Official Journal of the Canadian Association of Critical Care Nurses

Transcription

1 Summer 1999 Volume Ten Issue Two Official Journal of the Canadian Association of Critical Care Nurses Index: Critical thinking...4 Sucrose as analgesia for neonates experiencing mild pain...18 Challenging restricted visiting policies in critical care...24 Canadian Association of Critical Care Nurses

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3 The Official Journal of the Canadian Association of Critical Care Nurses Volume Ten, Number Two, Summer 1999 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 Copyright 1999 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, association and the publisher do not guarantee, warrant or endorse any product or service mentioned in this publication. For information on advertising, contact C.B. Pappin, Pappin Communications, The Victoria Centre, 84 Isabella Street, Pembroke, Ontario, K8A 5S5, telephone (613) , fax (613) , pappin@webhart.net. Send manuscript enquiries or submissions to Paula Price, ACCN Program, Centre for Health Studies, Mount Royal College, 4825 Richard Rd. S.W., Calgary, Alberta, T3E 6K6. The Official Journal of the Canadian Association of Critical Care Nurses is indexed in the Cumulative Index to Nursing and Allied Health Literature and RNdex Top 100: Silver Platter. Clinical Editor: Paula Price, RN, MN, Instructor, ACCN Program, Centre for Health Studies, Mount Royal College, 4825 Richard Rd. S.W., Calgary, AB, T3E 6K6, Telephone: (403) , Fax: (403) , pprice@mtroyal.ab.ca Publications Chairperson: Rosella Jefferson, RN, BScN, MSN, Vancouver, BC Editorial Review Board: Adult Consultants: Shari Comerford, RN, CNCC(C) Oshawa, ON Bonnie M. Davies, RN, BN, BA, Winnipeg, MB Kathleen Graham, RN, MScN, Ottawa, ON Joy Kramarich, RN, MScN, CNCC(C) Oakville, ON Martha Mackay, RN, MSN, CNCC(C), Vancouver, BC John Remington, RN, CNCC(C), Toronto, ON 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 1999 Subscription Rates 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 - $110 ( plus 7% GST). Payment should be made by cheque, money order or by VISA only. International and institutional subscription rate is $75.00 per year or $ for two years. Canadian Association of Critical Care Nurses Board of Directors President: Gwynne MacDonald, RN, MN, CNCC(C), London, ON Vice-President: Rosella Jefferson, RN, BScN, MSN, Vancouver, BC Secretary: Valerie Banfield, RN, BScN, MN, CNCC(C), Halifax, NS Treasurer: Petula Wong, RN, BScN, MEd, Halifax, NS Directors at Large: Heather Camrass, RN, BScN, CNCC(C), Ottawa, ON Lori Garchinski, RN, BSN, CNCC(C), Regina, SK Brenda Morgan, RN, BScN, CNCC(C), London, ON CACCN National Office P.O. Box 25322, London, Ontario, N6C 6B1 Administrator: Heather Reid, ARCT, BA, MSc caccn@execulink.com phone: (519) fax: (519) The Official Journal of the Canadian Association of Critical Care Nurses is printed on recycled paper. Article reprints Photocopies of articles appearing in 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 $5.00 per article. Back issues can be purchased for $ Page Three

4 Critical Thinking The spirit of inquiry Stinson (1986) made the following remarks about the status of nursing research: What constitutes the domain of nursing research is becoming less contentious within Canadian nursing. But the nursing profession in Canada has for the most part as yet to convince related health professionals, academics, research policy makers and the public at large that nursing is a professional discipline in its own right, with a research focus that is distinctive. Stinson (1986). Initial attempts at nursing research can be traced back to Lower Canada two centuries ago when Jeanne Mance and her fellow nurses attempted to improve the care of the sick (Stinson, 1986). It was not until 1971 that nursing research really began to emerge. That year, more than 375 nurses from across Canada gathered together in Ottawa at the first national nursing research conference. That event was the turning point for nursing research in Canada, the catalyst for propelling nursing research irreversibly on its way (Stinson, 1986). Another major turning point for nursing research took place on February 17, 1999: From Health Canada news release: Federal nursing research fund supports changing health needs, February 17, TORONTO - Health Minister Allan Rock today announced that the Government of Canada s 1999 budget allocates $25 million to a new Canadian nursing research fund. The Nurse Fund will finance research of critical issues related to nursing and the delivery of health care. Nurses play a vital role in the health system, and the 1999 federal budget recognizes the importance of research to the nursing profession at a time when health care is undergoing fundamental change, Mr. Rock stated to a gathering of nurses and other health care providers at Toronto s Princess Margaret Hospital. This $25 million Nurse Fund will develop research capacity, and support training and information sharing about solutions to the challenges facing nursing in the coming decade. In underscoring the importance of nurses in the health system, Minister Rock stressed the need to involve nurses WIN, WIN, WIN... Two years free CACCN membership OR free tuition to Dynamics 2000 in Halifax! Our association s journal, currently called the Official Journal of the Canadian Association of Critical Care Nurses, or OJCACCN, desperately needs a new name! All CACCN members are invited to think of a creative and innovative title, and , fax or mail your written entry to: CACCN - Journal contest P.O. Box 25322, London, Ontario, N6C 6B1 (519) (fax) caccn@execulink.com ( ) DEADLINE FOR ENTRIES (received in national office) is August 1, Note: The CACCN board of directors will be conducting a blind review of all entries and reserves the right to determine if and how a new name will appear. Good luck to all participants! Page Four

