Volume 28 Number 1

JANUARY/FEBRUARY 2006 Inside

FEATURES Page 3 The Nursing School Dilemma Qualified students are being turned away from nursing schools because of faculty shortage. Page 8 Update on Avian Influenza Pandemic Threat The risk of pandemic influenza is serious. Discover the latest steps that are being taken to help prevent a a worldwide influenza outbreak. Page 14 The Nurse Response Team: Carole Farley-Toombs, MS, RN, CNS University of Arizona, the American A Success Story Psychiatric Nurses Association (APNA) was In response to a recommendation The potential for violence in work set- from the Ontario Provincial tings is a significant issue. A careful assess- approached in 2004 to present a faculty government, one Canadian health ment of the potential risks is necessary for workshop at the National Student Nurses’ care facility transformed one of its the development of policies and strategies Association Annual Convention in Phoenix. campuses into an ambulatory care to promote prevention, early identification, The workshop was titled, “When Things center. Get Tense: Response vs. Reaction.” This arti- and effective intervention. Historically, the NEWS promotion and maintenance of safe work- cle reflects the content of that presentation. ing and care environments has been a cen- The OSHA General Duty Clause, Section Page 4-5 Ttral goal in Psychiatric Mental Health 5 (a, 1), states that “each employer shall AAACN 2006 Nursing practice. Review of the Psychiatric furnish to each of his employees employ- Annual Conference Mental Health Nursing literature on this ment, and a place of employment which is Make plans now to attend! topic reveals a focus on prevention and free from recognized hazards that are caus- Page 7 early intervention through attention to ing or likely to cause death or serious physi- Two AAACN Members environmental factors including clarity of cal harm. This includes the prevention and Appointed to JCAHO roles and expectations, education and control of the hazard of workplace vio- Committee training, and teamwork. After the tragic lence.” OSHA defines workplace violence as Congratulations to these two murder of three nursing faculty at the any physical assault, threatening behavior, members for their commitment to or verbal abuse occurring in the work set- serve on JCAHO’s PTAC Reprinted in part from Dean's Notes, Volume 25, Number ting. The workplace is defined as any loca- Committee. 4, pp. 1-3. Reprinted with permission of the publisher, Anthony J. Jannetti, Inc., East Holly Avenue/Box 56, tion whether permanent or temporary Page 16 AAACN Election Results Pitman, NJ 08071-0056; (856)256-2300; FAX: (856)589- continued on page 10 7463; Web site www.ajj.com Announced New Board of Directors members to The CE Evaluation Form and Objectives for this article appear on the AAACN Web site (www.aaacn.org). assume their responsibilities at the Please complete and submit this form to the AAACN National Office to obtain CE credit. close of the annual conference in Atlanta. The Official Publication of the American Academy of Ambulatory Care Nursing From the PRESIDENT The Obligation of Leadership The AAACN Board of Directors meets three times per year: at the annual conference, during the spring, Reader Services and in the fall. These meetings include but are not limit- AAACN Viewpoint ed to activities such as budget development and The American Academy of Ambulatory approval, strategic planning and evaluation, and Board Care Nursing East Holly Avenue Box 56 development activities. Monthly teleconference calls are Pitman, NJ 08071-0056 held during the remaining months to follow up and (856) 256-2350 • (800) AMB-NURS Fax (856) 589-7463 complete the work started at the face-to-face Board E-mail: [email protected] meetings. Web site: www.aaacn.org T In October 2005, the AAACN Board of Directors AAACN Viewpoint is owned and published Regina Phillips bimonthly by the American Academy of met in Chicago for the Fall Board Meeting. The weather Ambulatory Care Nursing (AAACN). The was beautiful and the meeting was very productive. During each meeting, the newsletter is distributed to members as a direct benefit of membership. Postage paid at directors engage in a Board development exercise. Board development consists Bellmawr, NJ, and additional mailing offices. of structured learning activities that are the joint responsibility of the Board Advertising chairperson, all Board members, and the executive staff (Nowicki, 1998). Contact Tom Greene, Advertising For this exercise, the Board reviewed “The Four Obligations of Leadership” Representative, (856) 256-2367. taken from the American Society of Association Executives (ASAE) January 2005 Back Issues symposium (Tecker Consultants, 2005). The Board discussed each obligation To order, call (800) AMB-NURS or (856) 256-2350. and how Board members have met them in the past. Next, we identified at Editorial Content least one action plan for each obligation to assure that we are successful in AAACN encourages the submission of news meeting them in the future. The first obligation is to ensure that the leadership items and photos of interest to AAACN mem- bers. By virtue of your submission, you agree team has access to a common stream of information from members and stake- to the usage and editing of your submission holders that allows them to understand their views of the world. The action for possible publication in AAACN's newslet- ter, Web site, and other promotional and edu- plan identified is for the Board to conduct followup telephone evaluations with cational materials. all task force volunteers once their assigned task is completed to give each vol- To send comments, questions, or article sug- unteer an opportunity to provide valuable feedback and suggestions to the gestions, or if you would like to write for us, contact Editor Rebecca Linn Pyle at Board for future tasks. [email protected] The second obligation is to provide a coherent stream of information back AAACN Publications and to members and stakeholders that allows them to understand not just what Products decisions have been made, but why. The action plan to help us meet this obli- To order, visit our Web site: www.aaacn.org. gation is to provide a written summary of the Board meeting activities to the Reprints SIGs and Committees via Board liaisons and to members via Viewpoint. In addi- For permission to reprint an article, call (800) AMB-NURS or (856) 256-2350. tion, the Board felt it was imperative that at least annually we provide a sum- mary and review of the strategic plan and goals to new and existing members. Subscriptions We offer institutional subscriptions only. The The third obligation is to bridge the gap between members’ and stake- cost per year is $80 U.S., $100 outside U.S. holders’ views of the world and the views held by those who seek to earn the To subscribe, call (800) AMB-NURS or (856) 256-2350. right to lead them. One way this obligation has been met is via the Leadership Indexing Symposia that are held during the annual conference. Moving forward, it is AAACN Viewpoint is indexed in the important to emphasize consensus among the SIGs, task forces, and commit- Cumulative Index to Nursing and Allied Health Literature (CINAHL). tee volunteers when there is disparity in views. In addition, it is imperative that © Copyright 2006 by AAACN. All rights we continue to provide ongoing opportunities for members to volunteer for reserved. Reproduction in whole or part, elec- and/or lead these groups in the future. tronic or mechanical without written permission of the publisher is prohibited. The opinions The last obligation of leadership is to understand that in the voluntary expressed in AAACN Viewpoint are those of the nature of associations, people choose to engage because they perceive that it is contributors, authors and/or advertisers, and do not necessarily reflect the views of AAACN, in their own self interest to do so. To meet this obligation, it is imperative that AAACN Viewpoint, or its editorial staff. we consistently recognize and demonstrate our appreciation for the work done Publication Management by by volunteers without whom AAACN and our products and services would not Anthony J. Jannetti, Inc. exist. It is also important that we continue to ask the question, “Why do you stay?” of each volunteer and member. This way, we can be assured of staying American Academy of Ambulatory Care Nursing continued on page 7 Real Nurses. Real Issues. Real Solutions.

