Official Journalof the CanadianAssociation ofCritical CareNurses

Canadian Association of Critical Care Nurses

Index:Critical thinking ...........................................4Sucrose as analgesiafor neonates experiencing“mild” pain.................................................18Challenging restrictedvisiting policiesin critical care ............................................24

Summer 1999Volume Ten

Issue Two

CACCN 10-2 Summer 1999

CACCN IFCHewlett Packard

New four-colour film supplied

CACCN 10-2 Summer 1999 Page Three

The Official Journal of the

Canadian Associationof Critical Care NursesVolume Ten, Number Two, Summer 1999

The Official Journal of theCanadian Association ofCritical Care Nurses is arefereed journal published fourtimes annually by PappinCommunications, Pembroke,Ontario. Printed in Canada.ISSN 1201-2580. Copyright 1999by the Canadian Association ofCritical Care Nurses, P.O. Box 25322, London, Ontario, N6C 6B1.No part of this journal may bereproduced in any mannerwithout written permission from CACCN.The editors, association and thepublisher do not guarantee,warrant or endorse any productor service mentioned in thispublication.For information on advertising,contact C.B. Pappin,Pappin Communications,The Victoria Centre, 84 Isabella Street, Pembroke, Ontario, K8A 5S5,telephone (613) 735-0952, fax (613) 735-7983, e-mail pappin@webhart.net.Send manuscript enquiries orsubmissions to Paula Price,ACCN Program, Centre forHealth Studies, Mount RoyalCollege, 4825 Richard Rd. S.W.,Calgary, Alberta, T3E 6K6.

The Official Journal of theCanadian Association ofCritical Care Nurses is indexedin the Cumulative Index toNursing and Allied HealthLiterature and RNdex Top 100:Silver Platter.

1999 Subscription RatesThe Official Journal of the Canadian Association of Critical Care Nurses ispublished four times annually, Spring, Summer, Fall and Winter- Four Issues - $60 / Eight issues - $110 ( plus 7% GST). Payment should bemade by cheque, money order or by VISA only. International and institutionalsubscription rate is $75.00 per year or $150.00 for two years.

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) 240-6553,Fax: (403) 240-6555, e-mail: 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

Canadian Associationof Critical Care NursesBoard of DirectorsPresident:

Gwynne MacDonald, RN,MN, CNCC(C), London, ON

Vice-President:Rosella Jefferson, RN, BScN, MSN,

Vancouver, BCSecretary:

Valerie Banfield, RN, BScN, MN, CNCC(C), Halifax, NS

Treasurer:Petula Wong, RN, BScN, MEd,

Halifax, NSDirectors 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 OfficeP.O. Box 25322,London, Ontario,N6C 6B1Administrator:Heather Reid, ARCT, BA, MSchttp://www.execulink.com/~caccne-mail: caccn@execulink.comphone: (519) 649-5284fax: (519) 668-2499

The Official Journal of theCanadian Association ofCritical Care Nurses isprinted on recycled paper.

Article reprintsPhotocopies of articles appearing inthe Official Journal of the CanadianAssociation of Critical Care Nursesare available from the CACCNNational Office, P.O. Box 25322,London, Ontario, N6C 6B1, at a costof $5.00 per article. Back issues canbe purchased for $18.00.

CACCN 10-2 Summer 1999 CACCN 10-2 Summer 1999Page Four

CriticalThinking

Stinson (1986) made the followingremarks about the status of nursingresearch:

“What constitutes the “domain” ofnursing research is becoming lesscontentious within Canadian nurs-ing. But the nursing profession inCanada has for the most part as yetto convince related health profes-sionals, academics, research policymakers and the public at large thatnursing is a professional disciplinein its own right, with a researchfocus that is distinctive.”

Stinson (1986).

Initial attempts at nursing researchcan be traced back to Lower Canada twocenturies ago when Jeanne Mance andher fellow nurses attempted to improve

the care of the sick (Stinson, 1986). Itwas not until 1971 that nursing researchreally began to emerge. That year, morethan 375 nurses from across Canadagathered together in Ottawa at the firstnational nursing research conference.That event was the turning point fornursing research in Canada, the catalystfor propelling nursing research“irreversibly on its way” (Stinson, 1986).

Another major “turning point” fornursing research took place onFebruary 17, 1999:From Health Canada news release:Federal nursing research fund supportschanging health needs,February 17, 1999.

TORONTO - Health Minister AllanRock today announced that theGovernment of Canada’s 1999 budget

allocates $25 million to a new Canadiannursing research fund. The Nurse Fundwill finance research of critical issuesrelated to nursing and the delivery ofhealth care. “Nurses play a vital role in thehealth system, and the 1999 federalbudget recognizes the importance ofresearch to the nursing profession at atime when health care is undergoingfundamental change,” Mr. Rock stated toa gathering of nurses and other health careproviders at Toronto’s Princess MargaretHospital. “This $25 million Nurse Fundwill develop research capacity, andsupport training and information sharingabout solutions to the challenges facingnursing in the coming decade.”

In underscoring the importance ofnurses in the health system, MinisterRock stressed the need to involve nurses

The spiritof inquiry

WIN, WIN, WIN....Two years free CACCN membership

ORfree tuition to Dynamics 2000 in Halifax!