5 in all aspects of health planning for the 21st century. He also pointed out that the recent health care restructuring across Canada has significantly affected the nursing profession and created challenges related to training and retention of nurses, as well as to attracting new people to the profession. The Nursing Research Fund Sources: Health Canada news release, Federal nursing research fund supports changing health needs, February 17, 1999; CHSRF Factsheet, The nursing research fund, February 16, 1999; Letter from the CHSRF, Open letter to all nursing researchers, March 30, With permission. The Nursing Research Fund is a 10year federally-funded initiative specifically aimed at strengthening Canada s ability to undertake research on nursing issues of: 1) policy; 2) management; 3) human resources; and 4) care. The fund also supports the dissemination of knowledge about solutions to the challenges facing nursing in the next decade. Four priority programs will be funded: 1) nursing research chairs; 2) training; 3) research funding; and 4) knowledge dissemination. The fund will be administered by the Canadian Health Services Research Foundation (CHSRF) in consultation with a broad-based advisory committee operating under the Canadian Nurses Association (CNA). In addition, the CNA and the Canadian Association of University Schools of Nursing (CAUSN) will become members of the CHSRF for the duration of the fund. In the spring of 1999, the final program structure was to be determined by the CHSRF board of trustees in consultation with the fund s advisory committee. Programs will be launched in , after establishing research priorities and assessment mechanisms. It is anticipated that all four programs will be initiated in the fiscal year The fund will be managed by the CHSRF and an advisory committee with representatives from all areas of nursing. The CHSRF is an independent not-for-profit corporation announced in 1996 with an initial endowment of $65 million from the federal government. The foundation supports high quality applied research, and the use of research results by health services decision-makers. Using merit review panels of peers to select award recipients, the CHSRF anticipates that by March 31, 2000, monies for these programs will be flowing to nursing researchers. Over the short term, the foundation is supporting training for nursing researchers through the programs of existing provincial and federal research agencies. Over the long term, however, the Nurse Fund will invest in four areas: Nursing Research Chairs: To enhance both the profile and leadership capacity of nursing research, the fund will support the salaries of university chairs for research. A national competition will make awards to four scholars with support for up to 10 years. The four awards will be geographically distributed across the country and one will be made for each of the following areas: nursing policy nursing management nursing human resources nursing care Training: To increase Canada s capacity for nursing research related to the changing role of nurses and nursing in the health care system, the fund will provide support for post-doctoral fellowships, career renewal awards, and student stipends at the masters and PhD levels. Page Five

6 Research Funding: The fund will support research projects on identifying critical policy and management issues facing nursing, as well as on sharing best practices about nursing care for patients. Knowledge Dissemination: This area of funding focuses on maximizing the impact of research results by creating a knowledge network for nurses, including information highway solutions. This will serve as a resource for developing nursing policy and for influencing the management of health care to facilitate and promote evidence-based decisionmaking in the health sector. What will CACCN s response be to this exciting change in the health care environment? How will we signal our vision of critical care nursing research and values with action and visibility? Research-based practice To build practice on research, Pepler (1994) identifies four independent components that are needed: (1) meaningful research questions that are relevant to practice; (2) sound research to answer questions that are relevant to practice; Page Six (3) knowledgable nurses with skills in using research findings; and (4) clinical environments open to inquiry and change. But what are the advantages of research-based practice? Pepler (1994) identifies a number of advantages: increased clarity in articulating the role of nursing, improved quality of care, increased cost effectiveness of health care, and increased nurses satisfaction. Clinicians are able to explain and predict outcomes of their practice at a given point in time and to reexamine their practice as new knowledge becomes available (Peplar, 1994). Yet a paramount requirement for the successful development of research-based practice is a spirit of inquiry and openness to change - a philosophy of inquiry. Without this willingness to question and to challenge rituals and traditions, nursing will not develop practice with a sound scientific base (Pepler, 1994). Critical care nursing research In a review of critical care nursing research from 1975 to 1985, VanCott and colleagues identified three predominant research foci: the structure of critical care units; the process of nursing; and predictions of patient outcomes. Of particular interest was patient stress and the impact of critical illness on families and nursing staff (VanCott, 1991). Yet to date, despite more than 20 years of research in critical care, very little is known about nursing s contribution to patient outcomes in critical illness (O Malley, 1994). CACCN s position The critical care nurse strives to make practice research-driven and acknowledges a responsibility to promote research within the specialty CACCN Standards for Critical Care Nursing Practice, (2nd Edition), (CACCN, 1997). In 1997 a new research portfolio was created by the CACCN board of directors to reflect the current needs of the association and in keeping with our commitment to research-based practice. The intent of this portfolio is: to support research activity within CACCN to support the communication of research findings within CACCN