2 VIEWPOINT JANUARY/FEBRUARY 2006 FEATURE The Nursing School Dilemma: Faculty Shortage Causes Potential Nursing Students to be Turned Away

In December 2005, the American Association of increase student capacity this year included forming Colleges of Nursing (AACN) released preliminary survey alliances with hospitals, the business community, and data showing that enrollment in entry-level baccalaureate other stakeholders to address faculty and clinical space nursing programs increased by 13% from 2004 to 2005. constraints. Some schools have expanded or opened new Though this increase is welcome, surveyed nursing col- accelerated programs for second-degree seekers looking to leges and universities denied 32,617 qualified applications transition into nursing while others have taken advantage due primarily to a shortage of nurse educators. AACN is of state and federal funding aimed at strengthening the very concerned about the increasing number of qualified nursing workforce. In addition to these school-based initia- Istudents being turned away from nursing programs each tives, both Johnson & Johnson and the Nurses for a year since the federal government is projecting a shortfall Healthier Tomorrow coalition continued their national of 800,000 registered nurses (RNs) by the year 2020. media campaigns to encourage careers in nursing. According to research conducted by Dr. Peter Buerhaus from Vanderbilt University, enrollments in nurs- Qualified Students Turned Away Despite ing programs would have to increase by at least 40% Nursing Shortage annually to replace those nurses expected to leave the Though interest in nursing careers is strong, access to workforce through retirement. professional nursing education is becoming more difficult. The AACN survey found that the number of graduates AACN’s preliminary findings show that 32,617 qualified from entry-level baccalaureate programs increased by applications to entry-level baccalaureate programs were 19.1% from 2004 to 2005. This data is based on informa- not accepted in 2005 based on responses from 432 tion supplied by the same 393 schools reporting for the schools. The number of qualified students turned away past two years. The recent rise in graduations follows 14, each year from these programs continues to increase with 4.3 and 3.2% increases in the number of graduates in 29,425, 15,944, and 3,600 students turned away in 2004, 2004, 2003, and 2002, respectively. This upward trend 2003, and 2002, respectively. The primary barriers to was preceded by a six-year period of graduation declines accepting all qualified students at nursing colleges and from 1996 through 2001. universities continue to be insufficient faculty, clinical AACN’s latest data confirm that interest in nursing placement sites, and classroom space. careers continues to grow, which is good news consider- To address these issues, AACN has focused its advoca- ing the projected demand for nursing care. Last year, the cy efforts on increasing funding for existing Nursing U.S. Department of Labor identified registered nursing as Workforce Development programs administered by the the top occupation in terms of job growth through the federal Division of Nursing and shaping new legislation to year 2012. According to the latest projections from the support faculty development and enrollment growth. U.S. Bureau of Labor Statistics, more than one million new Earlier this year, AACN secured a new funding stream for and replacement nurses will be needed by 2012. doctoral nursing education through the Department of Given the demands of today’s health care system, the Education’s Graduate Assistance in Areas of National Need greatest need in the nursing workforce is for nurses pre- (GAANN) program, which will help to address the faculty pared at the baccalaureate and higher degree levels. With shortage. AACN successfully lobbied to have nursing iden- the federal Health Resources and Services Administration tified as an area of national need for the first time through calling for baccalaureate preparation for at least two thirds the GAANN program. of the nursing workforce, the evidence clearly shows that Further, AACN has worked with colleagues in the higher levels of nursing education are linked with lower health care community to introduce new legislation to patient mortality rates, fewer errors, and greater job satis- address the faculty shortage and other nursing school faction among RNs. Nurse executives, federal agencies, resource constraints, including the Nurse Education, the military, leading nursing organizations, health care Expansion, and Development Act, and the Nurse Faculty foundations, magnet hospitals, and minority nurse advoca- Education Act. Without increased federal support, the cy groups all recognize the unique value that baccalaure- potential for future growth in nursing education programs ate-prepared nurses bring to the practice setting and their may be limited at a time when the demand for contribution to quality nursing care. well-educated nurses is rising. The robust interest in professional nursing can be For more information about this survey and survey attributed in part to successful outreach efforts guided by results, visit www.aacn.nche.edu nursing schools nationwide. Strategies employed to

WWW.AAACN.ORG 3 AAACN Conference to Inspire Nurses as Leaders

Annual Conference Is FAST Approaching! The American Academy of Ambulatory Care Nursing • Clinical Leadership Behaviors and Nurse Satisfaction in (AAACN) will hold its 31st Annual Conference in Atlanta, GA, an Outpatient Setting March 23-27, 2006, at the Sheraton Atlanta Hotel. • Using Emotional Intelligence Participants will network and share “best practice” ideas, During the closing session on Sunday, March 26, Carol attend a wide variety of education sessions, and explore the Rutenberg, MNSc, RNC, will present “Challenges in Today’s key leadership role of the ambulatory care nurse. World in Ambulatory Settings.” Ms. Rutenberg will lead a The conference will feature workshops on such topics as discussion on recent disasters and their impact on people’s telehealth, staffing, end-of-life care, and patient safety taught lives and work settings. Participants will be invited to share by the country’s foremost experts. Attendees will have the their own stories. opportunity to earn continuing education credits, see the Post-conference workshops on Monday, March 27, latest products and technologies in the exhibit hall and include the Ambulatory Care Nursing Certification Review attend special events. The complete registration brochure Course, an overview of the potential content of the ambula- and detailed information about the conference are available tory care nursing certification exam; and the AAACN at www.aaacn.org. Telehealth Nursing Practice Core Course (TNPCC), a com- prehensive session designed for nurses who handle tele- Program phone/telehealth inquiries from patients in any practice set- On Thursday, March 23, Shirley Kedrowski, MSN, RN, ting. Both courses earn participants contact hour credit. will present a pre-conference workshop, “Achieving Accreditation: Updates on Standards, Tracer Methods, Special Interest Groups Periodic Performance Review and Much More!” Kedrowski AAACN’s Special Interest Groups (SIGs) will also meet to will focus on Joint Commission on Accreditation of network during the conference. These groups represent Healthcare Organizations (JCAHO) requirements and how to Leadership, Patient Education, Pediatrics, Staff Education, meet the new and challenging standards for 2006. That Telehealth Nursing Practice, Tri-Service Military, and Veterans evening, there will be a session to welcome new members, Affairs. followed by an Opening Reception and Silent Auction. On Friday, March 24, former television news anchor Anne Continuing Education Ryder will present the keynote address, “Three Steps to Power, Participants have the opportunity to earn up to 19.4 Peace, and Perseverance: Lessons in Health Care from Mother contact hours for the 3-day conference. Additional hours will Teresa.” Ryder was the last journalist to interview Mother be given for the poster sessions and the pre- and postconfer- Teresa before her death, and she has traveled the world speak- ence workshops. ing about peace and spiritual balance. Concurrent sessions will be held March 24-26. Sessions include: Conference CDs • Using Evidence-based Practice to Improve Patient Care Audio CDs of individual sessions and the full confer- • The Graying of America: Baby Boomers’ Impact on ence CD-ROM will be available following the conference. Health Care Details will be available on the AAACN Web site. • Telehealth Nursing: The Compass for the Future • Pandemics, New Vaccines and Other Coming Attractions

