Recent letters
Displaying 1-10 letters out of 74 published
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Re:Cultural competence is a necessary skill
Submit responseI greatly appreciate and concur with Dr. Roscigno's insightful comments and suggestions regarding development of ethical skills. I would hope that cultural humility be part of developing and cultivating ethical sensitivity but did not point that out in this article.
The nurses with whom I work practice in a county hospital providing care to a primarily underserved population. Our nursing ethics council discussions often include cases of cultural misunderstandings and lack of appreciation for different cultural values and views. While family members/patients have not been part of these discussions, they have been invited to attend our yearly ethics conference. One former patient, a victim of medical error, will be speaking at the upcoming conference in July.
I encourage Dr. Roscigno to expand upon her discussion here and consider submitting it to Critical Care Nurse.
Conflict of Interest:
none
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Cultural competence is a necessary skill
Submit responseIn this article, the author presented some timely and important scenarios that highlighted the need for critical care nurses to develop sensitivity to ethical situations. I applaud the author for offering a logical and prescriptive theoretical solution, since recognition and action in ethical situations can be so important to meeting the holistic needs of patients or family members. Along with the Four Component Model, she suggested some strategies to develop ethical skills, including developing a nursing ethics group or ethics council; participating in interdisciplinary ethics rounds; seeking guidance and support from nursing or medical faculty; and seeking guidance from Magnet-designated institutions.
Although the Four Component Model does espouse the need for considering other points of view, goals, and desired outcomes, the current climate of healthcare often touts science, technology, and evidence-based medicine as the primary lens by which other points of view are regarded. The author's suggestions for developing ethical skills posited that becoming more aligned with the ethical values and beliefs within the discipline of nursing, the health profession as a whole, or with politically and socially defined "best" hospitals (ie, those with Magnet status), this approach will enable critical care nurses to develop their ethical skills. It is possible that nurses who follow this advice could be challenged to think outside of their own personal, disciplinary, and medical world view, but it is also likely that they will continue to limit their understanding of ethics by surrounding themselves with others who share similar world views (medical culture).
I would like to suggest that a deeper discussion of medical culture and its role in shaping how healthcare providers evaluate ethical dilemmas is warranted. Agich(1) reminds us that even well-meaning (those who mean to act ethically), caring, and professionally trained healthcare providers and ethics consultants shape the interpretation of ethical situations they and their colleagues encounter by viewing the situation within their own disciplinary/healthcare/science lenses. Jecker(2) adds that the very methods and rules guiding ethical consultation evaluations are rarely discussed, yet methods ultimately influence the interpretation and communication of ethical situations; what social, psychological, and political factors are considered; and whose voice is heard or ignored. Jecker et al(3) point out that ethical health care providers must first recognize that there can be multiple and competing "truths" (cultural viewpoints). The meanings of health/disease/injury, encountering a highly technical and specialized treatment environment, attempting to be autonomous or acting on behalf of a loved one, and making decisions for a future often fraught with uncertainties each create situations that require healthcare providers who are well versed in understanding the historical, social, political, and personal complexities by which all stakeholders may evaluate these situations.
Healthcare providers have to learn to be able to comfortably step outside their own world views and consider the patient's, family's, or group's potentially differing values, so that those whom we serve feel mutually respected. Healthcare providers have to become considerate of power and authority differentials in knowledge production, including evidence-based medicine, which may serve to disadvantage others in playing equal roles in decisions. Campinha-Bacote(4) calls this desire to consider others' viewpoints cultural humility. In order to develop cultural humility, critical care nurses need to be exposed to and engage with multiple perspectives, to develop a critical lens by which they evaluate what information is being considered, to see what information is being minimized or left out, and recognize how the decision-making process shapes ethical evaluations and decisions.
To attain this cultural competence goal, I would suggest that nurses go further than the suggested actions of aligning themselves with other healthcare provider ethics "experts." For instance, through my research, I and others are beginning to uncover healthcare providers' misconceptions of the impact on parents of children living with a child who may potentially have a disability. Some recent studies have shown local (individuals, units, or hospital) systems of attitudes, beliefs, expectations and notions (cultures) (5) about what it means to live with a disability.(6-8) Such beliefs can affect the shaping of information provided to families and or ultimate decisions about treatments.