7 to support the utilization of research findings within CACCN to explore opportunities to fund research activities of CACCN members. At the recent board of directors meetings held in London, Ontario, April 23-24, the board of directors approved the creation of a research endowment fund. The intent of this fund is to generate revenue to support a yearly research award of $ Criteria for selection, eligibility, and application process, and deadline for receipt of application will be outlined in the fall issue of the OJCACCN. We continue to explore other avenues of funding, e.g. corporate sponsorship, to bolster the amount of the award and/or create additional awards. CACCN Research Committee: A research committee is to be created with the following mandate: to review submitted research proposals to determine funding award winner to develop ideas to foster critical care nursing research to encourage critical care nursing research conducted by critical care nurses to develop a national proposal for a critical care nursing study to be endorsed and conducted by CACCN. The committee will be comprised of one CACCN representative from each of the three regions (Western, Central and Eastern) and one member of the national board of directors. Call for participants If you are an active CACCN member in good standing for a minimum of one year, and have a research background, submit to national office the following information: full name, CACCN membership number, mailing address, telephone and fax numbers, and address. Also to be included is a curriculum vitae and a statement of interest which outlines your research experience and reasons for wanting to participate. Members of the research committee will be determined from those names submitted to national office by July 1, To date, a research component has been added to CACCN s homepage. The focus of this initiative has primarily been to provide CACCN members with online access to research-related websites. Plans for future content include: question and answer; literature reviews; awards and grants; and an inventory of Canadian critical care nursing research. The intent of this inventory is to familiarize critical care nurses with ongoing or completed research projects that pertain to critical care nursing. In addition, we hope to supply contact names of researchers who would be willing to advise and/or provide additional information to critical care nurses interested in the focus of their studies. A business plan is currently being developed that will outline the associated costs and potential sources of revenue. CACCN research utilization committee At the next Chapter Connections Day, Saturday September 11, 1999, chapter presidents and the board of directors will explore the feasibility of a research utilization committee. Potential mandates could include: ongoing review of current critical care nursing research; dissemination of findings; hosting a consensus conference to ascertain best practice ; a pre-conference workshop at future Dynamics on research utilization/literature reviews. Future directions How can you become involved? The CHSRF would like to incorporate all nursing researchers more effectively into their mailing list. If you wish to be added to the CHSRF distribution network, please your name, position, full address, telephone, and fax number to monettes@chsrf.ca Gwynne MacDonald, President, CACCN References CACCN Standards for Critical Care Nursing Practice, (2nd Edition), (CACCN, 1997). O Malley, P. (1994). The role of the critical care clinical nurse specialist in critical care research. AACN. In A. Gawlinski & L. Kern (Eds.) The Clinical Nurse Specialist Role in Critical Care, pp Philadelphia: Saunders. Pepler, C. (1994). Research as the Basis of Practice. In J. Hibberd & M. Kyle, (Eds.) Nursing Management in Canada, pp Toronto: Saunders Canada. Stinson, S. (1986). Nursing Research in Canada. In S. Stinson & J. Kerr, (Eds.), International Issues in Nursing Research, pp Worcester: Billing & Sons. VanCott, M., Tittle, M., Moody, L. & Wilson, M. (1991). Analysis of a decade of critical care nursing practice research: 1979 to Heart & Lung, 20(4), pp Recruitment and Retention Awards for 1999 CACCN established the Recognition, Recruitment and Retention Awards to recognize members and the chapters for their outstanding achievements with respect to recruitment and retention. The CACCN board of directors is pleased to announce the following award winners for 1998/99: Recruitment award Retention award The following chapters have retained over 60% of their previous year s members, and will receive $ each: Greater Edmonton Chapter...61% London Regional Chapter...62% Montreal Chapter...68% Ottawa Regional Chapter...60% Toronto Chapter...63% The following chapters have recruited between 25 and 49 new members from April 1, 1998 to March 31, 1999, and will receive one full tuition to Dynamics 99 in Ottawa: British Columbia Lower Mainland Chapter...25 Calgary Chapter...27 Greater Edmonton Chapter...46 London Regional Chapter...32 Manitoba Chapter...31 Saskatchewan Chapter...29 The Toronto Chapter recruited 67 new members and will receive one full tuition to Dynamics 99 and $ Page Seven