4 VIEWPOINT JANUARY/FEBRUARY 2006 Silent Auction Donations Sought If you are coming to the conference, we hope you will think about bringing an item to donate to the Silent Auction. Small items such as jewelry or books are easy to pack. Larger items such as handmade quilts, baskets of goodies from your state, pictures, etc. could be shipped to yourself at the hotel. Moderators Needed Nursing memorabilia is always sought by participants. Please drop off your item at the Registration Desk prior to Thursday AAACN program planners are currently seeking evening. Your donation helps raise funds for the AAACN moderators for the 2006 Annual Conference in Atlanta. Scholarship Fund. A moderator introduces the speaker, distributes Pam DelMonte, Silent Auction Coordinator handouts, keeps the session on time, facilitates [email protected] discussions, and troubleshoots room or AV problems. If you are going to the conference and would like to “Meet Me” Area to be Tested at the Conference volunteer to be a moderator, please contact Pat Reichart A “Meet Me” area and sign up board will be placed in at [email protected]. When you receive your registration the Registration Area at the 2006 AAACN conference in brochure, contact Pat to let her know which sessions you Atlanta to help conference participants who are attending would like to moderate. alone to locate a colleague to go to dinner with or see Your help in making the annual conference a success Atlanta. This concept can also be used for an exercise is greatly appreciated! “buddy” in the morning or afternoon. Nurses interested in taking advantage of this opportunity to meet another col- league will indicate a date, time, and location of where to This I Know... meet with the hopes of connecting with someone else who Spring is the season that brings about yearly renewal, would like to share dinner or sight see at the same time. and for me, following long cold winters in Chicago; the most inspiring rite of spring is to attend the AAACN Annual Conference. Every year that I have the opportunity to Founders’ Scholarship attend a conference, I return with new points of view, a In honor of AAACN’s Past Presidents, new members and heightened sense of excitement, renewed spirit, and inspi- first-time conference participants can win complimentary reg- ration. istration to the 2007 conference in Las Vegas. To be consid- I find numerous reasons and benefits of attending ered for the Founders’ Scholarship, you will be asked to sub- AAACN conferences. The educational sessions feature top- mit a 100-word or less description at the 2006 conference in ics of interest related to professional practice, research, and Atlanta, stating how the conference inspires you and why you public policy. These sessions serve as the therapeutic balm would recommend AAACN to your colleagues. The winner for my professional soul, and they energize me to return will be announced during the Closing Ceremony. with new ideas to improve my practice. Learning is an essential component of every conference, and the broad range of educational and poster sessions provide me with the ability to earn continuing education credits. Acquiring CEs is an added incentive to attend the conference. Networking with peers from around the country, renewing contacts with successful colleagues, and involvement in the Leadership SIG provide opportunities to stay abreast of professional trends and advances as well as participate in active dialogue with my colleagues. Needless to say, the chance to travel and experience the culture, hospitality, and the historical attractions of other cities are also moti- vating factors for me to attend this conference. This spring, AAACN’s 31st Annual Conference in Atlanta, GA, promises to be the most exciting conference yet. With its sense of renaissance, spring is a great time to be with a group of wonderful people with points of view that expand and stimulate your thinking. So that you do not miss a truly renewing and inspiring experience, I invite and strongly encourage you to attend. Whether you are a first-time or a repeat conference attendee, I know there is no better place to be! Sandra Peterson, MSN, RN, CNAA, BC Chicago, IL

WWW.AAACN.ORG 5 AAACN Certification News Congratulations to these members who have validated their expertise by passing the American Nurses Credentialing Center (ANCC) Ambulatory Care Nursing NEWS Certification exam and received their certification creden- Member Get-a-Member tials in 2005: Carolyn Cardiello Jacqueline L. Billy Dean Campaign Adds 95 New Vicki L. Curry Horner Raulston, Jr. Members! Sheila Jo Davis Jan E. Inglis Carolyn S. Reder Susan B. Doyle Isabel M. Jillson Carol L. Russ Thanks to everyone who recruited new members as part Lisa Ann Duncan Kathy J. Knox Carol C. Saxman of the 2005 Member Get-a-Member campaign. Many mem- Cheryl A. Elliott Angela Louise Edna D. Shepherd bers recruited one colleague to join, and we are very happy Helen M. Finch Kouri Knez V. Smith about that. We know that “word of mouth” is the main way Dorothy P. Fleury Debra A. Kurth Gail R. tint we get new members and through those members who Judy B. Gavin Sharon L. Lanzetta John S. Trowbridge recruited one or more colleagues through this campaign, we Andrew J. Gillihan Noris E. Larkin Mirian Vaxquez will continue to grow larger and stronger each year. Celeste M. Maureen A. Cindi L. Willis Since there was a three-way tie for the top prize for Gospodaric- Molyneaux David C. this campaign, with three members recruiting six new Gillespie Paula M. Peters Zimmerman members, a drawing was held to determine one winner. Susan B. Guetzlaff Kay E. Powell The first prize winner was Cynthia A. Wilson from Palmetto Health Richland Hospital of Columbia, SC. Cynthia wins complimentary registration to the 2006 Annual Conference There are 560 certified in Atlanta, air fare, and three nights’ accommodation. The members who tied with Cynthia were Janet Moye and ambulatory nurses as of 12/31/05! Carol Rutenberg, who also recruited six new members. 2006 Exam Dates: May 20, October 14 AAACN certificates worth $100 will be sent to everyone For registration information, contact ANCC: who recruited three or more members. Ph: 800-284-2378 • Web: www.nursecredentialing.org Audio Seminar CD-ROMs Available Did you miss one of our recent LIVE Audio Seminars AAACN Resources Available on “The Emerging Role of Disease Management in Ambulatory Care” or “Review of Current Litigation Relative AAACN has several resources to assist you in preparing to the Practice of Telephone Nursing: How to Anticipate for the ambulatory certification examination. Nurses use and Avoid the Mistakes that Result in Bad Outcomes?” If the Core Curriculum for Ambulatory Care Nursing, the you did, CD-ROMs of all the live seminars, including 15 Ambulatory Care Nursing Certification Review Course CEs and the handout materials, are available on the Syllabus, the Ambulatory Care Nursing Self-Assessment, and AAACN Web site in the “Store.” the live or recorded Ambulatory Care Certification Review Course to prepare for the exam. For more information on these products visit the “Store” on the AAACN Web site at Need a www.aaacn.org Viewpoint Article? The index of Viewpoint articles on the Web site has been recently updat- Looking for Nurses Week gifts? ed to show, by category, the articles See page 14! from the newsletter between 1998 and 2006. Click on Resources/ Viewpoint index to locate the list. Erratum In the November/December 2005 issue of Viewpoint, the article entitled “Complementary Alternative Medicine (CAM): Ethics, Theory and Practice: Part 1” was published in part with permission from HealthForumOnline. Copyright and the provision of contact hour credit is solely the property of HealthForumOnline. AAACN apologizes for the inac- Send Us Your Articles! curate statements regarding contact hour credit that appeared on pages 1 and 15. To purchase the entire article and obtain 3 hours of contact hour For more information or to request author credit, go to www.healthforumonline.com, “Complementary Alternative guidelines, contact: Medicine (CAM): Ethics, Theory and Practice,” and access the posttest to obtain your CE credits. AAACN will not publish Part II as previously indi- Carol Ford, Managing Editor, [email protected] cated. We apologize for any inconvenience to our readers.

