Standards-Based Approach
I was assigned to offer nursing care to a patient with intra-aortic balloon pumping (IABP) that needed a detailed cared. The name of the patient was Jassim, aged 63 years old; diagnosed with post-operative myocardial infarction. The indication for IABP was supported by the presence of acute left ventricular failure post cardiac surgery. The patient had low cardiac output syndrome after cardiac surgery. Having received training on the care of patients with IABP, I was confident that I would provide safe and effective care. However, it turned out to be a little challenging than I had expected. My aim was to assess how Jassim responded to the therapy in regard to haemodynamic status (by recording hemodynamics on hourly basis), controlling arrhythmias, systemic vascular and relief of cardiac symptoms.
I was also keen to detect any sign of complication so as to introduce interventions in a timely manner. Further, I knew I was to make sure that the IABP was working properly by assessing timing, as well as to make appropriate troubleshooting. When I was waiting for the patient, I developed Jassim’s care plan that would make it possible to achieve desired outcomes (10). The nursing care plan detailed the nursing interventions that I would implement while caring for the patient. Having been trained, I was sure that I possessed the skills needed to monitor the patient for any complications, and initiate appropriate interventions.
Before anything else, I recognized the need to create caring-healing environment, for the patient to feel safe and secure, which would facilitate recovery (1). I understand that noise might have detrimental effects to the healing process. I had to reduce noise levels in order to guarantee patient’s comfort needs (1.2).There were two major sources of noise: conversations and medical devices. There were two colleagues nearby who were discussing their experience with another patient they were caring for. While there was nothing wrong with that discussion, I felt that it might have been registered as noise to my patient. Therefore, I approached them and asked them to converse in low tones. In conjunction with the charge nurse, I ensured that false or clinically insignificant and non-actionable alarms from medical devices were controlled. I endeavored to create and develop a caring relationship with the patient in order to personalize the patient care environment (1.4). Due to the respect that I had for Jassim, I ensured that he actively participated in his own care (2.1).
In an effort to ensure that Jassim actively participated in the care process, I educated him on how to sit and carry the affected leg (3). From my review of literature on how to care for persons with IABP, I had learned that the patient might feel reasonably overwhelmed by the medical equipment. Therefore, I tried to allay Jassim’s fears and anxiety by providing clear and simple explanations of the pump procedure (16). In particular, I stressed that he should not encourage sitting up more than 30 degrees while the affected leg had to be kept straight. It was also my job to ensure that the patient was quiet and relaxed, with the movement around the bed being at the minimum.
Days before I had been assigned to care for a post cardiac patient in ICU, I had felt that I was not competent enough for some troubleshooting (15). Consistent with requirements, I took an independent and accurate assessment of my abilities and realized that I needed to take further steps to enhance my competency level (15.2). Consequently, I consulted with my nursing colleagues on the unit as well as the physicians and IABP technicians who demonstrated some aspects of trouble-shooting. I was put on an 8-hour IABP training session to ensure that I was competent enough to care for IABP patients.
So, during the care, I was able to do some troubleshooting. First, I observed low helium, which was an indication that helium supply was below 24 fills and, therefore, the helium cylinder needed replacement. I appropriately communicated this to the cardiac technician who replaced the tank (4.1). At some point, I observed that there was no trigger. From my knowledge of IABP working, I understood that the IABP had lost the ECG trigger, and therefore, needed to be reconnected to the ECG leads (6.1). I had to manage the equipment effectively to optimize Jassim’s recovery (6.2). Post-insertion CXR was performed to determine whether the position of IAB catheter was correct. In addition, I inspected the dressing over the insertion site to find out whether there were signs of infection.
Jassim’s wife and younger sister had come to see him during the evening visiting hours. Jassim was evidently happy for the visit. The family asked me whether they could pray. I am a person who respects the values, spiritual beliefs, and customs of every patient (2.2). In addition, I believe that these spiritual beliefs might have a therapeutic effect. Therefore, I explained to them that they were free to pray, but their voices were to be at the minimum possible.
I reviewed Jassim’s hemodynamic data to determine if the patient could be weaned. I used the data to make an important clinical decision on whether the therapy needed to be continued or whether it was no longer needed (8.1). I was satisfied that the patient was hemodynamically stable, suggesting that the IABP was not needed (8.1). I felt that I was not sufficiently qualified to remove the IABP (15.1). My personal assessment on my ability to remove IABP was consistent with other nurses in the Arab region (Rushdy, Morsy, & Elfeky, 2015). In a study conducted in Egypt, 90% of the nurses were found to have unsatisfactory knowledge of weaning and IABP removal (Rushydy et al., 2015). Only 5% of the nurses had satisfactory knowledge of the nursing care of patients with IABP (Rushdy et al., 2015).
