact person for the family was positively associated with
reports of good care (r=0.48, p ≤ 0.001), as was having the
same group of nurses work with the patient (r= 0.54, p ≤
0.001). Other factors included feeling that the family had
enough time with the patient before he/she died (r=0.37, p ≤
0.01) and not feeling that the death was unexpected (r=0.35, p
≤ 0.01).
Multiple regression analysis revealed three factors which
predicted positive perceptions of overall care:
1. being informed by nurses and physicians of any
changes (ß = 0.39, p ≤ 0.01),
2. having the same group of nurses provide care (ß = 0.29,
p ≤ 0.05), and
3. having one individual act as the family contact (ß =
0.26, p ≤ 0.05). Together these factors accounted for
52% of the variance in perceptions of care.
Access to information: The majority of respondents (79%)
were satisfied or very satisfied with the amount of information
that they received (selecting three to five on a zero to five
scale). Seventy-six per cent indicated that they were informed
of changes, 75% felt the nurses were open and honest and 57%
felt they were offered options regarding care. Nevertheless,
20% did not feel that physicians spent enough time answering
questions, 22% felt that they had difficulty obtaining
information and 8% felt that procedures were not properly
explained.
Factors associated with the perception that information was
not forthcoming included: feeling visiting hours were too
limited (r=0.36, p ≤ 0.01), wanting to spend more time with
the loved one (r=0.46, p ≤ 0.01), not being with the loved
one when he/she died (r=0.52, p ≤ 0.001), believing that the
loved one’s pain was not properly controlled (r=0.30, p ≤
0.05), feeling that no trained health care professionals were
able to help them with their grieving (r=0.41, p ≤ 0.01),
feeling the nurses were too busy (r=0.58, p ≤ 0.001), and
24
feeling that the doctors did not spend enough time
answering questions (r=0.72 p ≤ 0.001). In a multiple
regression analysis, two factors accounted for 59% of the
variance in dissatisfaction with the information received: 1)
the perception that physicians did not spend enough time
answering family questions (ß = 0.61, p ≤ 0.001), and 2)
that the family was not there when the patient died (ß =
0.27, p ≤ 0.01).
Family support: Respondents were less positive about family
support received than quality of care or availability of
information. Forty-six per cent of families felt that they had a
support person in the hospital, while 56% indicated it was
helpful to have one person who acted as the family contact.
Sixty-nine per cent appreciated having a room for private
grief. Ten per cent felt that limitations in visiting hours were
problematic for them.
Attitudes towards organ donation: As organ procurement is
an increasingly important aspect of ICU work, respondents
were asked about their attitudes towards organ donation.
Eighty per cent indicated that they would be willing to donate
their own organs and 78% would be willing to donate the
organs of a family member. There were no significant
associations between experiences in the ICU and willingness
to donate organs. It is positive to note that respondents’
attitudes toward donation paralleled those of the general public
with 78% agreeing to donate (Roels, Roelants, Timmermans,
Hoppenbrouwers, Pillen, & Bande-Knops, 1997). Thus, it does
not appear that the ICU experience negatively or positively
affected these attitudes.
Implications
This study is a survey of families who were bereaved
subsequent to a family member dying in an ICU of an urban
teaching hospital. In general, findings were positive, with
83% of respondents endorsing a statement that their family
member received the best possible care at this hospital and
61% of respondents selecting the highest level of
endorsement. A small percentage of respondents (less than
6%) indicated that they were concerned that physicians
differed on the type of treatment that should be offered, that
treatment was continued despite the fact that it caused pain,
and/or that unwanted treatment was imposed on their loved
one. Important factors associated with perceptions of care
included opportunities to discuss treatment and have
questions answered by nurses and doctors, having a consistent
contact person at the hospital, having a consistent team of
nurses, and having time with the patient in preparation for
death. Three factors:
1. being informed of changes,
2. having consistent nursing staff, and
3. having a single hospital staff member act as the family
contact accounted for 52% of the variance in
perceptions of care.
More than 75% of respondents felt that they received
information in a timely manner and felt that staff was open and
honest with them. Approximately 20%, however, identified
difficulties in accessing information, particularly from
16 • 3 • Fall 2005
CACCN
physicians. Those who were dissatisfied with information
access also thought that their family member’s pain was not
controlled adequately. Interestingly, those who were
dissatisfied with the amount of information they received were
also concerned about the lack of time that they spent with their
family member and the fact that they were not with their
family member when he/she died. In a multiple regression
analysis, information from the physician and not being there
when the patient died accounted for 59% of the variance in
dissatisfaction with information.
These findings have important implications for ICU care.
Consistency in nursing and medical care may be difficult in an
ICU with daily nursing rotation, weekly physician turnover,
and changing assignments based on acuity and staffing, but is
a reasonable program objective considering the positive
influence this has on perceptions of care. Further, while the
important contribution of being absent at the time of the
patient’s death may represent anger or guilt on the part of
family members that is independent of the ICU experience,
this may point to the need for more flexible visitation policies,
although the units studied here did have flexible visiting hours.
Danis (1998) underlined the importance of contact between
the dying patient and family members in order to facilitate
acceptance of death. Goetschius (1997) recommends that ICU
staff assist family in developing a role for themselves during
this difficult process and provide positive feedback on that
role.
Finally, consistent with the findings in other research studies
(Fins & Solomon, 2001; Hanson et al., 1997; Malacrida et al.,
1998), information was found to be a key factor in the
satisfaction experienced by family members. This information
should include a clear and straightforward explanation of
medical procedures, prognosis and effective methods for
controlling discomfort (Glazer, 2000). In addition, families
should be involved to the greatest extent possible in treatment
and end-of-life decisions (Bowman, 2000; Fins & Solomon,
2001; Glazer, 2000).
The primary goal of any health care facility is to provide
humane care which results in the best possible outcomes
for the patient and their family. It is incumbent on critical
care facilities to continue to develop creative means for
ensuring that families of patients who die in the ICU are
provided with consistent information and attention, and
access to both their loved one and health care
professionals.
References
Bowman, K. (2000). Communication, negotiation and mediation:
Dealing with conflict in end-of-life decisions. Journal of
Palliative Care, 16(Suppl), S17-S23.
Danis, M. (1998). Improving end-of-life care in the intensive care
unit: What’s to be learned from outcomes research? New
Horizon, 6(1), 110-118.
Fins, J., & Solomon, M. (2001). Communication in intensive care
settings: The challenge of futility disputes. American
Journal of Critical Care, 29(Suppl 2), N10-N15.
Glazer, V. (2000). Talking with patients and families. Patient
Care, 32(21), 16-36.
CACCN
Goetschius, S. (1997). Families and end-of-life care: How do we
meet their needs? Journal of Gerontological Nursing, 3,
43-49.