8 Organ donation and the critical care nurse Background On November 24, 1998 the House of Commons undertook the study of the state of organ and tissue donation in Canada, as a result of two key events: a motion by Keith Martin, Member of Parliament for Esquimalt - Juan de Fuca on October 9, 1997 outlining a proposal to address Canada s organ donation problem which received the unanimous support of the House of Commons. the request of the Minister of Health, the Honourable Allan Rock, seeking advice on the role of the federal government in addressing this issue. The following terms of reference guided the proceedings: to consult, analyze and make recommendations regarding the state of organ and tissue donation in Canada to consult broadly with stakeholders, including, but not limited to, provinces, transplant centres, medical personnel, patients, families, organ and tissue retrieval organizations and international experts to consider the appropriate role of the federal government in the development of national safety, outcome and process standards for organ and tissue donations, as well as promoting of public and professional awareness and knowledge regarding organ and tissue donation, procurement and transplantation to consider the legislative and regulatory regimes governing organ and tissue donations in other countries. The House of Commons Standing Committee on Health, chaired by Mr. Joseph Volpe, M.P., conducted public hearings over a two-month period involving over 100 individuals. CACCN was invited to participate and asked by the standing committee to address the following key points pertaining to tissue and organ donation: the role of critical care nurses; attitudes; concerns; CACCN s position. The following brief was presented by Rosella Jefferson, CACCN vice-president, to the House of Commons Standing Committee on Health on Tuesday, March 16, Transcripts of the proceedings can be accessed on the Internet at: HEAL/meetings/evidence/healev71-e.htm On April 22, 1999 the House of Commons Standing Committee on Health released their report Organ and Tissue Donation and Transplantation: A Canadian Approach. This report outlines the committee s findings and rec- Page Eight ommendations to improve organ and tissue donation. The report can be accessed on the Internet at: /HEAL/Studies/Reports/healrp05-e.htm CACCN awaits the response of the Minister of Health, the Honourable Allan Rock, who is expected to respond to the report within 150 days. If you require additional information or would like to comment on this document, please contact the national office at caccn@execulink.com. Submission by the Canadian Association of Critical Care Nurses to the Canadian House of Commons Standing Committee on Health Introduction Critical care nursing practice is research based, in an environment committed to quality, holistic care, where optimal client/family outcomes are achieved through partnerships and appropriate use of resources (CACCN Vision Statement, 1994). Critical care nursing is a profession that cares for patients who are experiencing life-threatening health crises. Nursing the critically ill patient is continuous and intensive, aided by sophisticated technology and based on application of the nursing process - assessment of need, planning appropriate interventions, implementing the interventions and evaluating care. The critical care nurse must balance the need for the highly technological environment with the need for privacy, dignity and comfort. The critical care nurse must maintain that balance between the science of curing and the art of caring. Life-long learning and the spirit of enquiry are essential for the critical care nurse to enhance professional competencies and to advance nursing practice. The critical care nurse s ability to make sound clinical nursing judgments is based on a solid foundation of knowledge and experience (CACCN, 1997). Role of critical care nurses in organ donation The Standards for Critical Care Nursing Practice in Canada (CACCN, 1997) outlines the expectation that critical care nurses will participate in the organ donation process. A basic assumption in the competencies that provide the framework for the Certified Nurse in Critical Care - Canada (CNCC(C)) examination is that critical care nurses support organ donation in their practice (CNA, 1999 in press). CACCN also endorses the position paper on organ donation by the Canadian Nurses Association (CNA, 1994). The priority of the critical care nurse is to care for the client and family who is experiencing life-threatening illness or injury. Once it becomes apparent that survival will not be an outcome, the critical Call for participants for development of a position statement on organ and tissue donation and transplantation CACCN members! Your input is needed to develop a new position statement. The CACCN board of directors is seeking your assistance in the creation of a new position statement on organ and tissue donation and transplantation. Through feedback from membership, and our recent activities with the Standing Committee on Health on Organ and Tissue Donation (March 1999 witness submission by CACCN - reprinted in this issue), the board of directors endorsed the development of a CACCN position statement on this current and relevant topic. Team members for the development of this position statement will be determined from those names submitted to national office by June 30, Interested participants are requested to submit by mail, fax or the following information: full name, CACCN membership number, mailing address, telephone and fax numbers, and address. Also to be included is a statement of interest which briefly outlines your work experience and reason for wanting to participate in this process. The deadline for submitting your name is June 30, 1999.

9 care nurse s responsibility shifts to one of comfort and support. Through the relationship developed with the family, the critical care nurse is in a unique position during this period of transition to facilitate organ donation through the following steps: 1. Identification/participation in the identification of a potential organ donor. 2. Exploration of knowledge, beliefs and wishes regarding organ donation with the family. 3. Continued care of the organ donor by supporting the cardiovascular and respiratory system 4. Contact with the organ retrieval centre. 5. Collection of specimens for tissue typing. 6. Ongoing support for the family during the process of decision making, brain death declaration and grief. 7. Transfer/accompaniment of the donor to the operating room or to a transplant hospital. It is CACCN s position that the critical care nurse should recognize potential organ donors and participate in the process of organ donation. This process includes the exploration of the potential donor s and family s wishes and beliefs, provision of education as required regarding organ donation, and support for the family during the decision-making period. The nurse is in a position to promote the role of organ donation as a way to offer some meaning to a tragic and unexpected loss. While the critical care nurse can be crucial to successful organ retrieval, the premier focus of the critical care nurse remains the care of the donor and family. The critical care nurse must remain nonjudgmental throughout the process. If, despite appropriate education and discussion, a family declines organ donation as an option, it is the position of CACCN that the family s wishes be respected. Environmental aspects A nurse s ability to initiate organ donation can be restricted by environmental or medical barriers. If a facility has guidelines that limit a nurse s ability to initiate discussions, or there is a perception by the nurses that they may not initiate discussions, opportunities for organ donation may be lost. Because declaration of brain death is ultimately a medical decision, the nurse is dependent upon the support of the medical staff. If the physician in charge does not support organ donation, even the most committed critical care nurse will face barriers. A lack of in-house medical personnel may limit organ donation, particularly during the night shift in a non-teaching hospital. This is particularly true if the donor becomes suddenly unstable, shortening the window of opportunity for organ retrieval. The culture and medical practice of the unit where the critical care nurse works can significantly influence the organ donation support. Agencies must also value and support organ donation through policy development and practice that demonstrates commitment. Financial support is needed to provide orientation programs for new and existing staff regarding the process of organ donation. New nurses (and physicians) also need assistance to develop the skills required to effectively and sensitively approach potential organ donor families. Although we are not aware of any studies that demonstrate a relationship between staffing or bed shortages and actual organ donation, this is an area that may require further investigation. In a recent case in Toronto, a critical care bed/staffing shortage resulted in the cancellation of a transplantation and loss of a suitable organ. The impact of the current nursing shortage on organ donation or transplantation is not known. Emotional aspects of transplantation The nurse must balance activities related to organ donation with the needs of the family during the process of dying and grieving. The critical care nurse must maintain a dignified end to the donor s biological life, while providing opportunities for the family to say goodbye in their own unique way. Knowledge derived from research with family members regarding the effects that organ donation can have on the grieving process ranges from at least something good came out of this terrible event (Davis & Gillham-Eisen, 1998) to I regret that I didn t have a chance to hold my child later (Pelletier, 1992). The effect that organ donation has on the donor family is the priority of the critical care nurse. The process of organ donation can be particularly difficult for the critical care nurse. Organ donation often follows many hours or even days of intensive and exhaustive efforts to save the life of a young individual who experienced a sudden and unexpected tragedy. The family s experience is heart wrenching, and the nurse is often left emotionally drained. Leaving a client in a sterile operating suite, after laborious efforts at survival, can be very difficult. Knowing that another life may be saved does not negate the donor s tragedy. If the nurse works in a non-transplant centre, the nurse may only ever see the tragic side of organ donation. A nurse working in a transplant centre may be torn by having both a donor and recipient in the same unit. Nurses who work in critical care in a transplant centre may find transplantation difficult at times because their experience is often limited to those recipients who experience complications or subsequently die. On occasion, ethical questions regarding the appropriateness of some transplants place additional strain on the critical care nurse. Summary CACCN supports the process of organ donation. Nurses working in critical care are in a privileged position to positively influence organ donation success; however, the process can be emotionally very difficult. Facility commitment, agency culture and medical practice are also crucial to the process of organ donation. Despite our commitment to support organ donation as an option, the critical care nurse s primary responsibility is to the potential donor and their family. Throughout the process, the critical care nurse must remain non-judgmental and supportive of the family, regardless of their decision. Ultimately, the nurse must balance organ donation with the needs of the family who is experiencing the tragic and untimely loss of a loved one. Finding this balance is never an easy task. References CACCN. (1997). Standards for Critical Care Nursing Practice (2nd Edition). Canadian Association of Critical Care Nurses, London, Ontario: CACCN. Canadian Nurses Association. (1994). The Role of the Nurse in Organ Donation and Tissue Transplantation. Ottawa, Ontario; June. Canadian Nurses Association. (1999). Blueprint for the Critical Care Nursing Certification Examination. Ottawa, Ontario: CNA.- in press. Davis, I. and Gillham-Eisen, L. (1998). Reducing emotional conflict during the organ donor process. Official Journal of the Canadian Association of Critical Care Nurses, 9(4); Pelletier, M. (1992). The organ donor family members perception of stressful situations during the organ donation experience. Journal of Advanced Nursing, 17: Page Nine