6 VIEWPOINT JANUARY/FEBRUARY 2006 Two Members Appointed to President’s Message continued from page 2 JCAHO Committee abreast of what we do right and keeping aware of what Johnetta James, MSN, RN, Director, can be done better to successfully meet the needs of all Accreditation and Patient Safety at Duke members and ensure the continued success of AAACN. University Medical Center in Durham, In summary, the Board of Directors has multiple NC, was recently appointed as AAACN’s responsibilities that when met, fulfill the four obligations of representative on the JCAHO leadership. This development exercise assures us, as Board Ambulatory Care Professional and members, that we are on track as leaders by maintaining Technical Advisory Committee (PTAC). an ongoing exchange of information and an understand- Maureen T. Power, RN, MPH, LNC, was ing of the nature of volunteerism. If you have volunteered appointed as the alternate on this com- this year, you will receive a call from a Board member. It is Johnetta James mittee. Maureen will serve as the acting imperative that you, as volunteers and our members, pro- representative following Johnetta’s two- vide the Board with feedback, opinions, and suggestions. year term. PTAC committees represent This information is crucial for our success now and in the the views of a diverse group of profes- future. sional organizations and other interests, References as well as provide expert advice. PTAC Nowicki, C.R. (1998). Mentoring the stars: A mentorship program for members assist the Joint Commission in new board members. Pitman, NJ: Anthony J. Jannetti, Inc. Tecker Consultants. (2005). American Society of Association the development and refinement of Executives 2005 Symposium for Chief Executive Officers and standards, elements of performance, Chief Elected Officers. and survey processes. They also provide Regina C. Phillips, MSN, RN, is AAACN President and Delegation Maureen T. Power observations regarding environmental trends, educational needs, and other Compliance Process Manager, Humana, Inc., Chicago, IL. She can important issues facing each of the fields in which JCAHO be reached at [email protected] offers accreditation services. Congratulations Johnetta and Maureen!

P&H is a win-win for you and your patients.

Lower your readmission rates and improve your CHF patients’ lifestyle by educating them on man- agement at home. As an affiliate of the AAACN, Pritchett and Hull Associates, Inc. offers a variety of easy-to-read, well-illustrated materials designed to reinforce your professional advice. The products hi- light the Dos and Don’ts of CHF management, such as taking medicine, dieting (monitoring sodium and fluid intake), keeping track of body weight, getting proper rest, exercising and identifying when symp- toms are severe. Most of these materials are offered in Spanish, and all materials can be cus- tomized to help promote your facility. Each product can be incorporated into your existing CHF pro- gram easily. Pritchett and Hull offers a royalty to AAACN for orders placed via the AAACN Web site. Patient education focused Be sure to go to www.aaacn.org (click on STORE) Pritchett & Hull on outcomes since 1973 to see how both you and your patients benefit from Go to www.aaacn.org/store to link to the P&H site or call 1-800-241-4925 and identify Pritchett and Hull. yourself as an AAACN member when you order.

WWW.AAACN.ORG 7 Carol J. Weber, PhD, RN outbreaks in poultry in Asia have been ongoing. In 2005, the H5N1 virus was found in birds in Russia, Kazakhstan, Turkey, In August 2005, the World Health Organization (WHO) and Romania (WHO, 2005a). Other reported outbreaks in wild sent a document to all countries outlining recommended and domestic birds are also being investigated. response strategies to the possibility of an avian influenza “pandemic” (WHO, 2005a). Of concern is a bird flu virus Risks to Human Health called Influenza A (H5N1) virus. Bird flu viruses occur mainly The continued outbreaks of H5N1 virus in poultry popu- in birds, and do not usually infect humans. But the H5N1 lations pose two main risks for humans (WHO, 2005a). The virus has crossed the species barrier, and has the potential to first is the risk of direct infection when the virus crosses the become pandemic — a worldwide influenza outbreak. species barrier to infect humans. Whereas normal seasonal H5N1 virus, like other bird flu viruses, occurs naturally influenza causes only mild respiratory symptoms in most peo- among wild birds. Infected birds carry the flu virus in their ple, H5N1 infection causes rapid deterioration and high fatali- intestines and shed them in their saliva, nasal secretions, and ty commonly due to viral pneumonia and multi-organ failure. feces (Centers for Disease Control [CDC], 2005a). Other birds The second risk is that the virus will change into a form become infected when they have contact with contaminated that spreads easily from person to person. So far, the spread excretions. Bird flu viruses are very contagious among birds of H5N1 virus from person to person has been rare. But all and circulate among wild birds worldwide. Wild birds do not influenza viruses have the ability to change, and the possibility usually get sick from the viruses, but when they spread the exists that the H5N1 virus could change to one that can viruses to domesticated birds such as chickens, ducks, and spread easily from one person to another. For this reason sci- turkeys, they can be deadly. entists and others are watching the H5N1 situation in Asia The first case of human infection from H5N1 virus was very closely. reported in 1997, during an outbreak of bird flu in poultry in Hong Kong (CDC, 2005a). The virus caused severe respiratory Seriousness of a Pandemic Threat illness in 18 people, 6 of whom died. Most recently, human The risk of pandemic influenza is serious (WHO, 2005a). cases of H5N1 infection have occurred in Thailand, Vietnam, As poultry outbreaks continue, the risk that more people will Cambodia, Indonesia, and China. According to WHO be infected increases. Each additional human case gives the (2005b), of the 133 people in the five countries who have virus the opportunity to adapt and mutate, and develop into been infected with H5N1 from late 2003 through 2005, 68 a strain that spreads easily among humans. Since human-to- have died. Most of these cases occurred from contact with human transmission will most likely occur by coughing or infected poultry or surfaces contaminated with poultry feces sneezing, it is expected that the virus will spread rapidly and and secretions. But there is some thought that a few cases infect virtually all countries. Air travel will promote the spread, may have occurred from human-to-human spread of H5N1 especially since infected travelers can be asymptomatic but (CDC, 2005a). So far, the spread has not progressed beyond still contagious. Once international spread begins,0 experts one person, but scientists are concerned that if the H5N1 consider a pandemic unstoppable. virus were able to infect humans and spread easily from per- No one knows if the pandemic can be prevented. The best son to person, an influenza pandemic could begin. approach would be to eliminate the virus from birds, but The current outbreaks of influenza H5N1 in poultry began experts are doubtful that this can be achieved within the near in mid-2003 in eight countries in Asia: Cambodia, China, future (WHO, 2005a). An influenza vaccine against the H5N1 Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam virus would protect people, but there is no vaccine currently (CDC, 2005a). During that time, more than 100 million birds available. Vaccine development efforts are under way, but large- either died from the infection or were killed in an attempt to scale production of vaccine cannot occur until the new virus control the outbreak. The outbreak was considered under con- strain has emerged and the pandemic begun. Since the vaccine trol by March 2004. However, in June 2004, new outbreaks of must closely match the pandemic virus, the new vaccine can- influenza H5N1 among poultry were reported in Asia, some not be developed until the virus strain has been identified. This recurring (Cambodia, China, Indonesia, Thailand, and means that a vaccine will not be widely available until several Vietnam), and one for the first-time (Malaysia). Since then, the months after a pandemic has been declared. Even then, experts predict that global production of vaccine will not be able to Reprinted from Urologic Nursing, Volume 26, Number 1, pp. 67-68. keep up with expected demand (WHO, 2005a). Reprinted with permission of the publisher, the Society of Urologic WHO is urging countries to develop preparedness plans Nurses and Associates, Inc. (SUNA), East Holly Avenue, Box 56, and to stockpile antiviral drugs for use at the start of a pan- Pitman, NJ 08071-0056; (856)256-2300; FAX (856)589-7463; demic. WHO (2005a) experts believe that antiviral drugs Email: [email protected]; Web site: www.suna.org