Hall, R., & Rocker, G. (2000). End-of-life care in the ICU:
Treatments provided when life support was or was not
withdrawn. Clinical Investigations in Critical Care,
118,1424-1430.
Hanson, L., Danis, M., & Garrett, J. (1997). What is wrong with
end-of-life care? Opinions of bereaved family members.
Journal of the American Geriatric Society, 445, 13391344.
Heyland, D., Lavery, J., Tranmer, J., Shortt, S., & Taylor, S.
(2000). Dying in Canada: Is it an institutionalized,
technology supported experience? Journal of Palliative
Care, 16(Suppl), S10- S16.
Hunt, R., Bond, M., Groth, R., & King, P. (1991). Place of death
in South Australia: Patterns from 1910 to 1987. Medical
Journal of Australia, 155, 549-553.
Kirchhoff, K., & Beckstrand, R. (2000). Critical care nurses’
perceptions of obstacles and helpful behaviors in providing
end-of-life care to dying patients. American Journal of
Critical Care, 9, 96-105.
Kirchhoff, K., Spuhler, V., Walker, L., Hutton, A., Cole, B., &
Clemmer, T. (2000). Intensive care nurses’ experiences
with end-of-life care. American Journal of Critical Care,
9, 36-42.
Kollef, M. (2000). Outcomes research at the end of life. Critical
Care Medicine, 28, 269-270.
Lynn, J., Teno, J., Phillips, R., Wu, A., Desbiens, N., Harrold, J.,
et al. (1997). Perceptions by family members of the dying
experience of older and seriously ill patients. Annals of
Internal Medicine, 126, 97-102.
Malacrida, R., Bettelini, C., Degrate, A., Martinez, M., Badia, F.,
Piazza, J., et al. (1998). Reasons for dissatisfaction: A
survey of relatives of intensive care patients who died.
Critical Care Medicine, 26, 1187-1193.
McKissock, M, & McKissock, D. (1996). The nurses’ role
in caring for the newly bereaved. Lamp, 53(5), 3032.
McLean, R., Tarshis, J., Mazer, C., & Szalai, J.P. (2000). Death in
two Canadian intensive care units: Institutional differences
and changes over time. Critical Care Medicine, 28, 100103.
Prendergast, T., Claessens, M., & Luce, J. (1998). A national
survey of end-of-life care for critically ill patients.
American Journal of Respiratory Critical Care
Medicine, 158, 1163-1167.
Roels, L., Roelants, M., Timmermans, T., Hoppenbrouwers, K.,
Pillen, E., & Bande-Knops, J. (1997). A survey on attitudes
to organ donation among three generations in a country
with 10 years of presumed consent legislation. Transplant
Proceedings, 29, 3224-3225.
Rushton, C., & Scanlon, C. (1998). A road map for navigating
end-of-life care. Medical Surgical Nursing, 7(1), 5759.
Sager, M., Easterling, D., Kindig, D., & Anderson, D. (1989).
Changes in location of death after passage of
Medicare’s prospective payment system: A national
study. New England Journal of Medicine, 320, 433439.
Seals, C., & Cartwright, A. (1994). The year before death.
Avebury: Aldershot.
Singer, P., Martin, D., & Keiner, M. (1999). Quality end-of-life
care: Patients perspectives. JAMA, 281, 163-168.
16 • 3 • Fall 2005
25
Improving pain
management for critically
ill and injured patients
By Heather Ead, RN, BScN, Clinical Educator
Post-Anesthetic and Day Surgery Units,
Trillium Health Centre, Mississauga, Ontario.
In this article, the author discusses the negative outcomes of
pain, the barriers to effective pain management, and methods
to overcome these barriers.
Abstract
The negative outcomes
of under-treated pain
Key words: pain management, pain assessment, opiophobia
The under-treatment of pain continues to be a problem in
patient care. Evidence shows a significant percentage of
patients suffering with acute and chronic pain, despite the
treatment options available. This must be addressed, as undertreating pain has a long list of negative outcomes. In this
article, the author reviews the consequences of unrelieved
pain, barriers to pain management, and recommendations for
improvements. As health care professionals, nurses have a
responsibility to advocate for patients and provide the best
pain management possible. Efforts to improve pain
management will help avoid complications, such as chronic
pain syndrome, while improving comfort, function, and quality
of life.
The under-treatment of pain continues to be a problem and
the factors influencing unrelieved pain are numerous.
Evidence shows 39% of patients with chronic pain have
their pain under-treated (Jovey et al., 2002). In another
study, 30% of patients diagnosed with a painful condition
were not treated with analgesics (Allen et al., 2003).
Studies of prescriptions of analgesics demonstrate the
ongoing reluctance of physicians to order opioids. Thirtyfour per cent of physicians stated that they would not use
opioids to treat moderate to severe pain, even as a thirdline treatment when other methods had failed (Tunks,
2003). Consequently, 50 million people in the U.S. have
persistent pain (Mitka, 2003). Why does this suffering
continue, when it is both unnecessary and unethical to
under-treat pain?
Opioids remain the cornerstone to pain management today.
The author discusses improvements required regarding the
administration of opioids. This is only part of the solution,
as no one treatment can effectively resolve the
multidimensional nature of pain. The use of non-opioids,
adjuncts, and non-pharmacological therapy may be more
appropriate in some situations. Such alternatives can also
be used simultaneously with opioid analgesia to provide
balanced, optimized analgesia. Short-term use of
cyclooxygenase-2 inhibitors (COX-2I) reduces opioid
requirements without clinically significant delays in bone
healing or fusion (Long, Lewis, Kuklo, Zhu, & Riew,
2002).
26
Oligioanalgesia is the phenomenon of under-treating acute
pain (Jovey et al., 2002).
Oligioanalgesia has a long list of negative outcomes (See
Table One). Post-operative pain affects a variety of normal
physiological functions and can adversely influence the
surgical outcome for the patient (Buvanendran, Kroin,
Tuman & Lubenow et al., 2003). An example is poor
functional recovery after a total knee replacement, with
prolonged joint stiffness and decreased mobility
(Buvanendran, 2003).
Unrelieved pain can also produce delayed wound healing,
related to a decrease in peripheral blood flow (Ekman &
Koman, 2004). Ongoing pain can lead to anxiety, impaired
cognition, depression and sleep deprivation (Ekman &
Koman, 2004) as well as muscle spasms, which compound
discomfort for the patient.
Dysfunction of the immune system is another negative
outcome of persistent unrelieved pain (Jovey et al., 2002).
Imagine the significance of this in a patient who is
immunosuppressed: under-treating a patient with cancer can
result in increased metastatic spread of the primary tumour,
related to impaired immuncompetence and dysfunction of
natural killer cells. This challenges the expression of ‘a little
pain won’t kill you’.