10 C A C C N P O S I T I O N S T A T E M E N T Advance directives Definition Background Advance directives provide individuals with a method to identify their health care preferences for the event that they become incompetent to make such decisions in the future. There are two major groups of advance directives: instructional and proxy directives. Instructional directives allow an individual to identify what or how health care decisions are to be made if they become incompetent (Senate of Canada, 1995). Instructional directives are at times referred to as living wills, end-oflife instructions or treatment directives. Proxy directives allow individuals to specify who is to make health care decisions in the event that they become incompetent (Senate of Canada, 1995). Proxy directives are at times referred to as power of attorney for health care, mandate for health care, appointment directives, substitute decision maker for health care or personal directive agent. An advance directive only comes into effect when an individual is incompetent to make health care decisions. A competent individual can change, negate or destroy their advance directive at any time. The majority of advance directives are used to instruct health care professionals to withdraw or withhold medical treatments such as cardiopulmonary resuscitation, mechanical ventilation, dialysis, antibiotics, surgery, invasive diagnostic procedures, or artificial nutrition and hydration. However, advance directives may also be used to request medical treatment. Many different formats of advance directives are currently available in Canada. It has been recommended that a combined document which includes both a living will and power of attorney for health care would provide the best assurance that critical care patients desires concerning medical treatment will be respected (Silverman et al., 1992). Decision-making should be informed: consultation with health care professionals is seen as beneficial in helping individuals make an informed decision. Advances in medical technology now permit the extensive use of life-sustaining treatments. However, not all individuals want to receive life-prolonging therapies for every health crisis. Critically ill patients are often unconscious or incompetent to indicate their treatment preferences. Advance directives promote patient autonomy and self-determination by allowing individuals to identify their preferences regarding life-sustaining treatment for the event that they become incapable of expressing such wishes themselves. Advance directives also provide a framework to facilitate discussions about life-sustaining treatments and end of life decisionmaking between patients, family members or significant others, and the health care team. The ideal time for discussions about advance directives is before a health care crisis occurs. Both the Canadian Nurses Association (1994) and Canadian Medical Association (1992) support the concept of advance directives. Values from the Canadian Nurses Association Code of Ethics for Registered Nurses (1997) which are relevant to the topic of end of life decision-making and advance directives include health and well-being, choice, and dignity (Canadian Nurses Association, 1998). While the issue of advance directives has not been directly addressed in Canadian courts, some Canadian court decisions support the concept of advance directives (Sneiderman, 1991). It has been recommended that all Canadian provinces implement legislation related to advance directives (Senate of Canada, 1995). As legislation in each province can vary, critical care nurses should ensure that they are familiar with their current provincial legislation. However, lack of provincial legislation does not inherently negate the validity of an advance directive. Page Ten Research A 1997 survey conducted at the Canadian Association of Critical Care Nurses (CACCN) national conference found that 80% of respondents had cared for at least one patient with an advance directive and that 89% of respondents were in favour of advance directives (Leith, 1998). Previous research with Canadian physicians and nurses also found that the majority favoured the use of advance directives in clinical care (Hugues & Singer, 1992; Kelner et al., 1993). While research suggests that the Canadian general public supports the use of advance directives (Molloy et al., 1991; Storch & Dossetor, 1994), many individuals appear to have little experience and poor knowledge of advance directives (Sam & Singer, 1993). However, some Canadian patients, family members and health care professionals have been documented to have completed advance directives (Leith, 1998; Perry et al., 1995) and it has been suggested that the incidence of advance directives in Canadian health care will continue to increase (Leith, 1997). While research in critical care identifies that it is important for medical personnel to be aware of whether or not patients have advance directive statements (Goodman et al., 1998), some Canadian hospitals do not have policies regarding advance directives (Rasooly et al., 1994). Research suggests that many nurses require further education about advance directives in order to use them effectively in their daily practice (Crego & Lipp, 1998; Leith, 1998; Woods & DelPapa, 1996). Furthermore, critical care research has identified that at times problems may occur with interpreting and honouring advance directives (Ewer & Taubert, 1995). Yet, it has been suggested that advance directives could be beneficial in facilitating discussions about foregoing life-sustaining treatments (Johnson et al., 1995). CACCN s position CACCN supports an individual s right to direct their own health care including the right to accept or refuse life-sustaining treatment. CACCN