Our association’s journal, currently called theOfficial Journal of the Canadian Association ofCritical Care Nurses, or OJCACCN, desperatelyneeds a new name! All CACCN members areinvited to think of a creative and innovative title,and e-mail, fax or mail your written entry to:

CACCN - Journal contestP.O. Box 25322, London, Ontario, N6C 6B1

(519) 668-2499 (fax)caccn@execulink.com (e-mail)

DEADLINE FOR ENTRIES(received in national office) is August 1, 1999.

Note: The CACCN board of directors will be conductinga blind review of all entries and reserves the right todetermine if and how a new name will appear.

Good luck to all participants!

CACCN 10-2 Summer 1999 Page Five

in all aspects of health planning for the21st century. He also pointed out that therecent health care restructuring acrossCanada has significantly affected thenursing profession and createdchallenges related to training andretention of nurses, as well as toattracting new people to the profession.

The Nursing Research FundSources: Health Canada news release,Federal nursing research fund supportschanging health needs, February 17,1999; CHSRF Factsheet, The nursingresearch fund, February 16, 1999;Letter from the CHSRF, Open letter to allnursing researchers, March 30, 1999.With permission.

The Nursing Research Fund is a 10-year federally-funded initiativespecifically aimed at strengtheningCanada’s ability to undertake researchon nurs ing issues of : 1) pol icy;2) management; 3) human resources; and4) care.

The fund also supports thedissemination of knowledge aboutsolutions to the challenges facing nursingin the next decade.

Four priority programs will be

funded: 1) nursing research chairs;2) training; 3) research funding; and4) knowledge dissemination.

The fund will be administered by theCanadian Health Services ResearchFoundation (CHSRF) in consultationwith a broad-based advisory committeeoperating under the Canadian NursesAssociation (CNA). In addition, theCNA and the Canadian Association ofUniversity Schools of Nursing (CAUSN)will become members of the CHSRF forthe duration of the fund. In the spring of1999, the final program structure was tobe determined by the CHSRF board oftrustees in consultation with the fund’sadvisory committee. Programs will belaunched in 1999-2000, afterestablishing research priorities andassessment mechanisms. It is anticipatedthat all four programs will be initiated inthe fiscal year 1999-2000. The fund willbe managed by the CHSRF and anadvisory committee with representativesfrom all areas of nursing. The CHSRF isan independent not-for-profit corporationannounced in 1996 with an initialendowment of $65 million from thefederal government. The foundationsupports high quality applied research,and the use of research results by healthservices decision-makers.

Using merit review panels of peers toselect award recipients, the CHSRFanticipates that by March 31, 2000,monies for these programs will beflowing to nursing researchers.

Over the short term, the foundation issupporting training for nursingresearchers through the programs ofexisting provincial and federal researchagencies. Over the long term, however,the Nurse Fund will invest in four areas:Nursing Research Chairs: To enhanceboth the profile and leadership capacityof nursing research, the fund will supportthe salaries of university chairs forresearch. A national competition willmake awards to four scholars withsupport for up to 10 years. The fourawards will be geographically distributedacross the country and one will be madefor each of the following areas:• nursing policy• nursing management• nursing human resources• nursing careTraining: To increase Canada’s capacityfor nursing research related to thechanging role of nurses and nursing in thehealth care system, the fund will providesupport for post-doctoral fellowships,career renewal awards, and studentstipends at the masters and PhD levels.

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Six

Research Funding: The fund willsupport research projects on identifyingcritical policy and management issuesfacing nursing, as well as on sharing bestpractices about nursing care for patients.Knowledge Dissemination: This area offunding focuses on maximizing theimpact of research results by creating aknowledge network for nurses, includinginformation highway solutions. This willserve as a resource for developingnursing policy and for influencing themanagement of health care to facilitateand promote evidence-based decision-making in the health sector.

What will CACCN’s response be tothis exciting change in the health careenvironment? How will we “signal” ourvision of critical care nursing researchand values with action and visibility?

Research-basedpractice

To build practice on research, Pepler(1994) identifies four independent com-ponents that are needed: (1) meaningfulresearch questions that are relevant topractice; (2) sound research to answerquestions that are relevant to practice;

(3) knowledgable nurses with skills inusing research findings; and (4) clinicalenvironments open to inquiry and change.

But what are the advantages ofresearch-based practice? Pepler (1994)identifies a number of advantages:increased clarity in articulating the role ofnursing, improved quality of care,increased cost effectiveness of health care,and increased nurses’ satisfaction.“Clinicians are able to explain and predictoutcomes of their practice at a given pointin time and to reexamine their practice asnew knowledge becomes available”(Peplar, 1994). Yet a “paramount”requirement for the successfuldevelopment of research-based practice is“a spirit of inquiry and openness to change- a philosophy of inquiry. Without thiswillingness to question and to challengerituals and traditions, nursing will notdevelop practice with a sound scientificbase” (Pepler, 1994).