Therefore, I sought the services of the physician (15.1). Using my strong communication skills (4), I informed the physician about it. The physician expressed his gratitude and commenced weaning by decreasing the frequency of assistance. I had analysed the entire patient’s hemodynamic data to determine the baseline level that would be used to assess the patient’s response to weaning. Unfortunately, I observed an increase in PAP and a decrease in BP, which suggested that the heart was not yet coping and made the appropriate decision (13.3). Since I am trained to evaluate and respond effectively to changing situations (9.2), I communicated to the physician who discontinued weaning and ordered for the continuation of the therapy.
I was assigned to provide nursing care to a patient (named Tahani) with a pulmonary artery catheter. Tahani, aged 59 years old, was anticipated to have significant hemodynamic compromise postoperatively. My care was to be focused on four major aims. First, my job was to accurately and continuously monitor right and left heart function, with special focus on the venous parameters and cardiac output. Second, I was responsible for collecting, interpreting and effectively communicating the hemodynamic data from the catheter with the other members of the team (4.1). My effective and accurate understanding of the operations of the PA catheter would enable me accomplish this purpose (6.1). Third, I was supposed to monitor the therapy for early detection of complications and implementation of appropriate interventions. Fourth, I was responsible for educating Tahani on needs, limitations, and possible complications associated with the treatment. However, due to shift changes, I was able to only participate in the process ending at the insertion.
The physician wanted to go ahead and insert the catheter, without having the Tahani’s informed consent. The physician’s argument was that he had to save time to attend to other patients. After all, the PA catheter would be for the patient’s benefits. The physician felt that educating the patient and getting her sign the paper was time consuming. According to me, this was a clear instance of unprofessional conduct that called for a prompt and accurate response (14.4). Although I have tremendous respect for the role of every member of critical care team; and that I strongly respect their views on how we should proceed with patient care (17.1), I felt that it was my responsibility to intervene because the physician’s practice would compromise the rights of the patient and her family (11.4). It would deny them the opportunity to make an informed decision and actively participate in the care (12.1). Failure to facilitate informed decision-making would violate the principle of patient autonomy, which is a serious ethical issue facing many health professionals (14.2). I think I did not have the required moral courage to persistently confront the physician about his conduct. Fortunately, as the leader of the critical care team, I had cultivated a fruitful relationship with members of the team, and we always solved differences as a team (17.2).
Desperate to stop the physician, I consulted other members of the team who shared my views that it would be detrimental not to obtain a written informed consent (12.2). After engaging in an ethical discussion of the issue (14.3), it was resolved that as much as time was critical, it was important to adhere to ethical and legal requirements. This collaboration with members of the team helped me convince the physician that it was important to have an informed consent as anything on the contrary would not only be unethical, but also illegal (11.1). I informed the physician that the law requires medical professionals to obtain informed consent, and stressed the implications of the law regarding failure to obtain informed consent (11.1). The implication of the law is that the physician, and by extension the critical care team, would be held liable (11.2).
The critical care team agreed that it was essential to inform the patient about any possible complications/risks so that they could compare them with the possible benefits and make an informed consent (3.1). During this discussion, I observed that new and less experienced members of the team were reluctant to contribute. However, I encouraged them to share their opinions; insisting that in the team, there was no rank, experience, or profession (19.6; 18.1). We were all equal members of the same team. To encourage them speak, I confidently expressed my views during this collaborative discussion, challenging those perceived to be higher in ranks or more experienced (20.1). One of the new and less experienced members gathered courage and contributed to the discussion, while the other did not. The one who did not contribute approached me later and expressed her concerns (20.2). I knew I had to spend more time empowering them to speak up without any fear of victimization.
I explained to Tahani and her husband that as an invasive procedure, PA catheter is associated with some risks that they were supposed to know (3.1). I told them that complications may be related to the insertion infections, inaccuracies in measurements, and difficulties in interpreting PA catheter parameters. However, I assured them that care would be taken to prevent any infections of the insertion site. In stressed that the staff responsible for the patient was highly qualified and experienced, and therefore, measurement inaccuracies and interpretation complications were not expected. I also informed them that extreme complications such as pulmonary artery rupture and pulmonary infarct are extremely rare.