11 believes that advance directives provide an appropriate mechanism by which patients can identify their health care preferences for the event that they become incompetent to make health care decisions. CACCN recognizes that some advance directives can be vague and difficult to implement in clinical practice and recommends that ethical consultation may be appropriate in some instances. CACCN does not believe that all patients should be required to complete an advance directive. CACCN proposes that critical care nurses should ensure that they have adequate knowledge to provide patients and family members with information about the purpose, advantages, and limitations of advance directives. Critical care nurses need to take the time to reflect and acknowledge their own beliefs regarding advance directives, death and dying, because they may be required to discuss these sensitive issues with patients, family members or significant others. CACCN suggests that critical care nurses should act as patient advocates during discussions about advance directives within the health care team or with patients family members. Additional roles for critical care nurses with respect to advance directives include providing education and/or conducting research. CACCN encourages critical care nurses to verify that the health care facility where they are currently employed has implemented a policy regarding advance directives. CACCN would like to acknowledge the expertise and commitment demonstrated by the following CACCN members in the process of developing the position statement entitled Advance Directives. The position statement received the CACCN board of directors approval on April 24, The working group members were: Beverly Leith, Montreal, Quebec Alise Gilmore, Regina, Saskatchewan Lori Garchinski, Regina, Saskatchewan Shelley Snider, Cornwall, Ontario Gwynne MacDonald, London, Ontario CACCN member reviewers: Pam Hughes, Halifax, Nova Scotia, Francis Loos, Regina, Saskatchewan Grace MacConnell, Halifax, Nova Scotia Cindy MacVicar, Edmonton, Alberta Charlotte Pooler, Calgary, Alberta References Canadian Home Care Association/Canadian Hospital Association/Canadian Long Term Care Association/Canadian Nurses Association. Canadian Public Health Association/Home Support Canada. (1994). Joint Statement on Advance Directives. Ottawa: Authors. Canadian Medical Association. (1992). Policy summary on advance directives for resuscitation and other life-saving or sustaining measures, Canadian Medical Association Journal, 146(6), 1072A. Canadian Nurses Association (1997). The Code of Ethics for Registered Nurses. Ottawa:CNA. Canadian Nurses Association (1998). Advance directives: The nurses role. Ethics in Practice, ISSN Number Ottawa: CNA Crego, P.J. & Lipp, E.J. (1998). Nurses knowledge of advance directives. American Journal of Critical Care, 7(3), Ewer, M.S. & Taubert, J.K. (1995). Advance directives in the intensive care unit of a tertiary care cancer center. Cancer, 76, Goodman, M.D., Tarnoff, M. & Slotman, G.J. (1998). Effect of advance directives on the management of elderly critically ill patients. Critical Care Medicine, 26(4), Hugues, D.L. & Singer, P.A. (1992). Family physicians attitudes toward advance directives. Canadian Medical Association Journal, 146, Johnson, R.F., Baranowski-Birkmeier, T. & O Donnell, J.B. (1995). Advance directives in the medical intensive care unit of a community teaching hospital. Chest, 107, Kelner, M., Bourgeault, I.L., Hebert, P.C. & Dunn, E.V. (1993). Advance directives: The views of health care professionals. Canadian Medical Association Journal, 148(8), Leith, B. (1997). Advance directives in critical care. Official Journal of the Canadian Association of Critical Care Nurses, 8(4), Leith, B. (1998). Canadian critical care nurses and advance directives. Official Journal of the Canadian Association of Critical Care Nurses, 9(1), Molloy, D.W., Guyatt, G., Alemayehu, E. & McIlroy, W.E. (1991). Treatment preferences, attitudes toward advance directives and concerns about health care. Humane Medicine, 7, Perry, L.D., Nicholas, D., Molzahn, A.E. & Dossetor, J.B. (1995). Attitudes of dialysis patients and caregivers regarding advance directives. ANNA Journal, 22, , 481. Rasooly, I., Lavery, J.V., Urowits, S., Choudhry, S., Seeman, N., Meslin, E.M., Lowy, F.H. & Singer, P.A. (1994). Hospital policies on lifesustaining treatments and advance directives in Canada. Canadian Medical Association Journal, 150(8), Sam, M. & Singer, P.A. (1993). Canadian outpatients and advance directives: poor knowledge and little experience but positive attitudes. Canadian Medical Association Journal, 148(9), Senate Of Canada. (June 1995). Of Life and Death. Report of the special senate committee on euthanasia and assisted suicide, Minister of Supply and Services Canada. Silverman, H.J., Vinicky, J.K. & Gasner, M.R. (1992). Advance directives: Implications for critical care. Critical Care Medicine, 20, Sneiderman, B. (1991). The Shulman case and the right to refuse treatment. Humane Medicine, 7(1), Storch, J.L. & Dossetor, J. (1994). Public attitudes toward end-oflife treatment decisions: Implications for nurse clinicians and nursing administrators. Canadian Journal of Nursing Administration, 7, Woods, L.C. & DelPapa, L.A. (1996). Nurses attitudes, ethical reasons, and knowledge of the law concerning advance directives. IMAGE: Journal of Nursing Scholarship, 28(4), 371. Page Eleven