Critical carenursing research

In a review of critical care nursingresearch from 1975 to 1985, VanCott andcolleagues identified three predominant

research foci: the structure of criticalcare units; the process of nursing; andpredictions of patient outcomes. Ofparticular interest was patient stress andthe impact of critical illness on familiesand nursing staff (VanCott, 1991). Yet todate, despite more than 20 years ofresearch in critical care, very little isknown about nursing’s contribution topatient outcomes in critical illness(O’Malley, 1994).

CACCN’s position“The critical care nurse strives to

make practice research-driven andacknowledges a responsibility topromote research within the specialty”CACCN Standards for Critical CareNursing Practice, (2nd Edition),(CACCN, 1997).

In 1997 a new research portfolio wascreated by the CACCN board ofdirectors to reflect the current needs ofthe association and in keeping with ourcommitment to research-based practice.The intent of this portfolio is:• to support research activity withinCACCN• to support the communication ofresearch findings within CACCN

CACCN 10-2 Summer 1999 Page Seven

• to support the utilization of researchfindings within CACCN• to explore opportunities to fundresearch activities of CACCN members.

At the recent board of directorsmeetings held in London, Ontario, April23-24, the board of directors approvedthe creation of a research endowmentfund. The intent of this fund is togenerate revenue to support a yearlyresearch award of $750.00. Criteria forselection, eligibility, and applicationprocess, and deadline for receipt ofapplication will be outlined in the fallissue of the OJCACCN. We continue toexplore other avenues of funding, e.g.corporate sponsorship, to bolster theamount of the award and/or createadditional awards. CACCN Research Committee: Aresearch committee is to be created withthe following mandate:• to review submitted research proposalsto determine funding award winner • to develop ideas to foster critical carenursing research• to encourage critical care nursingresearch conducted by critical carenurses• to develop a national proposal for acritical care nursing study to be endorsedand conducted by CACCN.

The committee will be comprised ofone CACCN representative from each ofthe three regions (Western, Central andEastern) and one member of the nationalboard of directors.

Call for participantsIf you are an active CACCN member

in good standing for a minimum of oneyear, and have a research background,submit to national office the followinginformation: full name, CACCNmembership number, mailing address,telephone and fax numbers, and e-mail

address. Also to be included is acurriculum vitae and a statement ofinterest which outlines your researchexperience and reasons for wanting toparticipate. Members of the researchcommittee will be determined from thosenames submitted to national office byJuly 1, 1999.

To date, a research component hasbeen added to CACCN’s homepage. Thefocus of this initiative has primarily beento provide CACCN members with on-line access to research-related websites.Plans for future content include: questionand answer; literature reviews; awardsand grants; and an inventory of Canadiancritical care nursing research. The intentof this inventory is to familiarize criticalcare nurses with ongoing or completedresearch projects that pertain to criticalcare nursing. In addition, we hope tosupply contact names of researchers whowould be willing to advise and/orprovide additional information to criticalcare nurses interested in the focus oftheir studies. A business plan is currentlybeing developed that will outline theassociated costs and potential sources ofrevenue.

CACCN researchutilization committee

At the next Chapter Connections Day,Saturday September 11, 1999, chapterpresidents and the board of directors willexplore the feasibility of a researchutilization committee. Potentialmandates could include: ongoing reviewof current critical care nursing research;dissemination of findings; hosting aconsensus conference to ascertain “bestpractice”; a pre-conference workshop atfuture Dynamics on “researchutilization/literature reviews”.

Future directionsHow can you become involved? The

CHSRF would like to incorporate allnursing researchers more effectively intotheir mailing list. If you wish to be addedto the CHSRF distribution network,please e-mail your name, position, fulladdress, telephone, and fax number tomonettes@chsrf.ca

Gwynne MacDonald,President, CACCN

CACCN Standards for Critical Care Nursing Practice, (2nd Edition),(CACCN, 1997).

O’Malley, P. (1994). The role of the critical care clinical nurse specialist incritical care research. AACN. In A. Gawlinski & L. Kern (Eds.) The Clinical NurseSpecialist Role in Critical Care, pp 173-195. Philadelphia: Saunders.

Pepler, C. (1994). Research as the Basis of Practice. In J. Hibberd & M. Kyle,(Eds.) Nursing Management in Canada, pp 228-249. Toronto: Saunders Canada.

Stinson, S. (1986). Nursing Research in Canada. In S. Stinson & J. Kerr, (Eds.),International Issues in Nursing Research, pp 236-258. Worcester: Billing & Sons.

VanCott, M., Tittle, M., Moody, L. & Wilson, M. (1991). Analysis of a decade ofcritical care nursing practice research: 1979 to 1988. Heart & Lung, 20(4), pp 394-403.

References

Retention awardThe following chapters have retained over 60% of theirprevious year’s members, and will receive $100.00 each:Greater Edmonton Chapter .............................61%London Regional Chapter ...............................62%Montreal Chapter.............................................68%Ottawa Regional Chapter ................................60%Toronto Chapter...............................................63%

Recruitment and Retention Awards for 1999CACCN established the Recognition, Recruitment and Retention Awards to recognize members and the chapters for theiroutstanding achievements with respect to recruitment and retention. The CACCN board of directors is pleased to announce thefollowing award winners for 1998/99: Recruitment award

The following chapters have recruited between 25 and 49 newmembers from April 1, 1998 to March 31, 1999, and willreceive one full tuition to Dynamics ‘99 in Ottawa:British Columbia Lower Mainland Chapter.......25Calgary Chapter ..................................................27Greater Edmonton Chapter.................................46London Regional Chapter...................................32Manitoba Chapter ...............................................31Saskatchewan Chapter ........................................29The Toronto Chapter recruited 67 new members and willreceive one full tuition to Dynamics ‘99 and $100.00.