To date, healthcare providers have been primarily the ones who have shaped what is known about living with disability: 1. through what questions they ask and what questions they ignore; 2. who we have asked and who we have ignored; 3. how we asked; and 4. what information we share with each other in our classes, texts, scholarly literature, and talk. I do not mean to imply there is a conspiracy to shape information, but well-meaning healthcare providers sometimes do not know what they do not know, do not understand that medicine and nursing are cultures, and that our cultures can shape how we construct knowledge and understand ethical situations. Thus, we need to broaden our understanding of ethical issues beyond the healthcare viewpoint.
In addition to the author's suggestions for developing ethical skills, I would advocate for 1. inviting or attending diverse patient and family panels in which they are allowed to present their viewpoints on a contested topic, 2. reading patient or family memoirs, 3. reading qualitative research where the patients or families points of view are positioned in the forefront, and 4. listening to the values and beliefs of each patient/parent/or family and reflecting on their own beliefs. Together these steps would aid in a broader cultural understanding of differences. Considering that other's cultural viewpoints should hold equal weight to that of healthcare providers is important to developing a broader and critical understanding of the complex landscape of ethics in critical care. Taylor(9) reminds us that it would be "a supreme arrogance" to discount "cultures that have provided the horizon of meaning for large numbers of human beings of diverse characters and temperaments, over a long period of time" (p.72). Thus, critical care nurses must learn to move back and forth between nursing and medical values and beliefs and those of the many patients and families they serve.
References
1. Agich GJ. The question of method in ethics consultation. Am J Bioeth. 2001;1(4):31-41.
2. Jecker NS. Uncovering cultural bias in ethics consultation. Am J Bioeth. 2001;1(4):49-50.
3. Jecker NS, Carrese JA, Pearlman RA, Caring for patients in cross-cultural settings. Hast Cent Rep. 1995;25(1):6-14.
4. Campinha-Bacote J. A model and instrument for addressing cultural competence in health care. J Nurs Ed. 1999;38:203-207.
5. Philipsen G. A theory of speech codes. In: Philipsen G, Albrecht TL, eds. Developing Communication Theories. Albany, NY: State University of New York Press; 1997:119-156.
6. Verhagen EAA, Janvier A, Leuthner SR, et al. Categorizing neonatal deaths: a cross-cultural study in the United States, Canada, and the Netherlands. J Pediatr. 2009;156:33-37.
7. Roscigno CI, Swanson KM. Parents' experiences following children's moderate to severe traumatic brain injury: a clash of cultures. Qual Heal Res. 2011;21:1413-1426.
8. Roscigno CI, Savage TA, Kavanaugh K, et al. Divergent views of hope influencing communications between parents and hospital providers. Qual Heal Res. In press.
9. Taylor C. Multiculturalism and the Politics of Recognition. Princeton, NJ: Princeton University Press; 1992:25-74.Conflict of Interest:
None declared
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A true shock and awe moment... teamwork at its best!
Submit responseCritical care nurses are charged with making life-changing decisions for patients on a daily basis. The impact of experienced practitioners and teamwork undoubtedly play an intricate role in the positive outcomes of all patients, especially those patients who are in life-threatening situations. I recently found myself, along with my coworkers, in one of those situations involving a 23-year-old patient. Throughout a 6-hour code this patient received 53 shocks and 32 intravenous push (IVP) administrations, and exhausted 3 code drug boxes.
This young patient had a negative history except for undergoing an ablation in 2009 for recurrent supraventricular tachycardia. The patient's home medication consisted of lisinopril 2.5 mg orally daily and metoprolol tartrate 12.5 mg orally twice a day, as prescribed by his cardiologist. He arrived to the emergency department (ED) one evening for palpitations and was found to be in wide complex tachycardia at a rate of 230 beats/min. The ED treatment consisted of administering adenosine, which failed to yield results. Amiodarone 150 mg was delivered, which lowered his heart rate to about 150 beats/min. After consultation with cardiology, 5 mg of lopressor IVP was administered, which sustained the patient's heart rate at about 110 beats/min. The patient was then transferred to the ICU for further evaluation and monitoring.
Shortly after arrival to the ICU the patient developed atrial fibrillation with rapid ventricular response. The night nurse notified the cardiologist of rhythm changes and an order was received for a cardizem drip. As the drip rate was titrated up to 15 mg/hour, the heart rate became more controlled; however, ectopy continued.