8 VIEWPOINT JANUARY/FEBRUARY 2006 “could be used prophylactically near the start of a pandemic to reduce the risk that a fully transmissible virus will emerge or at least to delay its international spread, thus gaining time to augment vaccine supplies” (p. 6). While four antiviral drugs are on the market, and around 30 countries have purchased In the job market, large quantities of antiviral drugs, the manufacturers cannot fill these orders immediately. As for the remaining countries, many do not have the resources to either prepare for a pan- instant access demic or to purchase a stockpile of antiviral drugs. Impact in the U.S. is what you want. In May 2005, a multi-agency National Influenza Pandemic Preparedness and Response Task Group was created by the U.S. Secretary of Health and Human Services to plan for a potential pandemic (CDC, 2005b). The plan was Find it at the released in November 2005 (U.S. Department of Health & Human Services [DHHS], 2005a) and includes four major components: AAACN 1. Intensify surveillance and containment measures, both domestic and international. 2. Stockpile vaccines and antiviral medications, and work with industry to expand production capacity. 3. Create a seamless network of federal, state, and local pre- paredness. www.aaacn.org 4. Develop the education and communication to keep the public informed. The plan calls for purchasing enough H5N1 influenza vac- Candidates cine for 20 million people and enough influenza antiviral drugs for another 20 million people (DHHS, 2005b). To speed • Find your dream job. View the process of developing vaccines, research and develop- hundreds of local, regional, ment cooperating agreements have been signed by public and national job listings. and private agencies to produce and test multiple vaccines against H5N1 and other potential pandemic flu strains • Post your resume and let (DHHS, 2005c). employers find you. It will be difficult to prepare for a pandemic. While experts cannot predict the severity of the next pandemic, they predict • Respond on-line to career that 15% to 35% of the U.S. population could be affected opportunities. (CDC, 2005b). In the absence of vaccination or drugs, it is esti- mated that in the United States, “a ‘medium-level’ pandemic • Receive e-mail notifications of could cause 89,000 to 207,000 deaths, 314,000 and 734,000 new job postings. hospitalizations, 18 to 42 million outpatient visits, and another 20 to 47 million people being sick” (CDC, 2005b, p. 3). Large numbers of people seeking medical treatment will overwhelm health services, and the numbers of health care workers avail- able to work will be reduced. Other essential personnel such as Employers law enforcement, transportation, and communications will also be affected (CDC, 2005b; WHO, 2005a). Compared to other • Post your job opportunity on-line. public health emergencies, a pandemic will last much longer • Gain access to a resume data- because a second wave of global spread can be expected with- in 3 to 12 months after the first wave. base of the nation’s best nurses. • Resume Alert: Notifies you of a Summary new resume posting. So far, the current risk to people in the United States from the H5N1 bird flu outbreak in Asia is low (CDC, 2005a). The • Job Alert: Tells candidates about strain of H5N1 virus found in Asia has not been found in the your employment opportunities. United States; and as of November 2005, there have been no human cases of H5N1 flu reported in the United States. Travel to countries in Asia has not been restricted, but travelers are advised to avoid all direct contact with poultry, poultry farms, The AAACN Career Center is a member of the HEALTHeCAREERS™ Network, animals in live food markets, and any surfaces that appear to a nationwide on-line recruiting network of professional health care associations. be contaminated with feces from poultry or other animals For more information, visit our Web site at www.aaacn.org and click (CDC, 2005a). Meanwhile, medical and public health person- “jobs,” or contact the Customer Care Center at 888-884-8242. You may also send an e-mail to [email protected]. continued on page 12

WWW.AAACN.ORG 9 Safe Environments ing person). Assuming you could do this, where would you continued from page 1 go to get assistance in managing this situation? Who where an employee performs work-related duty. would assist you? How? If you were not able to get past Violence includes threat, which is a verbal or behav- the student to leave your office, how would you call for ioral expression of intent to inflict pain, injury, or other assistance? What would you say? What would they do to harm, and assault, which is any physical contact that assist? These questions guide the development of a com- results in injury whether minor (such as scratches or mild munication plan that should be incorporated in the orien- soreness) or major bodily harm. A weapon is any inanimate tation and training of faculty and staff. Since this behavior object that is used in a threatening manner or to inflict clearly violated the workplace violence policy, other policies harm. Violence includes threats to harm self or self-injuri- would guide how the person’s behavior would be ous behaviors. addressed systemically in follow-up after the immediacy of Violence is a complex phenomenon involving intra- the situation is addressed. personal, interpersonal, and environmental factors in Frameworks for Training dynamic relationship to one another. Workplace strategies to promote prevention must address each of these realms Education and training regarding intra and interper- in policies, procedures, environmental changes, education sonal dynamics related to aggression are also critical com- and training, clarification of roles and expectations, and ponents of a safe environment. The Cycle of Aggression ongoing evaluation of outcomes. and the Self Awareness Model are two frameworks that can Workplace settings need to have policies that include a be used to assist in training. strong commitment to the promotion and maintenance of The Cycle of Aggression. The Cycle of Aggression a safe work environment and a clear definition of what describes the stages of escalation in someone predisposed constitutes violence. The policy must be well-disseminated to the use of aggression to get needs met. The Cycle is and guide daily practice. An example of such a policy presented as the face of a clock. It begins at 12:00, with would be: “It is the policy of this institution to provide a precipitants that generate stress and/or a sense of loss safe and violence-free environment for faculty, employees, including unmet needs or expectations. An initial sense of students, and visitors. Acts or threats of violence against frustration can quickly escalate to generalized anxiety and faculty, employees, students, or visitors are serious offenses feelings of powerless and hopelessness (3:00 on the clock); that will not be tolerated. A threat is an expression of this feeds the intensity of the anxiety. This level of anxiety intent to inflict pain, injury, or other harm. The expression can be quickly converted to anger (6:00) because a sense may be verbal or non-verbal. The threat of harm may be of powerlessness and hopelessness is such an aversive feel- explicit or implied….” Human Resource policies should ing and the body is already mobilized to ‘fight the enemy.’ address a process for addressing violent behavior and con- Threatening/assault behaviors are used (6:00-9:00) to dis- sequences. Examples of other policies and procedures that charge this anger and regain a sense of power and control are important to have and to know include indications for by someone who has previously experienced this as a suc- involvement of security/police and how to obtain their cessful strategy or who has no experience with other meth- assistance, how after-hours entry is managed, and how ods of coping. A sense of relief and a decrease in anxiety is weapons are defined, prohibited, and managed if found. experienced (9:00-12:00) that reinforces this behavior. It is important to conduct an environmental assess- Recognize the risk factors for someone who may be ment and identify opportunities to minimize risk. Offices predisposed to the use of aggression. These include failure should be set up to minimize the potential for someone to to respond to constructive advice; blaming others for be trapped without access to help. For example, there errors, mistakes, or problems; communicating unrealistic should be a clear path to the door and a readily accessible demands; difficulty relating to others; decreased productiv- phone. Offices where employees interact with others ity; concentration problems; or appearing to be under the around sensitive issues (such as finances) should not be in influence of drugs or alcohol. When risk factors are identi- isolated areas. Escape/evacuation routes should be clearly fied, it is important to communicate concerns to others defined from each office or other workplace environment. and to develop a plan for addressing them that promotes Communication plans for situations that pose immi- consistency of response and is focused on ameliorating the nent danger should be explicit. This communication plan risk. A consistent, early response by all team members would include who would be called, what would be said to requires that the team communicates effectively and is convey the immediacy of the situation, and what would be committed to prevention and early intervention in a the expected response. For example, suppose you are health-promoting manner. meeting with someone who has been noted recently to be The Self-Awareness Model. The Self-Awareness Model intermittently agitated and anxious. The person becomes describes intrapersonal processes that can impact our abili- increasingly agitated during your meeting and begins to ty to respond effectively in threatening situations. It assists make threatening gestures towards you. Attempts to calm in recognizing a predisposition to react to specific or gen- the person only seem to escalate the behavior. Attempts to eralized stressors that elicit anxiety. Direct verbal or physical end the session go nowhere as the person refuses to leave. threats are an example of such stressors. Other stressors Ideally, your office is arranged so that you can back out of include perceived violation of rights, values, authority, or the room to elicit help (never turn your back on an escalat- self-esteem. The initial reaction is stress, which is actually a