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Eight

BackgroundOn November 24, 1998 the House of

Commons undertook the study of thestate of organ and tissue donation inCanada, as a result of two key events:• a motion by Keith Martin, Member ofParliament for Esquimalt - Juan de Fucaon October 9, 1997 outlining a proposalto address Canada’s organ donationproblem which received the unanimoussupport of the House of Commons.• the request of the Minister of Health,the Honourable Allan Rock, seekingadvice on the role of the federal govern-ment in addressing this issue.

The following terms of referenceguided the proceedings:• to consult, analyze and make recom-mendations regarding the state of organand tissue donation in Canada• to consult broadly with stakeholders,including, but not limited to, provinces,transplant centres, medical personnel,patients, families, organ and tissue retrievalorganizations and international experts• to consider the appropriate role of thefederal government in the developmentof national safety, outcome and processstandards for organ and tissue donations,as well as promoting of public and pro-fessional awareness and knowledgeregarding organ and tissue donation, pro-curement and transplantation• to consider the legislative and regula-tory regimes governing organ and tissuedonations in other countries.

The House of Commons StandingCommittee on Health, chaired by Mr.Joseph Volpe, M.P., conducted publichearings over a two-month periodinvolving over 100 individuals. CACCNwas invited to participate and asked bythe standing committee to address thefollowing key points pertaining to tissueand organ donation: • the role of critical care nurses; • atti-tudes; • concerns; • CACCN’s position.

The following brief was presented byRosella Jefferson, CACCN vice-president,to the House of Commons’ StandingCommittee on Health on Tuesday, March16, 1999. Transcripts of the proceedingscan be accessed on the Internet at:http://www.parl.gc.ca/InfocomDoc/36/1/HEAL/meetings/evidence/healev71-e.htm

On April 22, 1999 the House ofCommons’ Standing Committee onHealth released their report “Organ andTissue Donation and Transplantation: ACanadian Approach”. This report out-lines the committee’s findings and rec-

ommendations to improve organ and tis-sue donation. The report can be accessedon the Internet at:http://www.parl.gc.ca/InfoComDoc/36/1/HEAL/Studies/Reports/healrp05-e.htm

CACCN awaits the response of theMinister of Health, the Honourable AllanRock, who is expected to respond to thereport within 150 days.

If you require additional informationor would like to comment on this docu-ment, please contact the national office atcaccn@execulink.com.

Submission by theCanadian Associationof Critical Care Nursesto the Canadian Houseof Commons’ StandingCommittee on HealthIntroduction

Critical care nursing practice isresearch based, in an environment com-mitted to quality, holistic care, where opti-mal client/family outcomes are achievedthrough partnerships and appropriate useof resources (CACCN Vision Statement,1994). Critical care nursing is a professionthat cares for patients who are experienc-ing life-threatening health crises. Nursingthe critically ill patient is continuous andintensive, aided by sophisticated technol-ogy and based on application of the nurs-ing process - assessment of need, planning

appropriate interventions, implementingthe interventions and evaluating care.

The critical care nurse must balancethe need for the highly technologicalenvironment with the need for privacy,dignity and comfort. The critical carenurse must maintain that balancebetween the science of curing and the artof caring. Life-long learning and the spir-it of enquiry are essential for the criticalcare nurse to enhance professional com-petencies and to advance nursing prac-tice. The critical care nurse’s ability tomake sound clinical nursing judgments isbased on a solid foundation of knowl-edge and experience (CACCN, 1997).Role of critical care nursesin organ donation

The Standards for Critical CareNursing Practice in Canada (CACCN,1997) outlines the expectation that criticalcare nurses will participate in the organdonation process. A basic assumption inthe competencies that provide the frame-work for the Certified Nurse in CriticalCare - Canada (CNCC(C)) examination isthat critical care nurses support organdonation in their practice (CNA, 1999 inpress). CACCN also endorses the positionpaper on organ donation by the CanadianNurses Association (CNA, 1994).

The priority of the critical care nurse isto care for the client and family who isexperiencing life-threatening illness orinjury. Once it becomes apparent that sur-vival will not be an outcome, the critical

Organ donation and the critical care nurse

Call for participants for development of a position statementon organ and tissue donation and transplantationCACCN members! Your input is needed to develop a new positionstatement.The CACCN board of directors is seeking your assistance in the creationof a new position statement on organ and tissue donation andtransplantation. Through feedback from membership, and our recentactivities with the Standing Committee on Health on Organ and TissueDonation (March 1999 witness submission by CACCN - reprinted in thisissue), the board of directors endorsed the development of a CACCNposition statement on this current and relevant topic.Team members for the development of this position statement will bedetermined from those names submitted to national office by June 30,1999. Interested participants are requested to submit by mail, fax or e-mailthe following information: full name, CACCN membership number,mailing address, telephone and fax numbers, and e-mail address. Also tobe included is a statement of interest which briefly outlines your workexperience and reason for wanting to participate in this process.• The deadline for submitting your name is June 30, 1999.