Tahani’s husband asked me about the key benefits of PA catheter. I must admit that this question got me unaware. For a moment, I wondered what the benefits were! I did not have an explicit answer to the question, but I informed them that PA catheter necessity and benefits vary with individual patients. I remembered a recent review by Rajaram et al. (2013) that had reviewed 13 studies which compared patients treated with PA catheter and those treated without PA catheter. Rajaram et al. (2013) observed that their review contained high quality evidence, and that future studies were unlikely to change anything in relation to the reported effect of PA catheter.
The findings of this review helped me in responding to the question I had been asked (16.1). I confidently stated that high quality research suggests that there is no meaningful difference in the number of people that die during hospital stay, days spent in ICUs, and length of stay between patients who had and did not have PA catheter inserted (16.4). For the case of Tahani, PA catheter would be useful in providing hemodynamic data that we were unable to get by physical examination. I felt that this information was essential because it would equip them with the information they needed to make an informed decision concerning the care (3.1).
We obtained a signed informed consent from the patient as a way of preparing for the PA catheter (14.1). While setting up PA catheter equipment, I agreed with another member of the critical care team responsible for the patient, who suggested that emergency equipment be placed near the patient so that it would be possible to respond in a quick and efficient manner in the event that any complications arose (17.1). I helped the physician insert the PA catheter, which was the Swan Ganz (6.1). I helped the physician by preparing the patient for the insertion. Tahani was awake, and I informed her that a local anesthetic would be used to numb the area. As the physician was inserting the introducer, I helped by cleansing the insertion site and turning the patient’s head away from the site of insertion. While we prepared to insert the PA catheter, I flushed all the transducer system lumens and inspected balloon inflation and deflation (6.1). My shift ended just after the insertion process was complete.
Process Approach
While working at the Royal Hospital, my career plan was to become a specialist nurse. I believed that this position would enable me provide high quality and safe patient care. I also believed that I would have important leadership and mentoring skills. I would use my mentorship and leadership skills to meaningfully contribute to the professional growth of my colleagues, students on training at the facility, and less experienced members of staff. I reviewed several publications from several nursing bodies, and found that a specialist is Masters-prepared. I did not hesitate to enroll for an MSN program. My interest in the post cardiac surgery intensive care specialty was informed by my desire to interact with people who need the best, detailed care. I was aware that the success of patient outcomes following cardiac surgery depends on the quality of post-operative care provided in the intensive care unit. I believe that patient safety is significantly affected by the extent to which nurses are knowledgeable, experienced, and skilled.
I will demonstrate my professional growth over the last 12 months using care for a patient with invasive mechanical ventilation and another with transcutaneous pacing. The patient that made use of invasive mechanical ventilation was called Fathima, aged 64 years old. Fathima had been diagnosed with postoperative respiratory failure. Transcutaneous pacing was administered on Faisal, a 68-year old man after demonstrating clear signs of hemodynamically unstable bradycardia. The two events highlighted important lessons in relation to multi-disciplinary approach to patient care and evidence-based practice. Rather than detailing how I cared for the patients, this part is focused on what I learned from the experiences, and the role my participation in the postgraduate education program transformed played in regard to the lessons I learned.
Before my MSN program, I believed that I had the skills needed to care for patients with invasive mechanical ventilation on my own. In fact, I did not think that I needed anyone else to help me with the care of these patients. However, the knowledge I have from my MSN programs refutes my earlier assumptions. I now recognize that critically ill patients have complex medical conditions that place them at an elevated risk of death. Therefore, they need the kind of care that recognizes these complexities. In this light, care of ICU patients such as those with invasive mechanical ventilation requires a multidisciplinary approach.
In a multi-disciplinary care model different health professionals such as respiratory therapists, nurses, clinical pharmacists, physicians, and other health care professionals employ a team-based approach to the care of patients. Using the skills that I have gained from the MSN program, I have been able to understand the importance of multidisciplinary approach to the care of ICU patients. For instance, a multi-center study that used hospital-level organizational and patient level outcomes data found that multidisciplinary team approach independently accounted for reduced mortality among several sub-groups of ICU patients, including those with invasive mechanical ventilation (Kim et al., 2010). In order to have better patient outcomes, the therapy should be individualized because same therapies may not be as effective in all severities of the disease (Rittayamai & Brochard, 2015).