10 VIEWPOINT JANUARY/FEBRUARY 2006 mobilization of internal resources to protect and defend who is tense and angry, the person confronted will be from perceived imminent threat. Physiological mechanisms immediately predisposed to becoming tense. Facial expres- are activated by the adrenal system to prepare the body to sions and tone of speech can be mirrored, contributing to ‘fight or flee.’ Heart rate and blood pressure increase to an escalation of the situation. Recognizing this, assuming a oxygenate the muscles. Gastric mobility is inhibited non-threatening but centered stance and making an effort because of diversion of blood to the extremities. Saliva to maintain a calm, responsive expression and tone of thickens to prevent aspiration when ‘fighting or fleeing.’ voice can be helpful in diffusing the situation. The body is now physically prepared to protect itself from Psychological time vs. real time is a concept used to the ‘enemy.’ assist in resisting the urge to react precipitously when it Cognitive functions are focused on ‘identifying the feels like there is ‘no time to think.’ Cognitive and emo- enemy.’ This focus precipitates a ‘tunnel vision’ effect due tional functions are hampered in stressful situations, and it to a heightened sense of vigilance. This is because the requires a conscious effort to take a moment to clearly brain is receiving signals that danger lurks, and it becomes assess the situation and de-personalize it. Taking that hard to think of anything else. There’s a decreased sense of moment, and if possible, taking the time to check in with self-awareness, and thoughtful decision-making is impaired others for assistance in assessing the situation and develop- by the perceived immediacy of the situation. There’s an ing a response plan will provide the potential for a better increased predisposition towards framing the situation into outcome. ‘me against them’ or ‘me against her.’ This experience By integrating the knowledge from the two frame- takes a toll emotionally because unresolved anxiety and works, effective intervention plans can be developed and stress can contribute to the development of non-specific implemented. The Cycle of Aggression assists in determin- fear and anger, or depression and isolation. ing appropriate sets of intervention for different stages of escalation. Noon-to-3:00 interventions are focused on pre- Fight or Flight vention. The first is to ensure the creation and support of These physiological, cognitive, and emotional reactions an environment that values and integrates the concepts of to the precipitants propel behavioral reactions that Selye mutual respect, shared ownership of space and responsibil- (1976) identified as Fight or Flight reactions. Which set of ity, and multicultural awareness. Listening to understand, behavioral reactions is operationalized depends on person- empathy, allowing the person to put ‘feelings into words,’ ality, previous experience, and nature of the precipitant. and assisting a person to define the stressor and develop a Fight reactions include behaviors that are defensive, con- set of options are generally effective interventions in frontational, provocative, or hostile. Fight reactors may be responding to someone who is expressing frustration and rigid and controlling in dealing with the person or persons anxiety. These interventions assist the person to develop whose behaviors precipitated the initial stress. Flight reac- the capacity to communicate productively when feeling tions include denial, avoidance, withdrawal, and abandon- anxious and develop action plans for addressing the source ment. Flight reactors may have a tendency to appease or of stress. These empowering interventions short-circuit the to dismiss the seriousness of the situation. These normal powerlessness and hopelessness that feed aggression. behavioral reactions that result from physiological activa- Interacting with someone in the 3:00 to 6:00 stage, tion are generally non-productive in addressing the initial when feelings of powerless and hopelessness have con- precipitants. These individualized reactions become tributed to increased agitation, requires a different set of counter-productive in situations where a consistent interventions. Recall that the tendency at this stage is to response from a team is required. project blame to cope with feelings of hopelessness and The first step in developing the capacity for thoughtful, powerlessness. Don’t personalize. Get centered and attend productive response to threatening situations is identifying to body language and tone of voice; set the expectation and understanding the triggers that precipitate personal that the person will become less anxious and more reaction and what that reaction tends to be. Getting cen- engaged in productive discussion. Listen to understand. Be tered, tense/relax, and psychological time vs. real time are aware of your predisposition to react (become defensive concepts used to assist the body and mind to be more and rigid, or avoid and withdraw). Provide options to resilient and less reactive in stressful situations. decrease sense of powerless and hopelessness. Be sure Getting centered. Body language communicates a more options are realistic and appropriate and not attempts to powerful message than words. A basic stance can be appease (for example, offer to have the person meet with assumed in a stressful situation that is used to assist the someone else who can assist them to productively address body to feel more centered. The stance consists of putting the problem). Be aware of surroundings and the potential the feet slightly apart, knees slightly flexed, and arms to elicit help if interventions are not successful. loosely at your sides with hands open. Compare the stabili- Interventions at the 6:00 to 9:00 stage, when someone ty and sense of internal control when this stance is is verbally and physically threatening, are focused on main- assumed to one where feet are close together, with knees taining safety. Increase personal space; call for help rigid and arms crossed or hands on hips. Compare the (remember communication plan); stay centered and message conveyed by each. focused; be alert to potential weapons in the environment Tense/relax is based on the knowledge that tension (such as scissors on the desk); set limits in a calm, directive essentially is contagious. When confronted by someone manner (for example, “please lower your voice, we want

WWW.AAACN.ORG 11 to be of help;” “I can’t help you when you are behaving T SP GH OT LI L this way. Please stop threatening.”); ensure an escape T IG O H route; don’t turn your back. P T S

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tance to do so in such situations, but the lack of such con- • sequences contributes to the cycle. Other interventions at this stage are focused on the faculty and staff. Ensure an opportunity for debriefing. and supportive interventions. Focus on self-care activities. Do not engage in self-blame or blaming of others. Instead, objectively review the situation from all perspectives to identify opportunities to prevent or 7000 Independence Pkwy intervene earlier in the future. Suite 160-136 Carole Farley-Toombs, MS, RN, CNS, is the Associate Director for Plano, TX 75025 Clinical Operations and the Clinical Chief of Psychiatric Mental 214-663-9447 • 888-567-6820 Health Nursing, Strong Behavioral Health, University of Rochester Contact Kids First Triage at [email protected] for more information. Medical Center, Rochester, NY. Reference Selye, H. (1976). The stress of life (rev. ed.). New York: McGraw-Hill.