CACCN 10-2 Summer 1999 Page Nine

care nurse’s responsibility shifts to one ofcomfort and support. Through the relation-ship developed with the family, the criticalcare nurse is in a unique position duringthis period of transition to facilitate organdonation through the following steps:1. Identification/participation in the iden-tification of a potential organ donor.2. Exploration of knowledge, beliefs andwishes regarding organ donation with thefamily.3. Continued care of the organ donor bysupporting the cardiovascular and respi-ratory system4. Contact with the organ retrieval centre.5. Collection of specimens for tissuetyping.6. Ongoing support for the family duringthe process of decision making, braindeath declaration and grief.7. Transfer/accompaniment of the donorto the operating room or to a transplanthospital.

It is CACCN’s position that the criticalcare nurse should recognize potentialorgan donors and participate in the processof organ donation. This process includesthe exploration of the potential donor’sand family’s wishes and beliefs, provisionof education as required regarding organdonation, and support for the family dur-ing the decision-making period. The nurseis in a position to promote the role of organdonation as a way to offer some meaningto a tragic and unexpected loss.

While the critical care nurse can becrucial to successful organ retrieval, thepremier focus of the critical care nurseremains the care of the donor and family.The critical care nurse must remain non-judgmental throughout the process. If,despite appropriate education and discus-sion, a family declines organ donation asan option, it is the position of CACCNthat the family’s wishes be respected.Environmental aspects

A nurse’s ability to initiate organdonation can be restricted by environ-mental or medical barriers. If a facilityhas guidelines that limit a nurse’s abilityto initiate discussions, or there is a per-ception by the nurses that they may notinitiate discussions, opportunities fororgan donation may be lost. Because dec-laration of brain death is ultimately amedical decision, the nurse is dependentupon the support of the medical staff.

If the physician in charge does notsupport organ donation, even the mostcommitted critical care nurse will facebarriers. A lack of in-house medical per-sonnel may limit organ donation, particu-larly during the night shift in a non-teach-ing hospital. This is particularly true if the

donor becomes suddenly unstable, short-ening the window of opportunity fororgan retrieval. The culture and medicalpractice of the unit where the critical carenurse works can significantly influencethe organ donation support.

Agencies must also value and supportorgan donation through policy develop-ment and practice that demonstratescommitment. Financial support is neededto provide orientation programs for newand existing staff regarding the processof organ donation. New nurses (andphysicians) also need assistance to devel-op the skills required to effectively andsensitively approach potential organdonor families.

Although we are not aware of anystudies that demonstrate a relationshipbetween staffing or bed shortages andactual organ donation, this is an area thatmay require further investigation. In arecent case in Toronto, a critical carebed/staffing shortage resulted in the can-cellation of a transplantation and loss ofa suitable organ. The impact of the cur-rent nursing shortage on organ donationor transplantation is not known. Emotional aspects of transplantation

The nurse must balance activitiesrelated to organ donation with the needsof the family during the process of dyingand grieving. The critical care nurse mustmaintain a dignified end to the donor’sbiological life, while providing opportu-nities for the family to say goodbye intheir own unique way.

Knowledge derived from research withfamily members regarding the effects thatorgan donation can have on the grievingprocess ranges from “at least somethinggood came out of this terrible event”(Davis & Gillham-Eisen, 1998) to “I regretthat I didn’t have a chance to hold my childlater” (Pelletier, 1992). The effect thatorgan donation has on the donor family isthe priority of the critical care nurse.

The process of organ donation can be

particularly difficult for the critical carenurse. Organ donation often followsmany hours or even days of intensive andexhaustive efforts to save the life of ayoung individual who experienced a sud-den and unexpected tragedy. The fami-ly’s experience is heart wrenching, andthe nurse is often left emotionallydrained. Leaving a client in a sterileoperating suite, after laborious efforts atsurvival, can be very difficult. Knowingthat another life may be saved does notnegate the donor’s tragedy.

If the nurse works in a non-transplantcentre, the nurse may only ever see thetragic side of organ donation. A nurseworking in a transplant centre may be tornby having both a donor and recipient inthe same unit. Nurses who work in criticalcare in a transplant centre may find trans-plantation difficult at times because theirexperience is often limited to those recip-ients who experience complications orsubsequently die. On occasion, ethicalquestions regarding the appropriateness ofsome transplants place additional strain onthe critical care nurse.Summary

CACCN supports the process of organdonation. Nurses working in critical careare in a privileged position to positivelyinfluence organ donation success; howev-er, the process can be emotionally verydifficult. Facility commitment, agencyculture and medical practice are also cru-cial to the process of organ donation.