12 The CACCN Board of Directors Gwynne MacDonald, RN, MN, CNCC(C) Rosella Jefferson, RN, BScN, MSN Valerie Banfield, RN, BScN, MN, CNCC(C) Central Region, President Western Region, Vice-President Eastern Region, Secretary Gwynne was appointed to the CACCN board of directors in April 1997 and has been serving as the association s president since February In addition to the responsibilities of this role, Gwynne is also responsible for the portfolio of critical care nursing research. Prior to her involvement at the national level, Gwynne held a number of positions with the London Chapter of CACCN, as president, president-elect and chairperson of the education committee. Gwynne has worked as staff nurse, educator and clinical nurse specialist in critical care. She is currently coordinator, intensive care, at the University Campus of the London Health Sciences Centre, London, Ontario. Her research interests have included primary nursing, case management, therapeutic touch, and evidence-based protocols and guidelines for DVT prophylaxis, weaning and noninvasive monitoring. Gwynne received her bachelor of science in nursing from the University of Windsor, Windsor, Ontario and master of nursing from the University of Alberta, Edmonton, Alberta. She became a certified nurse in critical care, CNCC(C), in Rosella Jefferson joined the CACCN board of directors as a representative from the Western Region. She was appointed vice-president in October 1998 and is currently enjoying learning more about the challenges of national involvement in CACCN. Rosella s most recent education program, a masters in nursing program, was completed at the University of British Columbia in Initial education in nursing was completed in 1979 in the BScN program at McMaster University, Hamilton, Ontario. Rosella s love of nursing has been implemented in many previous positions, including staff nurse, head nurse and clinical instructor. Her present position as a clinical nurse specialist for the pediatric critical care program at British Columbia s Children s Hospital offers opportunities to be involved with patient and family care, nursing practice, program planning, nursing research and nursing education in both tertiary and community hospitals. Hearing from CACCN members will continue to be Rosella s goal as she works with the board to address issues important for critical care nurses. Valerie Banfield graduated with a BScN from Saint Xavier University Antigonish, NS in 1979 and began working in critical care 16 years ago. She has held various positions since that time: staff nurse, instructor (diploma program and post-graduate program in critical care nursing), and project nurse. In 1992, she received a masters in nursing from Dalhousie University. Her thesis was entitled Informational needs of families of patients who are critically ill. Presently, Valerie is a nurse educator in the perioperative area (post anaesthetic care unit) and the distance critical care program at the Queen Elizabeth II Health Sciences Centre, Halifax, NS. She has been an active member of CACCN and has held the research position on the executive at the provincial level. Valerie received her certification in critical care in 1995 and twice participated in certification exam development. Valerie has undertaken the portfolio of CACCN secretary, with the primary responsibility of preparing and coordinating national correspondence. Gwynne MacDonald Rosella Jefferson Valerie Banfield Page Twelve

13 Petula Wong, RN, BScN, MEd Heather Camrass, RN, BScN, CNCC(C) Eastern Region, Treasurer Central Region, Director Petula has completed her third year on the CACCN national board of directors. Petula is the national treasurer of CACCN and the chairperson of Dynamics 2000 to be held in Halifax, Nova Scotia. Petula finds the role of director challenging and rewarding. She encourages all members to consider the opportunity to serve on the CACCN board. Petula has worked as staff nurse, educator and manager in critical care. She is currently the manager of the renal dialysis unit and dialyzer reprocessing program. Petula received her bachelor of science degree in nursing from University of Toronto, her masters degree in education from Dalhousie University, and her health services management certificate from the Canadian Hospital Association. Heather Camrass began her first two-year term on the board of directors in April of this year, and will be responsible for coordinating the awards and corporate sponsorship portfolio. Heather has worked in critical care nursing for 10 years in the cardiovascular ICU at the Heart Institute in Ottawa, Ontario. She has also worked as a clinical specialist for vascular surgery and taught clinical for Algonquin College at the basic level. Petula Wong Heather Camrass Page Thirteen