There is much evidence pointing to the risk of developing
chronic pain if acute pain management is inadequate. This is
related to the structural changes that occur at the dorsal horn of
the spinal cord. The body’s main pain perception
“switchboard” is altered by the continuing pain impulse. An
imprint is left at the spinal cord, with perception of pain
continuing beyond the expected rehabilitative phase (Jovey et
al., 2002). The result is sensitization of the peripheral and
central nervous system with a decreased threshold to perceive
pain impulse. For the patient, this means that even a small
stimulus can cause the perception of pain. There is also
evidence of ongoing pain leading to the development of new
sensory and sympathetic nerve terminals, as well as increases
in excitatory neurotransmitters, which all have negative
outcomes in regards to the patient’s level of comfort (Jovey et
al., 2002).
16 • 3 • Fall 2005
CACCN
The stress response to unrelieved pain is characterized by
tachycardia, hypertension, increased myocardial oxygen
consumption,
hypercoagulability,
and
persistent
catabolism (Wong et al., 2004). For a healthy individual,
tachycardia may not prove clinically significant. To the
patient with existing co-morbidities, the stress response
could result in cardiac arrhythmias, cardiovascular events
and deep vein thrombosis (Wong et al., 2004). Patients in
pain are at greater risk of developing respiratory problems,
as their ability to perform deep breathing and coughing
exercises is challenged. Therefore, increased occurrence of
atelectasis, pneumonia, oxygen desaturation and
pulmonary emboli are potential negative outcomes of
under-treated pain.
The critically ill patient is particularly susceptible to the
negative effects of untreated pain. Discomfort related to
invasive tubes, diagnostic tests, as well as post-operative
pain is common for the critical care patient. Pain for these
patients can cause increased sympathetic nervous activity,
ventilator dyssynchrony, and cardiovascular events (Wong et
al., 2004).
Table One
Negative Impact of Pain
The negative impact of a child left in pain is also important
to consider. Pain in children can increase anxiety, create
fear, and lead to future avoidance of seeking treatment.
Some health care professionals choose to under-treat a
child’s pain, due to fears of causing over-sedation and
respiratory depression (Howard, 2003). There continues to
be great difficulty bridging the gap between safe and
effective pain management and its every day application in
the pediatric population (Howard, 2003). Like adults,
children with untreated pain can have long-term
consequences, such as chronic and neuropathic pain
(Howard, 2003).
Decreased quality of life is a negative outcome of pain.
Patient satisfaction is one of the most frequently used
outcome measures for evaluating the quality of patient care
(RNAO, 2002). Pain should be reduced to a level that will
allow the patient to perform physiotherapy and activities of
daily living. Pain ratings of four out of 10 or higher have been
shown to interfere with such functioning (Pasero &
McCaffery, 2003).
Benefits of Adequate Analgesia
Elevated BP, heart rate, risk for cardiac ischemia in
susceptible patients.
No added stress to cardiac system.
Patient becomes agitated, depressed, exhausted, and less
able to cope with daily challenges.
Psychological comfort ensured, sleep pattern not disrupted.
Delayed rehabilitation, increased risk for complications
such as thrombosis, pulmonary embolus, muscle
wasting, pressure ulcers.
Able to participate in rehabilitation process, physiotherapy.
Lack of interest in dietary intake, poor nutritional
status, dehydration.
Able to follow prescribed dietary regimen.
Stress hormones, antidiuretic hormone and glucose
elevations, difficulty maintaining desired range of
blood sugar, blood pressure, and heart rate, retention
of water and sodium, electrolyte imbalances,
urinary retention.
No added stress to endocrine system. Ability to maintain normal
urinary and renal function.
Reluctant to take deep breaths, atelectasis, pneumonia,
hypoxia, respiratory depression.
Able to follow activities such as chest physiotherapy,
deep breathing and coughing post-operatively.
Occurrence of peripheral and central sensitization,
neuronal plasticity.
Avoidance of complication such as development of
Chronic Pain Syndrome.
Confusion, delirium, subsequent increased risk
of falls and other injury.
Less risk of emotional upset, confusion, and negative
family/social impact.
Delayed gastric emptying, constipation and ileus.
Increased risk of complications causing extended stay
in hospital such as pneumonia.
Negative impact on the patient’s view of health care;
may avoid seeking medical consultations/check-ups
in the future.
Adequate pain control improves the return of bowel function.
Overall length of stay optimized.
Patient satisfied with care, and more likely to take an active role
in his/her health status, with a preventative focus.
(Ekman & Koman, 2004; Jovey et al., 2002; Pasero & McCaffery, 2004; RNAO, 2002; Ross, 2004; Wong et al., 2004)
CACCN
16 • 3 • Fall 2005
27
Ongoing pain can also become a barrier to health teaching.
Before discharge teaching can be accomplished, the patient
must be comfortable. If the patient is in moderate to severe
pain, it is difficult for him or her to concentrate and learn.
Studies indicate that at appropriate doses, opioids can improve
cognition and patient learning (Buss, 2004).
Another negative outcome of untreated pain is that the
patient’s rights are not being met. The Canadian Pain
Society Pain Manifesto states the patient has the right to
have the best pain relief possible (Jovey et al., 2002). Undertreating pain is both unethical and an unnecessary breach of
human rights.
The economic impact of unrelieved pain is both immense and
difficult to measure. However, as an example, lost productive
time in the United States from common pain conditions
among active workers costs an estimated $61.2 billion
annually (Stewart, Ricci, Chee, Morganstein, & Lipton,
2003).
In summary, the negative outcomes of under-treated pain are
vast. Virtually every organ system is affected and the patient’s
rights and quality of life are negatively impacted. Moreover,
unmanaged pain can lead to significant complications, which
can devastate the patient’s long-term health (Ekman & Koman,
2004).
Barriers to effective pain management
The first step in improving pain management for patients is
for nursing to recognize the barriers. Barriers to effective pain
management have likely existed for as long as people have
suffered from pain. In the 1870s, the availability of morphine
by over-the-counter accessibility and self-medicating
practices led to ‘narcomania’ (Meldrum, 2003). This
overindulgence in opioids resulted in an irrational fear of
opioids for some: opiophobia. This fear exists among patients,
families and health care professionals even today (Jovey et
al., 2002).
With the regulated and controlled dispensing of opioids,
fear of opioids should not be as common as it is.
Unfortunately, some overcautious and misinformed health
care professionals still suffer from opiophobia, which
results in inadequate pain management. Professionals’
discomfort in administering opioids is usually related to
concerns of causing addiction, overdose, respiratory
depression, or death. However, the incidence of addiction
after using opioids for pain management is less than 1%
(Joranson, Ryan, Gilson, Dahl, 2000). A recent study
showed that despite the increased medical use of strong
opioids such as morphine and hydromorphone, abuse
levels have not exceeded 1% (Joranson et al., 2000).