Objectives LVM Systems, Inc. This educational activity is designed for nurses and other health 1818 East Southern Avenue professionals to increase awareness of responses to violence in Suite 15A, Mesa, AZ 85204 the workplace. For those wishing to obtain CE credit, an evalua- (480) 633-8200 • www.lvmsystems.com tion form is available on the AAACN Web site. After studying the information presented in this activity, you will be able to: For more information about LVM Systems and its products, call 1. Summarize the necessary items to be included in policies 480-633-8200, ext. 232, e-mail [email protected], or visit related to violence in the workplace. the LVM Web site at www. lvmsystems.com 2. Outline two frameworks to use for training employees about violence in the workplace. 3. Relate reactions to violence to the interventions that can be Avian Flu Pandemic used as a response. continued from page 9 nel are watching closely and preparedness plans are under way to respond to the threat of an avian influenza pandemic. This article, co-provided by AAACN and Anthony J. Jannetti, Inc., provides 1.0 contact hour. Anthony J. Jannetti, Inc. (AJJ) is accredit- Carol J. Weber, PhD, RN, is a Professor, Regis University, ed as a provider of continuing nursing education by the American Department of Nursing, Denver, CO. Nurses Credentialing Center’s Commission on Accreditation (ANCC- COA). AAACN is a provider approved by the California Board of Resources Registered Nursing Provider Number CEP 5336, for 1.0 contact hour. Centers for Disease Control. (2005a). Key facts about avian influenza Licensees in the state of CA must retain this certificate for four years (bird flu) and avian influenza A (H5N1) virus. Retrieved November after the CE activity is completed. 15, 2005, from http://www.cdc.gov/flu/avian/gen-info/facts.htm This article was reviewed and formatted for contact hour credit by Centers for Disease Control. (2005b). Information about influenza pandemics. Sally S. Russell, MN, CMSRN, AAACN Education Director, and Retrieved November 3, 2005, from http://www.cdc.gov/flu/pandemic/ Rebecca Linn Pyle, MS, RN, Editor. U.S. Department of Health & Human Services. (2005a). HHS releases pan- demic influenza plan: Plan provides guidance to prepare nations’ health care system for a pandemic. Retrieved November 3, 2005, from http://www.hhs.gov/news/press/2005pres/20051102.html U.S. Department of Health & Human Services. (2005b). HHS buys Erratum In the “AAACN Members Venture to China: People to additional vaccine as preparations for potential influenza pan- demic continue. Retrieved November 3, 2005, from People Ambassador Program for Ambulatory Care Nursing http://www.hhs.gov/news/press/2005pres/20051027.html Delegation a Success” (Viewpoint, November/December 2005, p. 3), U.S. Department of Health & Human Services. (2005c). NIAID and the group photo of the nurses we labeled incorrectly. The Chinese MedImmune join forces to develop potential pandemic influenza nurses in the photo are from the Shanxi Gaoxin Hospital in Xi’an. vaccines. Retrieved November 3, 2005, from http://www.hhs.gov/news/press/2005pres/20050928.html World Health Organization. (2005a). Avian influenza frequently asked ques- tions. Retrieved November 3, 2005, from http://www.who.int/csr/dis- ease/avian_influenza/avian_faqs/en/index.html World Health Organization. (2005b). Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO. Retrieved November 29, 2005, from http://www.who.int/csr/dis- ease/avian_influenza/country/cases_table_2005_11_29/en/index. html

12 VIEWPOINT JANUARY/FEBRUARY 2006 Order your Nurses Week Gifts Early AAACN’s line of “Ambulatory Nurses are Everywhere Caring for You” products can help you recognize your colleagues during Nurses Week, May 6-12, 2006. New this year is our travel mug with Stainless Steel interior. Order your items early – there is a limited supply of each product.

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ONLINE at: MAIL with payment to: 3 Easy Ways www.aaacn.org American Academy of Ambulatory Care Nursing to order East Holly Avenue/Box 56 FAX with credit card Pitman, NJ 08071-0056 from AAACN information to: 856-218-0557

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Shipping ■ home Subtotal Name ______Address ■______work Facility Name Shipping Total ______GRAND TOTAL City ______State ______Zip ______TAX ID: 51-023 1130 ■ home DUNs: 209739138 ■ Preferred Phone ______work Order Total UPS Ground UPS 2nd Day Air E-mail address ______Up to $24 $4 $12 Method of Payment: ❏ Check ❏ Cash ❏ Credit Card $25 - $49 $6 $14 $50 - $99 $9 $16 __ American Express __ Mastercard __ Visa Exp. Date ______$100 - $149 $11 $19 A credit $150 - $199 $15 $24 Account # ______- ______- ______- ______coupon will $200 - $299 $20 $27 be issued for $300 - $500 $23 $30 Name on card______overpayments Canadian orders under $15 ■ Add 25%of subtotal for UPS Standard Signature ______■ Add 25%of subtotal for Airmail Parcel Post International Orders, except Canada Credit card billing address if different from shipping address ______■ P06VPNW Add 25% of subtotal for Airmail Parcel Post ______SuccessThe Nurse Response Team: Success AA SuccessSuccess StoryStorySuccess

Shirley E. Gay, Anne Hansen Helen Hunter, Carolyne Sauvé Introduction The Ottawa Hospital (TOH), one of the largest health sciences centers in Canada, is a conglomeration of six pre-existing sites, affiliates, and campuses. The Ottawa Civic Hospital, Ottawa General Hospital, The Riverside Hospital, the Rehabilitation Center, the Ottawa Regional Cancer Center, and the University of Ottawa Heart Institute came together between 1998 and 2005 in response to the strong recommendation from the Ontario Provincial government as a means of improving efficiencies and maintaining funding. While maintaining the Civic and General Campuses as terti- ary care facilities, the Riverside Campus was converted Members of the Nurse Response Team at the Ottawa Hospital, Ontario, Canada. Pictured here (L-R): Debbie Wetzstein, RN; Judy Downing, RN; Pierrette Gore, RN; Anne into an Ambulatory Care Center. Lily, RN; and linda Fitzpatrick, RN. Formerly a community hospital, the Riverside Hospital was transformed into an Ambulatory Care Center that accommodates seven floors of outpatient clinics including a 30-station, state-of-the-art hemodialysis unit, a iotherapy) on the former emergency services. The support community ophthalmology program with four operating departments also began using Code Blue as a method of theaters, and a surgical program with day-surgery facilities accessing emergency assistance. It quickly became evident and six operating theaters. The volume of patients seen at that an alternate level of emergency response was the center exceeds 200,000 visits annually. required. Background Response As a community hospital, the Riverside Hospital had A work group comprised of clinical nurse managers, provided full emergency services to the surrounding area. nurse educators, and clinical directors of the various units With the merger and conversion to an ambulatory care and programs across the campus was formed. The first pri- ority was to review the literature and search the Internet facility, the emergency services were moved out of the for similar health care facilities and situations in Canada. campus to the other two tertiary care facilities – the Civic The search did not reveal any stand-alone ambulatory care and General Campuses. The move, while a viable solution, facilities with similar relationships to large tertiary centers. presented clinical challenges to the delivery of care. One The work group, with further brainstorming, created The such challenge was the ability to respond to medical Nurse Response Team. The team’s purpose was to address emergencies in a newly created stand-alone ambulatory urgent care required in non-clinical areas only (such as care center. waiting rooms, cafeteria, laboratory facilities, and diagnos- Despite a comprehensive media blitz to redirect emer- tic imaging) because pre-existing protocols were already in gency care to the tertiary campuses, patients in the com- place to respond to cardiac arrest and medical emergen- munity continued to arrive at the center seeking emer- cies in clinical areas. The members of the team included gency medical attention. The volunteer staff of the registered nurses representing the various specialty clinics throughout the campus. Consideration was given to hours Information Center at the main entrance became an infor- of work, staff resources, and patient acuity. mal triage service. With no other options available to them Implementation plans included consultation with the to address clients’ requests for emergency service needs, College of Nurses of Ontario to ensure that standards and Code Blue was called for any patient or visitor in physical expectations of care were being met, the Nursing distress, regardless of the severity of their condition. In a Professional Practice Department of the organization to two-week period, a Code Blue was called seven times to ensure compliance with the Model of Clinical Nursing assist patients who were not having a cardiac arrest. The Practice, and the Hospital Legal Department to ensure lia- problem was compounded by the dependence of support bility concerns were addressed. The team developed poli- departments (such as laboratory, patient registration, phys- cies and protocols in consultation with the corporate car-