Despite our commitment to supportorgan donation as an option, the criticalcare nurse’s primary responsibility is tothe potential donor and their family.Throughout the process, the critical carenurse must remain non-judgmental andsupportive of the family, regardless oftheir decision. Ultimately, the nurse mustbalance organ donation with the needs ofthe family who is experiencing the tragicand untimely loss of a loved one. Findingthis balance is never an easy task.

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 CareNurses, 9(4); 25-28.

Pelletier, M. (1992). The organ donor family members’ perception of stressfulsituations during the organ donation experience. Journal of Advanced Nursing, 17:90-97.

References

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Ten

DefinitionAdvance directives provide

individuals with a method to identifytheir health care preferences for the eventthat they become incompetent to makesuch decisions in the future. There aretwo major groups of advance directives:instructional and proxy directives.Instructional directives allow anindividual to identify what or how healthcare decisions are to be made if theybecome incompetent (Senate of Canada,1995). Instructional directives are attimes referred to as living wills, end-of-life instructions or treatment directives.Proxy directives allow individuals tospecify who is to make health caredecisions in the event that they becomeincompetent (Senate of Canada, 1995).Proxy directives are at times referred toas power of attorney for health care,mandate for health care, appointmentdirectives, substitute decision maker forhealth care or personal directive agent.

An advance directive only comes intoeffect when an individual is incompetentto make health care decisions. Acompetent individual can change, negateor destroy their advance directive at anytime. The majority of advance directivesare used to instruct health careprofessionals to withdraw or withholdmedical treatments such ascardiopulmonary resuscitation,mechanical ventilation, dialysis,antibiotics, surgery, invasive diagnosticprocedures, or artificial nutrition andhydration. However, advance directivesmay also be used to request medicaltreatment. Many different formats ofadvance directives are currentlyavailable in Canada. It has beenrecommended that a combined documentwhich includes both a living will andpower of attorney for health care wouldprovide the best assurance that criticalcare patients’ desires concerning medicaltreatment will be respected (Silverman etal., 1992). Decision-making should beinformed: consultation with health careprofessionals is seen as beneficial inhelping individuals make an informeddecision.

BackgroundAdvances in medical technology now

permit the extensive use of life-sustainingtreatments. However, not all individualswant to receive life-prolonging therapiesfor every health crisis. Critically illpatients are often unconscious orincompetent to indicate their treatmentpreferences. Advance directives promotepatient autonomy and self-determinationby allowing individuals to identify theirpreferences regarding life-sustainingtreatment for the event that they becomeincapable of expressing such wishesthemselves. Advance directives alsoprovide a framework to facilitatediscussions about life-sustainingtreatments and end of life decision-making between patients, familymembers or significant others, and thehealth care team. The ideal time fordiscussions about advance directives isbefore a health care crisis occurs. Boththe Canadian Nurses Association (1994)and Canadian Medical Association(1992) support the concept of advancedirectives. Values from the CanadianNurses Association Code of Ethics forRegistered Nurses (1997) which arerelevant to the topic of end of lifedecision-making and advance directivesinclude health and well-being, choice,and dignity (Canadian NursesAssociation, 1998).

While the issue of advance directiveshas not been directly addressed inCanadian courts, some Canadian courtdecisions support the concept ofadvance directives (Sneiderman, 1991).It has been recommended that allCanadian provinces implementlegislation related to advance directives(Senate of Canada, 1995). As legislationin each province can vary, critical carenurses should ensure that they arefamiliar with their current provinciallegislation. However, lack of provinciallegislation does not inherently negate thevalidity of an advance directive.

ResearchA 1997 survey conducted at the

Canadian Association of Critical Care

Nurses (CACCN) national conferencefound that 80% of respondents had caredfor at least one patient with an advancedirective and that 89% of respondentswere in favour of advance directives(Leith, 1998). Previous research withCanadian physicians and nurses alsofound that the majority favoured the useof advance directives in clinical care(Hugues & Singer, 1992; Kelner et al.,1993). While research suggests that theCanadian general public supports the useof advance directives (Molloy et al.,1991; Storch & Dossetor, 1994), manyindividuals appear to have littleexperience and poor knowledge ofadvance directives (Sam & Singer,1993). However, some Canadianpatients, family members and health careprofessionals have been documented tohave completed advance directives(Leith, 1998; Perry et al., 1995) and ithas been suggested that the incidence ofadvance directives in Canadian healthcare will continue to increase (Leith,1997).

While research in critical careidentifies that it is important for medicalpersonnel to be aware of whether or notpatients have advance directivestatements (Goodman et al., 1998), someCanadian hospitals do not have policiesregarding advance directives (Rasooly etal., 1994). Research suggests that manynurses require further education aboutadvance directives in order to use themeffectively in their daily practice (Crego& Lipp, 1998; Leith, 1998; Woods &DelPapa, 1996). Furthermore, criticalcare research has identified that at timesproblems may occur with interpretingand honouring advance directives (Ewer& Taubert, 1995). Yet, it has beensuggested that advance directives couldbe beneficial in facilitating discussionsabout foregoing life-sustainingtreatments (Johnson et al., 1995).