These are encouraging numbers for practitioners who have
concerns regarding opioids diverted for recreational use.
In fact, the data suggest that opioid analgesia is a
relatively small part of drug abuse. Of drugs used for
illicit purposes, opioids are used 3.8% of the time. More
frequently abused are alcohol, amphetamines and
sedatives (Joranson et al., 2000). Despite an increase in
28
the clinical use of opioids, prevalence of abuse of these
agents remains low and has been stable for the past seven
years (Joranson et al., 2000).
Another barrier to effective pain management is that some
health care professionals fear hastening death in terminally ill
patients. However, Jovey et al. (2002) argue that fear in this
palliative care situation outweighs common sense with regard
to providing quality of life for the patient.
Other barriers due to lack of knowledge affect pain
management in infants and children. There is a
misconception among some health care professionals that
infants do not feel pain. In fact, the nervous system in
children and infants can be more sensitive than in adults
(Howard, 2003). This is clinically significant, as lower
thresholds of mechanical and thermal stimuli could result
in a greater perception of painful stimulus than would
occur in adults (Howard, 2003). There remains a lack of
confidence in prescribing and administering pain
medication to pediatric patients (Norton, Gundersen, &
Pitcher, 2002).
The elderly are also a group that often receives inadequate
pain management (Allen et al., 2003). There is a
misconception among some practitioners that cognitive
impairment blunts the perception of pain. Although the
elderly may be more sensitive to the effects of opioids, this is
no reason to withhold analgesia or under-treat pain. Instead,
one should assess the individual, and start with low doses of
analgesia. Fear of causing delirium or confusion is a barrier
to pain management for the elderly. In a recent study, fewer
than 25% of elderly post-operative patients received their
mean level of prescribed opioid analgesia (Allen et al.,
2003).
Thus, we see that individuals at both ends of the age
spectrum experience pain the most. Children and infants can
be more sensitive to noxious stimuli, while the elderly may
have depression and osteoarthritis to augment their intensity
of pain (Howard, 2003). We must remember that pain knows
no age limit.
The lack of attention to pain management in many nursing
schools’ curricula is a barrier to pain management (Ekman &
Koman, 2004). Little course content on the principles of pain
management perpetuates the existence of misconceptions
regarding pain management. For example, a common
misconception is that the nurse or doctor is the expert on the
patient’s pain but, in fact, the patient is the expert on his or her
own pain. These attitudes are learned through professional
education programs, and passed on from year to year (Tunks,
2003). However, the patient’s self report is the most accurate
assessment of patient’s pain level (RNAO, 2002).
A lack of accountability regarding pain management is yet
another barrier. Nursing and medical staff can perceive it is
beyond their role to eliminate their patient’s pain. Such lack
of accountability has been cited as a major factor
contributing to inadequate pain management (Pasero &
McCaffery, 2003).
16 • 3 • Fall 2005
CACCN
The tradition of PRN dosing creates peaks and valleys of
analgesic blood levels, and causes more side effects and less
effective control of pain. Furthermore, there is a higher
occurrence of tolerance to opioids, as compared to analgesia
administered on a regular schedule (Jovey et al., 2002).
Scheduled or ‘round the clock’ dosing, as well as controlled
release (CR) formulations provide more stable analgesia and
fewer side effects (Yaksh, 2001). Stable blood analgesic
levels then provide pre-emptive analgesia (analgesia prior to
onset of pain), which facilitates functional recovery
(Cheville, Chen, Oster, McGarny, & Narcessian, 2001).
Hydromorphone for both chronic and post-operative pain is
an excellent alternative to the gold standard of morphine.
Some authors refer to morphine as the ‘old standard’ and
hydromorphone as the ‘new gold standard’. Apart from
stable opioid levels, this controlled release formulation is
also a “cleaner” opioid causing no histamine release or active
metabolites
(Golembiewski,
2003).
Therefore,
hydromorphone is a safe option where it is desirable to avoid
histamine-induced hypotension, or for patients with impaired
renal function or advanced age, where accumulation of active
metabolites would otherwise be a concern (Golembiewski,
2003).
Another barrier to recognize is prejudice. Patients with HIV
are stigmatized, and their illness creates a barrier to
effective pain management (Ross, 2004). Even a higher
percentage of patients with Acquired Immunodeficiency
Virus (AIDs) suffer, and this pain is often left untreated.
This is very unfortunate as the HIV virus is a
neuropathogen, causing direct damage to nerve tissue.
Therefore, HIV patients have many sites and types of
neuropathic pain (Ross, 2004).
Patients with a history of drug addiction or alcohol abuse are
also at risk of having unrelieved pain. A patient with such
history should not be penalized by having analgesia withheld,
but rather have a clear agreement between the patient and
health care provider that opioids are only to be given to treat
pain. Appropriate use of opioids does not lead to addiction
(Jovey et al., 2002).
Another belief that acts as a barrier is that opioids will mask
acute pain, impairing the diagnosis (Jovey et al., 2002).
Evidence shows this to be untrue. The patient’s pain should be
treated to maintain comfort throughout the diagnostic phase.
Early administration of intravenous opioids has been shown in
clinical trials not to interfere with diagnosis and, in some trials,
to actually enhance diagnostic accuracy (Jovey et al., 2002;
RNAO, 2002).
A poor pain assessment is another barrier to pain management.
Assessments may not be thorough or performed less
frequently than necessary. There may be a lack of validity
given to the patient’s self-report, which may be tied to
inadequate knowledge on pain and pain management (Ekman
& Koman, 2004). Use of a standard pain rating scale facilitates
consistency in pain assessments. At our facility, the Numeric
Rating Scale (NRS) and the Wong-Baker Faces Pain rating
scale (RNAO, 2002) are consistently used to facilitate pain
assessment. The Wong-Baker pain scale is particularly useful
CACCN
where language barriers are present. The most commonly
used, valid and reliable pain scale is the Numerical Rating
Scale (NRS) (Buss, 2004). The target on this 0 to 10 scale is
for the patient to report a pain level of three or less (Buss,
2004). Using the NRS, a pain score of more than four out of
10 interferes with function and indicates the need for further
assessment or intervention (Pasero & McCaffery, 2003). A
more thorough assessment could reveal a different diagnosis,
such as a full bladder, hematoma, or a cast or dressing that is
too tight and restricting circulation (Buss, 2004).
Lack of time to complete the patient assessment is another
challenge in our fast-paced health care system. Nursing
shortages and the current billing format for physicians does
not encourage thorough pain assessment (Tunks, 2003).
Overcoming the barriers of pain
management
One can see the list of barriers of pain management is long
(refer to Table Two). Identifying the long list of challenges
should not be viewed as discouraging, but rather as the first
step in addressing and initiating pain management
improvement measures. Improved pain management can be
achieved as an ongoing strategy.
Many of the barriers of pain management are due to a lack of
knowledge of the principles and options in pain management.