14 VIEWPOINT JANUARY/FEBRUARY 2006 diac arrest committee that governs corporate emergency response, the regional paramedic and ambulance services, Case Study and the Department of Anesthesia. A documentation record was drafted. Information sessions were held to dis- A 54-year old male walks through the front door of the seminate the information to all clinic personnel and sup- Riverside Ambulatory Care Center looking for the port departments on campus. Emergency Department. He has chest pain radiating When called to the scene, the team assesses the level of into his jaw, and is pale and diaphoretic. He is informed intervention required and determines the need to call there is no ER here, but to have a seat and someone will “911.” A crash cart is always brought to the Nurse come and help him. Overhead a call goes out, “Nurse Response Call to facilitate any deterioration in the condition Response Team front lobby, Nurse Response Team front of the client and to provide the nursing team with the per- lobby.” Four registered nurses respond and arrive with sonal protective equipment (PPE) if the client has a febrile all the tools to perform an assessment. Within 10 min- respiratory condition. The protocol includes the application utes, he is on an ambulance stretcher en route to an of an automated external defibrillator (AED) when required. emergency department at one of the Ottawa Hospital’s Each event is recorded and kept on file at the campus. two in-patient sites. Anesthesia is only called if deterioration in the client’s condi- tion warrants a change in response to Code Blue. Evaluation of the Initiative Since its inception in January 2002, the Nurse Response Team has been called more than 200 times. Fifty percent of the calls have required ambulance assistance, one-third of the calls have been cardiac in nature, and the What Next? remainder have been, for the most part, minor conditions. The merger plans for the Ambulatory Care Center are Presently, there is ongoing evaluation with quarterly now complete, and it is hoped that staff from the recently meetings being held by a newly formed team council and completed programs will be involved in the Nurse a team-member survey has been distributed. Education Response Team. Plans are being made to initiate a rotation sessions with mock codes and hypothetical case scenarios that will allow for the development of new team members, are held bi-monthly. Even though many of the calls contin- and at the same time, provide respite for the senior mem- ue to be for clients seeking medical attention at an emer- bers of the team. gency department, revisions to the documentation record In addition, the completion of the merger has had an will now include an area to indicate whether the response impact on the hours of operation of the campus. A num- call is for a visitor, campus patient, or someone seeking ber of the clinics are now open into the evening hours, assistance at an emergency department to formally capture and as a result, there is an increase of traffic on the campus these statistics. These statistics and a closer look at the during this time. The same situations that resulted in the client base will then guide the formulation of strategies to formation of the Nurse Response Team are now beginning properly communicate with the public. to occur later in the day. An important step in maintaining the objective of the Outcomes Nurse Response Team is the relationship with the Regional The outcomes for the Ottawa Hospital have been posi- Ambulance and Paramedic Service. To ensure the relation- tive. In addition to meeting the public’s need of receiving ship continues to be a positive one, regular communication an appropriate response to urgent medical needs, with the service is imperative. We are presently in the non-clinical departments on the campus are supported in process of planning annual roundtables to discuss and the event of an urgent medical need in their area. In addi- address the various concerns. Future plans will also include tion, the all-nurse team has raised the profile of nursing an evaluation process of the initiative and will aid in the practice at TOH within the community and has assured development of recommendations for transferability to clients both internally and externally that the assistance of other ambulatory care settings. a team of experienced health care professionals will be Shirley E. Gay, BScN, RN, is the Clinical Director of Ambulatory available to assist with their medical emergencies. Care, Eye Care, and Mental Health, the Ottawa Hospital, Ontario, The Nurse Response Team has aided in ensuring that Canada. She may be contacted via e-mail at sgay@ottawahospi- community and hospital emergency resources are appro- tal.on.ca priately and efficiently utilized. The regional ambulance teams or the campus cardiac arrest team are no longer Anne Hansen, BScN, RN, is a Clinical Educator of Ambulatory Care, the Ottawa Hospital, Ontario, Canada. called needlessly. Clients not requiring ambulance and paramedic services are redirected to the appropriate health Helen Hunter, BScN, RN, is a Clinical Educator of Ambulatory care facility, walk-in clinics, family practice physicians, or Care, the Ottawa Hospital, Ontario, Canada. emergency departments. The Communication Center vol- Carolyn Sauvé, BScN, RN, is the Clinical Manager of unteer staff is reassured that by initiating the Nurse Ambulatory Care, the Ottawa Hospital, Ontario, Canada. Response Team, immediate assistance is available.

WWW.AAACN.ORG 15 American Academy of Ambulatory Care Nursing Presorted Standard Real Nurses. Real Issues. Real Solutions. U.S. Postage PAID Volume 28 Number 1 Bellmawr, NJ Permit #58

Viewpoint is published by the American Academy of Ambulatory Care Nursing (AAACN) AAACN Board of Directors President Regina C. Phillips, MSN, RN Process Manager Humana, Inc. 2627 E. 74th Place Chicago, IL 60649 773-375-6793 (h) 312-627-8748 (w) [email protected]

President-Elect Beth Ann Swan, PhD, CRNP, FAAN Associate Professor Thomas Jefferson University Jefferson College of Health Professions Department of Nursing 130 South 9th Street, Suite 1230A Philadelphia, PA 19107-5233 215-503-8057 (w) [email protected]

Immediate Past President Kathleen P. Krone, MS, RN 5784 E. Silo Ridge Drive Ann Arbor, MI 48108 734-662-9296 (h) [email protected]

Secretary CAPT Sara Marks, NC, USN AAACN is the association of professional nurses and associates who identify ambulatory care practice as 831 I Avenue essential to the continuum of accessible, high quality, and cost-effective health care. Its mission is to advance the Coronado, CA 92118 619-524-0089 (w) art and science of ambulatory care nursing. [email protected]

Treasurer Charlene Williams, MBA, BSN, RN, BC Manager, Cleveland Clinic Nurse on Call Cleveland Clinic AAACN Election Results Announced 2972 Somerton Road Cleveland Heights, OH 44118 216-738-4888 (w) AAACN would like to congratulate these members on their election 216-321-0714 (h) [email protected] to the AAACN Board of Directors and Nominating Committee. Directors Carole A. Becker, MS, RN 602-604-1243 (w) [email protected]

Karen Griffin, MSN, RN, CNAA 210-617-5300 x4152 (w) [email protected]

Kitty Shulman, MSN, RN, C 208-381-7010 (w) [email protected]

AAACN Viewpoint East Holly Avenue, Box 56 Pitman, NJ 08071-0056 (856) 256-2350 (800) AMB-NURS President-Elect Director Director Nominating (856) 589-7463 FAX [email protected] Charlene Williams, Belinda A. Doherty, Marianne Sherman, Committee www.aaacn.org BSN, MBA, RNC, BC Maj. USAF, NC, MBA, MS, RN,C Representative Rebecca Linn Pyle, MS, RN BSN, CPUR Ruth Ann Obregon, Editor Cynthia Nowicki Hnatiuk, EdD, RN, CAE MSN, MBA, RN Executive Director Sally S. Russell, MN, CMSRN Board members will assume their responsibilities at the close of the annual confer- Education Director Patricia Reichart ence in Atlanta. President-Elect Charlene Williams will begin orientation to serve as Association Services Manager Carol Ford President in 2007. Directors Belinda Doherty and Marianne Sherman will help to provide Managing Editor Bob Taylor leadership and strategic direction to the association, and Ruth Ann Obregon, as a new Layout Designer Tom Greene Nominating Committee representative, will begin immediately identifying active mem- Director of Marketing Regina Donohue bers with leadership potential to run for office in future elections. Membership Services Coordinator/ Registration Manager Robert McIlvaine Circulation Manager © Copyright 2006 by AAACN