Early in the morning, the call for Code Blue was heard from the overhead speakers. We responded to the call and found the patient in ventricular tachycardia with cardiopulmonary resuscitation in process. One of the neuro ICU RNs who had been flexed to the medical/surgical ICU that day was caring for the young patient. ACLS protocol was followed, a shock was delivered, and the patient was subsequently intubated along with central catheter and arterial catheter placement.
When you have worked in the ICU for a while, you know there are continuous codes that command an all hands on deck attitude for the entire shift to take care of the patient. The patient's rhythm continued from sinus tachychardia to ventricular tachycardia to ventricular fibrillation to sinus tachycardia to ventricular tachycardia. We delivered shocks, epinephrine, amiodarone, lidocaine, and sodium bicarbonate. Amiodarone, lidocaine, norepinephrine, phenylephrine, esmolol, procainamide, midazolam, fentanyl, and Nimbex drips were titrated as necessary to maintain optimal outcomes. Hypothermic Protocol was initiated as well. Temporary pacing wires were inserted at the bedside in attempt to override the ventricular tachycardia.
Finally, after 6 hours of work, our results yielded a critical but stabilized patient. Throughout the lengthy code this young patient had 4 ICU RNs at his bedside at all times, a critical care physician, cardiologist, respiratory therapist, and a pharmacist. Additionally, the Assistant Director of Nursing and Department Manager were consistently facilitating the needs of the staff for the patient to receive the care he needed. Later in the evening, the young man was transported via air to another facility for possible left ventricular assist device placement and further evaluation.
At a later date, the patient returned to the ICU to visit with those who provided care and to express his appreciation. To all of our amazement this patient had no physical or mental deficits and was currently being monitored with a LifeVest defibrillator and continued with close monitoring by his cardiologist. The patient had returned to college and anticipates graduating soon.
It goes without saying teamwork is the key to meeting our patient's needs whether big or small. Combining the efforts of all parties from multiple disciplines of medicine affected this patient's life. A rather exhausted ICU crew made a difference. On this day a patient's life changed. On this day it reminded us all this is why we do what we do!
The staff involved in this 6-hour code were Deb Dale-Ford, RN (night shift staff nurse and the patient's primary nurse), Anita Powell, BSN, RN, CCRN, CNRN (day shift staff nurse and the patient's primary nurse), Dr. David Ryon (Pulmonary/Critical Care), Dr. Asem Rimawi (Cardiology), Jim Stark, RRT, Amy Harris, RPh, CACP, Jennifer Lampert, BSN, RN, CMSRN (Assistant Director of Nursing), Melanie Mahone, RN, CNRN (Team Leader GW Neuro ICU), Josh Johnson, BSN, RN, CCRN (Team Leader GW Neuro ICU), Michelle Decorrevont, RN (Department Manager GW M/S ICU), Sheila Ferrell, BSN, RN (Team Leader GW M/S ICU), and Craig Mims, RN (staff nurse).
Conflict of Interest:
None declared
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Thank you for a great article!
Submit responseThis excellent article elucidates and explains how to practically and realistically implement evidence-based practice (EBP) in the clinical setting. As a BSN student, the relevance and essentiality of EBP and change agency is frequently featured and expounded on in theory lectures; yet, we only know about EBP and change agency in "theory." This article enlightened me to the process and channeling of "applying the best evidence to support nursing practice." I wholeheartedly appreciate the ideas, examples, and guidance presented in the aforementioned article. I know that this article will help EBP and change agency resonate in my current and future nursing practice.