14 After becoming a member of CACCN six years ago, Heather joined the local Ottawa Chapter executive as the chapter secretary and three years ago became chapter president. Nationally, Heather has presented two oral presentations at Dynamics - Phrenic Nerve Frostbite and Minimally Invasive Direct Coronary Artery Bypass. Heather is currently on the planning committee for Dynamics 99 in Ottawa this fall. As Heather moves from a regional to national focus, she is looking forward to being part of a national association that brings nursing into the forefront by expanding the voice that critical care nursing has across this country. Lori Garchinski, RN, BSN, CNCC(C) Western Region, Director Newly elected to the CACCN board of directors, Lori Garchinski began her first term in April Lori is currently a staff nurse in the surgical intensive care unit at the General Hospital in Regina, Saskatchewan. She has been a critical care nurse for 10 years and enjoys the challenges that this field has to offer. As well, Lori undertook the challenge and received her certification in critical care nursing, CNCC(C), in For eight years now, Lori has been involved with CACCN at the provincial level, and has been in the positions of member-at-large, president and currently as publications chairperson. Although the Saskatchewan Chapter is a smaller chapter, she is very proud and pleased to have been part of the excellent work the chapter has done in promoting critical care nursing in that province. Lori is looking forward to working with the board of directors over the next two years as critical care nursing enters the new millennium - what an exciting time to be a part of history and to continue to strive to make the voice of critical care nursing heard nationally. Lori feels that we not only need to be strong advocates for the patients we serve, but also for each other and our profession. As Lori strives to fulfil the responsibilities of the recruitment and retention portfolio, as well as help CACCN fulfil its mission of maintaining and enhancing the quality of care provided to critically ill patients and their families, she hopes to hear from many CACCN members and welcomes all suggestions, comments and issues that need to be addressed. Brenda Morgan, who resides in London, Ontario, began her term on the board in April During the next year, Brenda will continue to be responsible for the certification portfolio, as well as chairperson for Dynamics 99 being held September in Ottawa, Ontario. Brenda graduated from the Centennial College diploma nursing program in 1975, and from the University of Western Ontario, BScN program in April She is currently in the MScN program at McMaster University. Brenda has worked in critical care at the London Health Sciences Centre for the past 20 years in a variety of roles, staff nurse, charge nurse and educator. This is Brenda s second time on the board of directors. Her past activities include: London regional chapter president ( ), national president ( ), Dynamics chairperson 1991 and 1994, and critical care representative on the Canadian Nurses Association s advisory committee. Brenda is currently a member of the critical care certification committee and is the editor of the first and second editions of the Study Guide for the Critical Care Nursing Certification Examination, published by CACCN. Brenda is looking forward to the second year of her term on the board and hopes to see many CACCN members at Dynamics 99 in Ottawa. Lori Garchinski Brenda Morgan Brenda Morgan, RN, BScN, CNCC(C) Central Region, Director 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 1999 Annual General Meeting of the CACCN. The CACCN Annual General Meeting will be held on Monday, September 13, 1999 at 1630 hrs at the Crowne Plaza Hotel, Ottawa, Ontario in conjunction with Dynamics 99. Members unable to attend the Annual General Meeting are reminded that their proxy vote must be received in CACCN national office by 2400 hrs, September 1, The proxy vote form is printed on page 17 of this issue, and can also be obtained from your chapter president or CACCN national office. Page Fourteen

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16 Question to the board Where does all that money go? The members of the board of directors (BOD) are accountable for answering a question sometimes asked by CACCN members regarding the use of the membership fees. Accolades to the questioners! We certainly agree that matters of this nature should be transparent for all, especially in a not-for-profit organization such as ours. Firstly, national representation is included in the membership fee for our particular professional organization. This means that critical care nurses from across the country can have a voice that is united; this voice should consequently also be louder, more definite and more effective in developing critical care nursing as a profession. This voice is used to develop position papers that portray the views of critical care nurses involved with an issue in question. When CACCN members identified, for example, that Withdrawal of Life Support was an issue of significance and variance in practice, the BOD asked for volunteer members from critical care units across the country to develop a position paper draft for the issue. These critical care nursing members were selected according to their abilities, knowledge and experience. This draft was then reviewed by the BOD as well as being considered for review request from other potential groups, such as the CNA or the Critical Care Medicine Society. When the position paper is approved and final, all members benefit from its use. Similarly, standards for critical care practice have been developed by CACCN and used to develop the critical care nursing certification process. Critical care nurses interested in accessing the best practices recommended nationally use these standards. When approached by the Parliamentary Standing Committee on Health for input regarding the issue of organ donation, CNA asked CACCN to be involved. The processes involved in examples such as these can only occur in a national organization with national representation. Membership in CACCN means that members receive the only Canadian critical care nursing journal - one that is published quarterly with a professional critical care nurse as its editor and professional critical care nurses on its review board. These nurses ensure that a blind review process is used to assess articles, involving criteria that strive for excellence when published. In addition, CACCN members have an avenue to access this experienced group to assist in developing writing and publishing skills. Every year, a national critical care nursing conference is offered in a city located in the western, central or eastern region of Canada. Planning for this conference commences more than two years B.I.G. CRITICAL CARE NURSES LOOKING TO THE FUTURE With development underway on a new critical care building at the Health Sciences Centre, the critical care program is looking to the future. Presently, however, we are looking for critical care nurses. We offer: an extensive orientation program ongoing training and educational opportunities staffing schedules that may be flexible to individual needs excellent support structure opportunities to join committees a central location research opportunities room for advancement participation in nursing rounds As the province s recognized Trauma Centre and Aboriginal Health Care facility, the Health Sciences Centre has permanent full and part-time opportunities for critical care nurses in: Surgical/Intermediate Intensive Care Unit Medical Intensive/Coronary Care Unit Post Anesthesia Care Unit - Adult and Pediatric Pediatric Intensive Care Unit Adult and Pediatric Emergency Neonatal Intensive Care Unit If you have critical care experience, are excited about career development within your profession, and would like to explore your potential at the Health Sciences Centre, please send a resume to: Mail: Human Resources, HEALTH SCIENCES CENTRE, 60 Pearl Street, Winnipeg, Manitoba, R3E 1X2 Fax: (204) ; SusanGoertzen@hsc.mb.ca; or call the Centre s Nurse Recruiter at (204) Page Sixteen Bone Injection Gun In extreme emergencies When every second counts... When it s a matter of life and death You Can Make a Really BIG* Difference *BIG = Bone Injection Gun The adult instant intraosseous infusion system used in critical conditions such as severe trauma, emergency medicine, and mass casualties. It is also an alternative to unsuccessful intravenous access during adult emergencies. CALL: KRESS USA CORPORATION at (888) or fax (314)