There is a great need to update the current curriculum of
nursing and medical programs. Patient care would benefit
from a program that presented pain management methodology
in a coherent and comprehensive manner (Mitka, 2003).
Education programs should be designed to foster the
knowledge, skills, and appropriate beliefs about the
assessment and management of pain (RNAO, 2002). Clinical
competency in pain assessment and management demands
ongoing education.
The World Health Organization (WHO) encourages a stepped
approach to pain management, which uses pharmacological
and nonpharmacological treatments. The WHO approach also
gives direction for use of nonopioid, opioid and adjuvant
medications for pain management, and when these agents
should be introduced, depending on the level and type of pain
(RNAO, 2002). These methods of multimodal balanced
analgesia should be included in the basic curriculum of
nursing and medical schools. Education of nurses on the
principles of pain assessment and management supports their
role as an advocate and resource for the patient and family.
Through education, the barrier of opiophobia, fears of
addiction, opioid diversion, and biases towards the patient
complaining of pain after a ‘standard’ dose of analgesic can be
addressed. Health care professionals must remember that there
is no true ‘standard’ dose of analgesics, as the response varies
from patient to patient. Biases and myths such as standard
dosing are learned at the undergraduate level (Tunks, 2003)
and perpetuated in clinical practice. Optimal pain management
can be provided when analgesics are dosed until effective, or
until unwanted side effects are present. Nurses must ensure
that analgesia is individualized, and avoid a “cookie cutter”
approach in managing patients’ pain.
16 • 3 • Fall 2005
29
Education could also increase awareness of the patient groups
that are at particularly high risk of under-managed pain, such
as the elderly, cognitively impaired, children, patients with
HIV and cancer (Ross, 2004). A non-judgmental approach can
be taught that is best in assessing and treating pain. This is
important since the patient with HIV will likely have a number
of pain syndromes and the intensity of pain increases as the
disease progresses (Ross, 2004).
Providing education for nurses can increase awareness of the
benefits of controlled release formulations. Content should
include that PRN analgesics are only meant to “mop up” the
break-through pain. Waiting until the patient calls for pain
medications creates delays in onset of analgesia and less
effective pain control (Jovey et al., 2002). Knowledge
regarding the use of nonsteroidal anti-inflammatory agents
(NSAIDs), COX-2Is and other adjuncts must be disseminated
to health care professionals (Yaksh, 2000). At our facility, the
acute pain services (APS) department provides classes for
nursing and allied health staff on a monthly basis. The classes
cover the basics of pain management, use of patient-controlled
analgesia (PCA), and epidural analgesia. Pain management
classes also review the benefits of using non-opioids and
adjuncts, such as lowered required doses of opioids, less
respiratory depression and drowsiness. The classes review the
contraindications to COX-2Is and NSAIDs, which follows the
acronym GRAB. This acronym indicates that patients with a
history of (G) gastrointestinal bleeds, (R) renal dysfunction,
(A)allergy to NSAIDs or (S) sulpha medications, or (B)
bleeding disorders are not to be prescribed NSAIDs or COX2Is.
Table Two
Barriers to Effective Pain Management
Opiophobia
Fear of addiction, opioid diversion for illicit use
Biases/prejudices regarding complaints of pain as
inaccurate or drug-seeking
Inadequate assessments of pain
Focusing on administering analgesia only on a
PRN basis
Lack of accountability
Avoiding the of use of analgesia with pediatric
and elderly patients
Lack of course content on pain management
principles in nursing and medical schools
Multimodal and proactive analgesia have great benefits in
reducing pain levels. Since the pain pathways, perception, and
transmission of pain are complex, no single analgesia or
treatment can manage pain adequately (Ekman & Koman,
2004).
Education of staff to improve assessment of pain is another
necessary step to improving pain management. Assessing
the patient’s complaints of pain as the fifth vital sign is a
huge step in improving pain management. Regular
assessment of this fifth vital sign, and evaluating the
effectiveness of interventions to treat pain are necessary to
achieve a goal of comfort (Lynch, 2001). However, the lack
of a universal pain assessment tool remains. More research
is needed in this area to determine the most accurate and
reliable pain assessment tool for adults, children,
cognitively impaired and nonverbal patients, and those with
language barriers (Howard, 2003).
The role and structure of APS must be reviewed to ensure
adequate coverage of patients. The staff of our APS is
frequently stretched to their limits, in regards to the high
volume of patients that are referred to their services, including
critically ill patients. Improvements can be made to help
provide the highest standard of pain care for all patients. The
APS at our facility has recently expanded in response to
increasing referral rates. This expansion has facilitated the
provision of more staff education, increased coverage for
patient care and quality monitoring and best practice projects.
With the aging population and increased surgery volumes,
there may very well be a need for further expansions in the
APS.
Methods to Overcome/Address Barriers
Education and increased awareness of staff and patients regarding
safe use of opioids
Use of patient-provider contracts, as well as education as noted above
Education of staff that the patient is the expert in pain, self-report
is the most reliable indicator
Utilizing a consistent pain assessment tool that includes patient’s
self-report as an indicator of pain
Assessment of pain as ‘the 5th Vital Sign’ as per RNAO
Best Practice Guidelines
Use of controlled-release opioid formulations and “round the clock”
administration to provide more stable blood analgesic levels,
and fewer side effects
Education of staff reviewing their role as patient advocates, and the
statements of the Canadian Pain Society’s Pain Manifesto
Education of staff reviewing pain management principles and
safe analgesic administration
Education as noted above, updating the curriculum in nursing
and medical schools
(Allen et al., 2003; Ekman & Koman, 2004; Howard, 2003; Jovey et al., 2002; Pasero & McCaffery, 2003; Tunks, 2003)
30
16 • 3 • Fall 2005
CACCN
An APS also facilitates better education of the patient and
family, which is another method of pain management. Patient
education can decrease anxiety, reducing the perception of
pain. Conversely, lack of education increases feelings of
apprehension with heightened awareness of pain impulses
(Jovey et al., 2002).
Summary
The task of improving pain management for patients is an
important initiative. The outcomes for the patient and health
care system will outweigh the time and effort these
initiatives necessitate. Improved patient comfort,
satisfaction, decreased complications, and reduced length of
stay can be tied to improved pain management (Jovey et al.,
2002).
Quality patient care demands the provision of optimal pain
management. The Canadian Council of Health Services
Accreditation states that effective pain management is an
expected component in the regular evaluation and
accreditation process (RNAO, 2002). This reinforces the
importance of ongoing quality improvement efforts. As
opioids are the cornerstone of pain management, we must
reinforce their role in analgesia. Through education we can
improve the comfort level of both staff and patients regarding
opioid use, overcome fears and dispel myths passed down
from previous generations. Avoiding the occurrence of opioid
diversion for non-medical use should not be done at the
expense of pain control for the suffering patient.