Over the last 12 months, I witnessed the critical role of evidence-based practice, and learned how to implement it. Practice grounded in research findings has a high likelihood of producing desirable patient outcomes. From my MSN program, I have learned that rather than supporting existing practices, research evidence should be used to determine the best practices implement in patient care (Melnyk, Gallagher-Ford, Long, & Fineout-Overholt, 2015). This is a huge transformation for me in relation to my perceptions about research. I thought people read research papers to be sure that what they are doing is supported. This perception meant that I would somehow prefer to review papers that supported my preconceptions about nursing interventions, while ignoring those that seemed to challenge my preferred interventions.
In addition to understanding the role of evidence-based practice, I learned the skills that are used in evidence-based nursing. I am now conversant with the seven steps of evidence based practice (Melnyk et al., 2014). The MSN program greatly helped me in cultivating a spirit of inquiry along with an evidence-based culture and environment, which is the basic step of evidence based practice. The other steps that I am now aware of are asking the PICO(T) question, searching for the best evidence, critically appraising the evidence, integrating evidence with clinical expertise and patient preferences, evaluating the outcomes of the evidence based practice change, and disseminating the outcome to my colleagues in the hospital and beyond (Melnyk et al., 2014). I want to use the skills I have gained from my MSN program to champion the adoption of evidence-based practice in my hospital, where the practice is not well established among nurses.
In the next 3-5 years, I see myself becoming not only an expert post-cardiac surgery critical care nurse specialist, but also an accomplished nurse leader in interdisciplinary teams. I also hope to become a reputable authority in evidence-based practice post-cardiac surgery intensive care settings; and use that knowledge and skills to mentor students and colleagues and advocate for policy and practice improvement in my country’s health care system. To achieve these career goals, I intend to enroll for Doctor of Nursing Practice within the next two years. I also intend to seek training workshop opportunities to ameliorate my knowledge and skills. Additionally, I shall collaborate with my colleagues to create practice communities, especially through the use of online tools such as twitter, from where we shall be sharing knowledge and skills related to our profession and sub-specialty.
In order to determine whether I am on the right track towards my ultimate career growth goals, I will use the Australian Nursing & Midwifery Council’s (2009) Continuing Competence Framework for self-assessment against the ACCCN’s Competency Standards for Specialist Level Critical Care Nurses. The self-assessment tool consists of four components including maintaining a professional portfolio, assessment of practice, continuing professional development, and recency of practice (Australian Nursing & Midwifery Council, 2009). Self-assessment will enable me to identify areas that will need further practice and learning.
In conclusion, from my experience at post cardiac surgery ICU at the Royal Hospital and my participation in the postgraduate education program, I have learned that a specialist critical care nurse has to demonstrate high levels of professional competency in the ACCCN standards in order to provide safe and effective care. My participation in the postgraduate program has helped me learn how to care for patients in ways that enhance patient outcomes. It has also highlighted areas in my competencies that need to be attended to. This is why I have decided to find ways to improve my competencies. Among others, I have decided to take more active roles in my professional organizations, participate in professional conferences, and seek more opportunities for professional growth not only for me, but also for my colleagues and students that I will interact with. I intend to be an expert post-cardiac surgery critical care nurse specialist and an accomplished nurse leader in interdisciplinary teams, with a doctoral qualification.
References
Australian Nursing & Midwifery Council. (2009). Continuing Competency Framework. Retrieved from http://www.equals.net.au/pdf/73727_Continuing_Competence_Framework.pdf
Kim, M. M., Barnato, A. E., Angus, D. C., Fleisher, L. F., & Kahn, J. M. (2010). The effect of multidisciplinary care teams on intensive care unit mortality. Archives of Internal Medicine, 170(4), 369-376.
Melnyk, B. M., Gallagher‐Ford, L., Long, L. E., & Fineout‐Overholt, E. (2014). The establishment of evidence‐based practice competencies for practicing registered nurses and advanced practice nurses in real‐world clinical settings: proficiencies to improve healthcare quality, reliability, patient outcomes, and costs. Worldviews on Evidence‐Based Nursing, 11(1), 5-15.
Rajaram, S. S., Desai, N. K., Kalra, A., Gajera, M., Cavanaugh, S. K., Brampton, W., & Rowan, K. (2013). Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev, 2.
Rittayamai, N., & Brochard, L. (2015). Recent advances in mechanical ventilation in patients with acute respiratory distress syndrome. European Respiratory Review, 24(135), 132-140.
Rushdy, T. I., Youssef, W., & Elfeky, H. (2015). Nurses' knowledge and practice regarding care of patients connected to intra-aortic balloon pump at Cairo university hospitals. Egyptian Journal of Nursing, 10(1).