CACCN’s positionCACCN supports an individual’s

right to direct their own health careincluding the right to accept or refuselife-sustaining treatment. CACCN

C A C C N P O S I T I O N S T A T E M E N T

Advance directives

CACCN 10-2 Summer 1999 Page Eleven

believes that advance directives providean appropriate mechanism by whichpatients can identify their health carepreferences for the event that theybecome incompetent to make health caredecisions. CACCN recognizes that someadvance directives can be vague anddifficult to implement in clinical practiceand recommends that ethicalconsultation may be appropriate in someinstances. CACCN does not believe thatall patients should be required tocomplete an advance directive.

CACCN proposes that critical carenurses should ensure that they haveadequate knowledge to provide patientsand family members with informationabout the purpose, advantages, andlimitations of advance directives.Critical care nurses need to take thetime to reflect and acknowledge theirown beliefs regarding advancedirectives, death and dying, becausethey may be required to discuss thesesensitive issues with patients, familymembers or significant others.CACCN suggests that critical carenurses should act as patient advocatesduring discussions about advancedirectives within the health care teamor with patients’ family members.Additional roles for critical care nurseswith respect to advance directivesinclude providing education and/orconducting research. CACCNencourages critical care nurses to verifythat the health care facility where theyare currently employed hasimplemented a policy regardingadvance directives.

CACCN would like to acknowledge theexpertise and commitment demonstratedby the following CACCN members in theprocess of developing the positionstatement entitled “Advance Directives”.The position statement received theCACCN board of directors’ approval onApril 24, 1999.

The working group members were:Beverly Leith, Montreal, QuebecAlise Gilmore, Regina, SaskatchewanLori Garchinski, Regina, SaskatchewanShelley Snider, Cornwall, OntarioGwynne MacDonald, London, Ontario

CACCN member reviewers:Pam Hughes, Halifax, Nova Scotia,Francis Loos, Regina, SaskatchewanGrace MacConnell, Halifax, Nova ScotiaCindy MacVicar, Edmonton, AlbertaCharlotte Pooler, Calgary, Alberta

Canadian Home Care Association/Canadian HospitalAssociation/Canadian Long Term Care Association/Canadian NursesAssociation. Canadian Public Health Association/Home Support Canada.(1994). Joint Statement on Advance Directives. Ottawa: Authors.

Canadian Medical Association. (1992). Policy summary on advancedirectives for resuscitation and other life-saving or sustaining measures,Canadian Medical Association Journal, 146(6), 1072A.

Canadian Nurses Association (1997). The Code of Ethics forRegistered Nurses. Ottawa:CNA.

Canadian Nurses Association (1998). Advance directives: Thenurses’ role. Ethics in Practice, ISSN Number 1480-9990. Ottawa: CNA

Crego, P.J. & Lipp, E.J. (1998). Nurses’ knowledge of advancedirectives. American Journal of Critical Care, 7(3), 218-223.

Ewer, M.S. & Taubert, J.K. (1995). Advance directives in theintensive care unit of a tertiary care cancer center. Cancer, 76, 1268-1274.

Goodman, M.D., Tarnoff, M. & Slotman, G.J. (1998). Effect ofadvance directives on the management of elderly critically ill patients.Critical Care Medicine, 26(4), 701-704.

Hugues, D.L. & Singer, P.A. (1992). Family physicians’ attitudestoward advance directives. Canadian Medical Association Journal, 146,1937-1944.

Johnson, R.F., Baranowski-Birkmeier, T. & O’Donnell, J.B. (1995).Advance directives in the medical intensive care unit of a communityteaching hospital. Chest, 107, 752-756.

Kelner, M., Bourgeault, I.L., Hebert, P.C. & Dunn, E.V. (1993).Advance directives: The views of health care professionals. CanadianMedical Association Journal, 148(8), 1331- 1338.

Leith, B. (1997). Advance directives in critical care. OfficialJournal of the Canadian Association of Critical Care Nurses, 8(4),21-25.

Leith, B. (1998). Canadian critical care nurses and advancedirectives. Official Journal of the Canadian Association of CriticalCare Nurses, 9(1), 6-11.

Molloy, D.W., Guyatt, G., Alemayehu, E. & McIlroy, W.E. (1991).Treatment preferences, attitudes toward advance directives and concernsabout health care. Humane Medicine, 7, 285-290.

Perry, L.D., Nicholas, D., Molzahn, A.E. & Dossetor, J.B. (1995).Attitudes of dialysis patients and caregivers regarding advance directives.ANNA Journal, 22, 457-463, 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 life-sustaining treatments and advance directives in Canada. CanadianMedical Association Journal, 150(8), 1265-1270.

Sam, M. & Singer, P.A. (1993). Canadian outpatients and advancedirectives: poor knowledge and little experience but positive attitudes.Canadian Medical Association Journal, 148(9), 1497-1502.

Senate Of Canada. (June 1995). Of Life and Death. Report of thespecial senate committee on euthanasia and assisted suicide, Minister ofSupply and Services Canada.

Silverman, H.J., Vinicky, J.K. & Gasner, M.R. (1992). Advancedirectives: Implications for critical care. Critical Care Medicine, 20,1027-1031.

Sneiderman, B. (1991). The Shulman case and the right to refusetreatment. Humane Medicine, 7(1), 15-21.