The negative impacts of pain are far reaching, including
economic, physiological and psychological outcomes.
Recognizing the negative impact of unrelieved pain, as well
as the barriers to effective pain management are the first
steps in optimizing pain management. Improving pain
management through pre-emptive analgesia, continuous
release formulations and multimodal treatments, as well as
treating pain as the fifth vital sign, are some simple
principles that can improve quality of life for patients. The
most important contributing factor to positive outcomes has
been the intensive involvement of a physician (Meldrum,
2003), with nurses and allied health staff being important
members of the pain management team. As advocates for
patients, it is a nursing responsibility to address the current
issues in pain management. Through ongoing efforts to
improve pain management, we are abiding by the Canadian
Pain Society’s patient Pain Manifesto: the health care
professional is obligated to make every effort to control the
patient’s pain.
References
Allen, R., Thorn, B., Fisher, S., Gerstle, M.S., Quarles, K.,
Bourgeois, M., Dijkstra, K., & Burgio, L. (2003).
Prescription and dosage of analgesic mediation in
relation to resident behaviors in the nursing home.
Journal of the American Geriatrics Society, 51, 534538.
Buss, H. (2004). Phase II pain management: Comfort enhances
surgical experience. Journal of Perianesthesia
Nursing, 19(1), 39-41.
CACCN
Buvanendran, A., Kroin, J., Tuman, K., Lubenow, T., Elmofty,
D., Moric, M., et al. (2003). Effects of perioperative
administration of a selective COX-2 inhibitor. The
Journal of the American Medical Association, 290,
2411-2418.
Cheville, A., Chen, A., Oster, G., McGarry, L., & Narcessian,
E. (2001). A randomized trial of control-release
Oxycodone during inpatient rehabilitation following
unilateral total knee arthroplasty. The Journal of Bone
and Joint Surgery, 83-A, 572-576.
Ekman, E., & Koman, A. (2004). Acute pain following
musculoskeletal injuries and orthopaedic surgery. The
Journal of Bone and Joint Surgery, 86-A, 1316-1324.
Golembiewski, J. (2003). Morphine and Hydromorphone for
post-operative analgesia: Focus on safety. Journal of
Perianesthesia Nursing, 18, 120-122.
Howard, R. (2003). Current states of pain management in
children. The Journal of the American Medical
Association, 290, 2464-2469.
Jovey, R., Boulanger, A., Gallagher, R., Gillen, M., Goldman,
B., Pelose, P., & Thompson, E. (2002). Managing pain:
The Canadian health care professional’s reference
(2nd ed.). Toronto: Healthcare and Financial Publishing.
Joranson, D.E., Ryan, K.M., Gilson, A.M., & Dahl, J.L.
(2000). Trends in medical use and abuse of opioid
analgesics. The Journal of the American Medical
Association, 290, 1710-1714.
Long, J., Lewis, S., Kuklo, T., Zhu, Y., & Riew, D. (2002). The
effect of cyclooxygenase-2 inhibitors on spinal fusion.
The Journal of Bone and Joint Surgery, 84-A, 17631767.
Lynch, M. (2001). Pain as the fifth vital sign. Journal of
Intravenous Nursing, 24(2), 85-94.
Meldrum, M. (2003). A capsule in history of pain
management. The Journal of the American Medical
Association, 290, 2470-2475.
Mitka, M. (2003). “Virtual Textbook” on pain developed effort
seeks to remedy gap in medical education. The Journal
of the American Medical Association, 290, 2395-2396.
Norton, L., Gundersen, B., & Pitcher, K. (2002). Children and
pain medications: The pharmacist’s view. The Pain
Practitioner, 12(4), 4-8.
Pasero, C., & McCaffery, M. (2003). Accountability for pain
relief: Use of comfort-function goals. Journal of
Perianesthesia Nursing, 18(1), 50-52.
Ross, E. (2004). Pain management: Hot topics. Philadelphia:
Hanley & Belfus.
Registered Nurses Association of Ontario. (2002). Nursing
Best Practice Guideline: Assessment and
management of pain. Toronto: Author.
Stewart, W., Ricci, J., Chee, E., Morganstein, D., & Lipton, R.
(2003). Lost productive time and cost due to common
pain conditions in the U.S. work force. The Journal of
the American Medical Association, 290, 2443-2454.
Tunks, E. (2003). The chronic need to improve the
management of pain. Pain Research and
Management, 8, 187-188.
Wong, C., Burry, L., Molino-Carmuna, S., Leo, M., Tessler, J.,
Hynes, P., & Mehta, S. (2004). Analgesic and sedative
pharmacology in the intensive care unit. Dynamics,
15(1), 23-26.
Yaksh, T. (2000). Analgesics, pain and tolerance: The St.
John’s discussion. Pain research and management,
5(1), 19-22.
16 • 3 • Fall 2005
31
Question to the Board
Is there any means of reimbursement
for obtaining my specialty certification?
CACCN response:
The Canadian Association of Critical Care Nurses (CACCN)
encourages critical care nurses across Canada to obtain their
certification in either adult or pediatric critical care. Although
the CACCN represents critical care nurses nationally, it is not
the organization that maintains the certification program. The
Canadian Nurses Association (CNA) offers certification in a
variety of nursing specialties, including critical care, both
adult and pediatric.
Each year, the CACCN supports the endeavours of individual
critical care nurses by including the names of CACCN
members who have certified and re-certified during that year
in a draw. A limited number of names are drawn for both
newly certified and re-certified nurses in both pediatric and
adult critical care specialties. Those CACCN members who
have their names drawn will receive reimbursement of their
certification or re-certification fees. Each institution and each
province may have funding available to help nurses attain this
goal as well. You may wish to check with your provincial
licensing body, or your nursing union for available funds. As
well, the Canadian Nurses Foundation (CNF) has funding
available for people who have attained certification status.
In the recent past, due to the Privacy of Information
Legislation, we have had difficulty receiving the names of all
CACCN members who have certified and re-certified from the
CNA. If you have achieved this important goal in 2005, we
would like to hear from you so we may include your name to
be a part of the CACCN Certification Award draw. Your name
will be published in Dynamics, the Official Journal of the
CACCN as a way to celebrate your success.
The CACCN would like to acknowledge all the critical care
nurses who have attained certification status this year, and in the
past. Congratulations on your commitment to achieve
certification in the specialty of adult or pediatric critical care.
Grace MacConnell
BOD, Eastern Region Rep
Your privacy is important to us!
From time to time CACCN receives requests for our
membership list. We do give out the list, with business
addresses only, to researchers, hospitals, or other health
care-based organizations. If you would prefer that your
name and business address not be given out, please
contact the CACCN national office, in writing, to request
that your name not be on this list.