Conflict of Interest:
None declared
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Clinical sign of neuroendocrine activation
Submit responseI have an outpatient CHF clinic and care for patients admitted for heart failure exacerbation as well. I enjoyed your article on fluid management in heart failure. In Table 3, under Issue 4, you talk about assessing for elevated blood pressure as a possible indication of neuroendocrine activation. I have noticed that persistent tachycardia is also an indication of neuroendocrine activation. I think it is more reliable than elevated blood pressure because many of these patients have low blood pressure. One should also be cautious to make sure tachycardia isn't related to another issue such as overdiuresis, hypoxia, pain or fever. Thank you
Conflict of Interest:
None declared
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Re:IAH/ACS
Submit responseThank you for your questions and your interest in the article. It was our pediatric colleagues that initially dealt with abdominal compartment syndrome (ACS) successfully in newborns with omphalocele and gastrochisis.(1) There are some variations in the pediatric population. The definition of intra-abdominal pressure (IAP) in pediatrics is the same; however, the average IAP in a critically ill child is 7 mm Hg and in a critically ill adult, 5-7 mm Hg. A child is considered having intra-abdominal hypertension (IAH) at a sustained pressure of 10 mm Hg, whereas an adult has IAH at 12 mm Hg. ACS in the pediatric population is defined as "a sustained IAP of 10 mm Hg or greater associated with new organ dysfunction or failure."(2) The abdominal perfusion pressure (APP) is the same in the pediatric population as it is in adults (60 mm Hg).(2) The gold standard for indirect IAH measurement in the child is via the urinary catheter with a transducer. The instillation amount of normal saline should be a minimum volume of 3 mL or 1 mL/kg up to a maximum volume of 25 mL.(2) I would refer you to the second reference for a thorough overview of this problem in the pediatric population.
References
1. Kuhn MA, Tuggle DW. Abdominal compartment syndrome in the pediatric patient. In: Ivatury RR,Cheatham ML, Malbrain M, Sugrue M, eds. Abdominal Compartment Syndrome. Georgetown, TX: Landis Bioscience; 2006: 217-222.
2. Ejike JC, Mathur M, Moores DC. Abdominal compartment syndrome: focus on the children. Am Surg. 2011;77(7):S72-S77. -
Re:RN, MEd
Submit responseThanks for your comments. Yes, too bad we are not always in the discussion chain and may need to live with others' decisions.
If more literature is published that reflects the patient's perspective, I believe architects will pay more attention to their (and nursing's) input.
Conflict of Interest:
None declared
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IAH/ACS
Submit responseAs a PICU RN, I am wondering if the recommendations in the article also apply to the critically ill pediatric population? Is maintaining an APP of 60 mm Hg appropriate for a pediatric patient, 1 year of age? With the transducer method, is there a weight-based guideline to be used for pediatric patients? Thank you very much for your kind attention.
Conflict of Interest:
None declared
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RN
Submit responseI have been concerned about noise in the ICU. I worked nights for 25 years and there is a lot of noise. The design of the unit should take into consideration how supplies will be delivered, how trash will be removed and how linens will be supplied. If all these ancillary services have to come into the unit to get to the work rooms it creates noise due to the large carts used. Also, many times carts have to be left in the hallways while supplies are being restocked, making it difficult to navigate the hallways with a patient in a bed. If the supply rooms are off the same hall as the patient rooms, the doors are constantly opening and closing causing noise. Break rooms should be located off the main hallway for the same reason. A dedicated hallway to restock supply rooms should be a priority.
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RN, MEd
Submit responseThe information shared is valuable and important research. I would like to share my thoughts from our nurses' perspective related to construction of a new ICU in 2005.
Prior to the 2005 construction, the SICU was configured in a horseshoe shape. One nurse could stand in the center and essentially visualize all 12 patients. Nurses could see and help each other with minor and major crises.
In the new construction, nurses did have input and were able to get more glass windows instead of solid wall between us and our patients than was originally designed by the architects. However, the consequences of this "hotel hallway" architectural design are significant. Nurses find it hard to leave their patients for lunch--most bring lunch or leave and return to the unit with a tray from the cafeteria. They feel they cannot really visualize 4 patients well enough to be gone a full 30 minutes.
The other major problem with the design is the isolation, both socially and physically. Nurses essentially have to abandon their assigned patients to be able to converse with someone in another hallway. Patients can be coding or have other emergencies and nurses in another hallway are unaware, unlike with the old design where visualization of patients promoted better teamwork and support.
My observation is that all new construction tends to use the "hotel hallway" design. I have been critical of this design and I have shared my thoughts whenever I can interject my opinion about the design. I asked whether SCCM has any guidelines on construction and did not find anything specific to design. So, I am glad that this research shows need for consideration of architectural factors from a patient/family perspective.
I believe architects need input from patients/families AND nurses in order to create the optimal environment for care of critically ill patients.
Conflict of Interest:
None declared