Please write to:
CACCN National Office,
P.O. Box 25322, London ON N6C 6B1
DYNAMICS 2006 – CALL FOR ABSTRACTS
Abstracts are currently being accepted for oral and poster
presentations for Dynamics 2006, to be held in St. John’s,
Newfoundland, September 24-26. Topics of interest include
clinical reviews and research, innovative projects and
solutions, and ethics. All submissions must be evidence-based.
Abstract submission guidelines
Submissions for Dynamics 2006 will be accepted as:
Hard copy and 3 1/2” disk or CD ROM (Word or WordPerfect)
OR e-mail and attached files (Word or WordPerfect)
Submissions must include the following:
• Abstract: maximum 300 words, include only title and
abstract (do not identify author(s) on abstract)
• Reference List: reference list in APA format
(maximum 2 pages)
• Presentation Information:
(separated from the abstract and references)
- identify preferred format of presentation (oral or poster)
- list names of all authors
- provide contact information for first author including:
name, fax number, mailing address with postal code, home
and work telephone numbers, and e-mail address
• Presentation experience:
• for each author, indicate presentation experience
(frequency, location of presentation, audience size,
evaluation summaries and references)
32
Important note
• Only completed submissions received by midnight,
January 31, 2006, will be considered.
• All correspondence will be with the first author only.
• One presenter for each accepted abstract will be entitled to
a discounted tuition.
• All other expenses are the responsibility of the presenter(s).
• Notification regarding selection decisions will be provided
by March 1, 2006.
• Abstracts accepted for presentation at Dynamics 2006 must
not be presented at a national or provincial level for a
period of 12 months prior to, and/or six months after
Dynamics 2006. Abstracts are the property of CACCN
during this period of time, and may be published in
Dynamics, The Official Journal of the Canadian
Association of Critical Care Nurses.
Please Send Submissions To:
16 • 3 • Fall 2005
Dynamics 2006 Abstracts,
CACCN, PO Box 25322,
London, Ontario N6C 6B1
or e-mail: [email protected] (with file attached)
Telephone: (519) 649-5284
Fax: (519) 649-1458
CACCN
Available Awards
The Spacelabs
Innovative Project Award
The Spacelabs Innovative Project Award will be presented to a
group of critical care nurses who develop a project that will
enhance their professional development. The primary contact
person for the project must be an active member of CACCN (for
at least one year). If the applicant(s) are previous winners of this
award, there must be a one-year lapse before submitting again.
Applications must be received in CACCN national office on or
before January 15. Presentation of the award will be made at
Dynamics. Applications will be judged according to the following
criteria:
1.
2.
3.
4.
5.
6.
7.
8.
the number of nurses who will benefit from the project
the uniqueness of the project
the relevance to critical care nursing
consistency with current research/evidence
ethics
feasibility
timeliness
impact on quality improvement.
Within one year, the winning group of nurses is expected to
publish a report that outlines their project in Dynamics, the
Official Journal of the Canadian Association of Critical Care
Nurses. Do you have a unique idea?
Editorial Awards
The Editorial Awards will be presented to the authors of
two written papers in Dynamics, the Official Journal of
the Canadian Association of Critical Care Nurses,
which demonstrate the achievement of excellence in the
area of critical care nursing. A $750.00 award will be
given to the author(s) of the best article sponsored by
Edwards Lifesciences, and $250.00 given to the author(s)
of the runner-up article sponsored by 3M Canada. It is
expected that the money will be used for professional
development. More specifically, the funds must be used by
the recipient:
1. within 12 months following the announcement of the winners,
or within a reasonable time;
2. to cover and/or allay costs incurred while attending critical
care nursing-related educational courses, seminars,
workshops, conferences or special programs or projects
approved by the CACCN, and
3. to further one’s career development in the area of critical care
nursing.
Eligibility
1. The author is an active member of the Canadian Association of
Critical Care Nurses (minimum of one year). Should there be
more than one author, at least one has to be an active member
of the Canadian Association of Critical Care Nurses (minimum
of one year).
2. The author(s) is prepared to present the paper at Dynamics of
Critical Care (optional).
3. The paper contains original work, not previously published by
the author(s).
4. Members of the CACCN board of directors, awards
committee or editorial committee of Dynamics, the
Official Journal of the Canadian Association of Critical
Care Nurses, are excluded from participation in these
awards.
CACCN
Criteria for evaluation
1. The topic is approached from a nursing perspective.
2. The paper demonstrates relevance to critical care nursing.
3. The content is readily applicable to critical care nursing.
4. The topic contains information or ideas that are current,
innovative, unique and/or visionary.
5. The author was not the recipient of the award in the previous
year.
Style
The paper is written according to the established guidelines for
writing a manuscript for Dynamics, the Official Journal of the
Canadian Association of Critical Care Nurses.
Selection
1. The papers are selected by the awards committee in
conjunction with the CACCN board of directors.
2. The awards committee reserves the right to withhold the
awards if no papers meet the criteria.
Presentation
The awards are presented by representatives of the sponsoring
company or companies at the Dynamics of Critical Care Conference.
Recruitment and Retention Award
This CACCN initiative was established to recognize members and
the chapters for their outstanding achievements with respect to
recruitment and retention. Individual members will be recognized
for long-standing service to the association as well.
Recruitment Initiative
This initiative will benefit the chapter if the following
requirements are met:
• If the chapter recruits 25-49 new members from April 1 to
March 31 of the next year, they receive one full tuition to
Dynamics of that year.
• If the chapter recruits 50-100 new members from April 1 to
March 31 of the next year, they receive one full tuition to
Dynamics of that year plus $100.00.
Retention Initiative
This initiative will benefit the chapter if the following
requirements are met:
• If the chapter has 100% renewal of its previous year’s
members, the chapter will receive $250.00.
• If the chapter has greater than 80% renewal of its previous
year’s members, the chapter will receive $150.00.
• If the chapter has greater than 60% renewal of its previous
year’s members, the chapter will receive $100.00.
The Guardian Scholarship –
Baxter Corporation Award for
Excellence in Patient Safety
The Baxter Corporation Guardian Scholarship will be presented
to an individual or an interdisciplinary team who propose to make,
or who have made, significant contributions toward patient and/or
caregiver safety in the critical care environment. Recipients of this
award will identify ideas that encompass safety and improve the
quality of care in their practice area.
Eligibility
The principal investigator (or applicant) must:
• Be a member of CACCN in good standing for a minimum of
one year
16 • 3 • Fall 2005
33
• Be licensed to practise nursing in Canada
• CNA certification preferred.
Members of the awards committee or the board of directors are
not eligible.
Application requirements
• The projects will be consistent with the theme of the upcoming
Dynamics conference.
• The project will describe an innovative approach, to develop
new or revised processes, to encompass patient safety and
improve the quality of care at the unit, hospital or health care
system level.
• The project/proposal will show evidence of collaboration
among team members.
• A complete application form that includes:
• A proposal of a project, or a description of a completed
project, which makes a significant contribution toward
patient and caregiver safety in critical care. The proposal will
include the background perspective, statement of the
problem, and intended means to change practice. The
proposal should include a timeline by which the project will
occur.
• Approval from an established institutional ethical review board
for projects involving human subjects and/or access to
confidential records, if applicable. (Applicants may refer to the
CNA publication Ethical Guidelines for Nursing Research
Involving Human Subjects, or the research review process in
their institution).
• brief curriculum vitae for the principal applicant and team
members describing educational and critical care nursing
background and CACCN participation.
• Proof of active CACCN membership
• Proof of CNA certification in critical care (if applicable).
34
Review Process
• Each proposal will be reviewed by a committee made up of one
member of the CACCN BOD, one member of the Baxter
Corporation and one member of the CACCN Annual
Conference Planning Committee (preferably the Chair).
• Proposals are reviewed for their contribution to patient safety,
evidence of transferability of the project, innovation,
sustainability, and leadership within critical care practice areas.
• Deadline for receipt of applications is June 1 of each year.
• The successful candidate will be chosen and notified in writing
by July 1.
Terms and Conditions of the Award
• A proposed project must be initiated within three months of the
receipt of the scholarship.
• Any changes to the timelines require written notification to the
board of directors of CACCN.
• All publications and presentations must recognize The Baxter
Corporation and CACCN.
• An article related to the project is to be submitted to Dynamics,
the Official Journal of CACCN, for publication and the
project will be presented at a future Dynamics conference.
Budget and Financial Administration
• One half of the awarded funds will be available to support the
project expenses immediately.
• The remaining funds will be awarded upon the publication of
an article describing the project in Dynamics, the Official
Journal of CACCN.
The total funds available are $5,000.00. The award funds may be
granted to a maximum of two applicants ($2,500 each).
NOTE: The CACCN Board of Directors & Baxter Corporation
retain the right to amend the award criteria.
16 • 3 • Fall 2005
CACCN
D Y N A M I C S
The Official Journal of the Canadian Association of Critical Care Nurses
Information for Authors
Dynamics, the Official Journal of the Canadian Association of Critical Care Nurses (CACCN), is distributed to
members of the CACCN, to individuals, and to institutions interested in critical care nursing. The editorial board
invites submissions on any of the following: clinical, education, management, research and professional issues in
critical care nursing. Critical care encompasses a diverse field of clinical situations which are characterized by the
nursing care of patients and their families with complex, acute and life-threatening biopsychosocial risk. While the
patient’s problems are primarily physiologic in nature, the psychosocial impact of the health problem on the patient
and family is of equal and sometimes lasting intensity. Articles on any aspect of critical care nursing are welcome.
The manuscripts are reviewed through a blind peer review process. Manuscripts submitted for publication must follow
the following format:
1. Title page with the following information:
• Author(s) name and credentials • Place of employment • If there is more than one author, the names should be listed
in the order that they should appear in the published article • Indicate the primary person to contact and address for
correspondence.
2. A brief abstract of the article on a separate page not to exceed 100 words.
3. Body of manuscript:
• Length: a maximum of 15 pages including tables, figures and illustrations, and references • Format: double spaced,
1 1/2 inch margins on all sides. Pages should be numbered sequentially including tables, figures and illustrations.
Prepare the manuscript in the style as outlined in the American Psychological Association’s (APA) Publication Manual
5th Edition. • Tables, figures, illustrations and photographs must be submitted each on a separate page after the
references. • References: the author is responsible for ensuring that the work of other individuals is acknowledged
accordingly. Direct or indirect quotes must be acknowledged according to APA guidelines • Permission to use
copyrighted material must be obtained by the author and included as a letter from the original publisher when used in
the manuscript.
4. Copyright:
• Manuscripts submitted and published in Dynamics become the property of the CACCN. Authors submitting to the
journal are asked to enclose a letter stating that the article has not been previously published and is not under
consideration by another journal.
5. Submission:
• The original and three copies should be forwarded to: CACCN National Office, P.O. Box 25322, London, Ontario,
N6C 6B1 or to the editorial office as printed in the journal. Disks are not requested with the original submission. If the
manuscript is accepted for publication, the author(s) will be requested to submit the manuscript on disk. Accepted
manuscripts are subject to copy editing.
CACCN
16 • 3 • Fall 2005
35
W
H
Y
C
A
C
C
The voice for Canadian critical care nurses involved in practice, education, research
and administration in:
• Medical ICU
• Cardiovascular ICU
• Neonatal and Pediatric ICU
• Burn Units
• Trauma Units
Mission
Statement
The Canadian Association of Critical
Care Nurses is a non-profit,
specialty organization dedicated to
maintaining and enhancing the
quality of care provided to critically
ill patients and their families.
We serve the public, our members
and the critical care nursing
community by meeting the
professional and educational needs
of critical care nurses.
These needs are met by:
• developing and implementing
standards of critical care nursing
practice
• providing educational
opportunities
• supporting and facilitating critical
care nursing research
• providing opportunities for
networking
• identifying and addressing political
and professional issues
• collaborating with other
professional organizations
Objectives
i) to provide informed guidance in
shaping the delivery system as it
relates to the care of the critically ill
ii) to determine standards for critical
care nursing
iii) to determine certification
standards for national testing for the
specialty of critical care nursing
iv) to promote and provide
educational opportunities
v) to improve the quality of patient
care through the promotion of
nursing research in critical care
vi) to promote membership and
chapter development.
N
?
• Surgical ICU
• Neurosurgical ICU
• CCU
• Recovery Room
Application for membership
Name: ____________________________________________________________
Address: __________________________________________________________
(Street)
_________________________________________________________________
(City)
(Province)
(Postal Code)
W (____) ____ - ________ H (____) ____ - ________ F (____) ____ - _______
Employing Agency: _________________________________________________
Position: __________________________________________________________
Area of Employment: _______________________________________________
Nursing Registration No.: ______________________ Province: _____________
Chapter Affiliation: _________________________________________________
Sponsor’s Name: ___________________________________________________
(If applicable)
Please check one:
❏ New Member $64.20 (includes 7% GST)
❏ Renewal $64.20 (includes 7% GST) - Present Number _______________
Are you a CNA member? ❏ Yes, ❏ No
Signature: ________________________________________________________
Date: ____________________________________________________________
Please Note: This application is for both national and chapter membership.
Make cheque or money order payable to:
Canadian Association of Critical Care Nurses (CACCN)
Mail to: CACCN, P.O. Box 25322, London, Ontario, N6C 6B1
Telephone: (519) 649-5284, Fax: (519) 649-1458
e-mail: [email protected]
www.caccn.ca
16 • 3 • Fall 2005