Storch, J.L. & Dossetor, J. (1994). Public attitudes toward end-of-life treatment decisions: Implications for nurse clinicians and nursingadministrators. Canadian Journal of Nursing Administration, 7, 65-89.

Woods, L.C. & DelPapa, L.A. (1996). Nurses’ attitudes, ethicalreasons, and knowledge of the law concerning advance directives.IMAGE: Journal of Nursing Scholarship, 28(4), 371.

References

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Twelve

Gwynne MacDonald,RN, MN, CNCC(C)

Central Region, President

Gwynne was appointed to theCACCN board of directors in April 1997and has been serving as the association’spresident since February 1998. Inaddition to the responsibilities of thisrole, Gwynne is also responsible for theportfolio of critical care nursing research.Prior to her involvement at the nationallevel, Gwynne held a number ofpositions with the London Chapter ofCACCN, as president, president-electand chairperson of the educationcommittee.

Gwynne has worked as staff nurse,educator and clinical nurse specialist incritical care. She is currently coordinator,intensive care, at the University Campusof the London Health Sciences Centre,London, Ontario. Her research interestshave included primary nursing, casemanagement, therapeutic touch, andevidence-based protocols and guidelinesfor DVT prophylaxis, weaning andnoninvasive monitoring.

Gwynne received her bachelor ofscience in nursing from the University ofWindsor, Windsor, Ontario and master ofnursing from the University of Alberta,Edmonton, Alberta. She became a certifiednurse in critical care, CNCC(C), in 1995.

Rosella Jefferson,RN, BScN, MSN

Western Region,Vice-President

Rosella Jefferson joined the CACCNboard of directors as a representativefrom the Western Region. She wasappointed vice-president in October1998 and is currently enjoying learningmore about the challenges of nationalinvolvement in CACCN.

Rosella’s most recent educationprogram, a masters in nursing program,was completed at the University ofBritish Columbia in 1998. Initialeducation in nursing was completed in1979 in the BScN program at McMasterUniversity, Hamilton, Ontario.

Rosella’s love of nursing has beenimplemented in many previous positions,including staff nurse, head nurse andclinical instructor. Her present position asa clinical nurse specialist for the pediatriccritical care program at British Columbia’sChildren’s Hospital offers opportunities tobe involved with patient and family care,nursing practice, program planning,nursing research and nursing education inboth tertiary and community hospitals.

Hearing from CACCN members willcontinue to be Rosella’s goal as sheworks with the board to address issuesimportant for critical care nurses.

Valerie Banfield,RN, BScN, MN, CNCC(C)

Eastern Region, Secretary

Valerie Banfield graduated with aBScN from Saint Xavier UniversityAntigonish, NS in 1979 and beganworking in critical care 16 years ago.She has held various positions since thattime: staff nurse, instructor (diplomaprogram and post-graduate program incritical care nursing), and project nurse.In 1992, she received a masters innursing from Dalhousie University. Herthesis was entitled “Informationalneeds of families of patients who arecritically ill”.

Presently, Valerie is a nurseeducator in the perioperative area(post anaesthetic care unit) and thedistance critical care program at theQueen Elizabeth II Health SciencesCentre, Halifax, NS. She has been anactive member of CACCN and hasheld the research position on theexecutive at the provincial level.Valerie received her certification incritical care in 1995 and twiceparticipated in certification examdevelopment.

Valerie has undertaken the portfolioof CACCN secretary, with the primaryresponsibility of preparing andcoordinating national correspondence.

The 1999-2000CACCN Board of Directors

Gwynne MacDonald Rosella Jefferson Valerie Banfield

CACCN 10-2 Summer 1999 Page Thirteen

Petula Wong,RN, BScN, MEd

Eastern Region, Treasurer

Petula has completed her thirdyear on the CACCN national boardof directors. Petula is the nationaltreasurer of CACCN and thechairperson of Dynamics 2000 to beheld in Halifax, Nova Scotia. Petulafinds the role of directorchallenging and rewarding. Sheencourages all members to considerthe opportunity to serve on theCACCN board.

Petula has worked as staff nurse,educator and manager in criticalcare. She is currently the manager ofthe renal dialysis unit and dialyzerreprocessing program.

Petula received her bachelor ofscience degree in nursing fromUniversity of Toronto, her mastersdegree in education fromDalhousie University, and herhealth services managementcertif icate from the CanadianHospital Association.

Heather Camrass,RN, BScN, CNCC(C)

Central Region, Director

Heather Camrass began her firsttwo-year term on the board of directorsin April of this year, and will beresponsible for coordinating the

awards and corporate sponsorshipportfolio.

Heather has worked in critical carenursing for 10 years in the cardiovascularICU at the Heart Institute in Ottawa,Ontario. She has also worked as aclinical specialist for vascular surgeryand taught clinical for AlgonquinCollege at the basic level.

Petula Wong Heather Camrass

CACCN 10-2 Summer 1999Page Fourteen

After becoming a member of CACCNsix years ago, Heather joined the localOttawa Chapter executive as the chaptersecretary and three years ago becamechapter president. Nationally, Heatherhas presented two oral presentations atDynamics - Phrenic Nerve Frostbite andMinimally Invasive Direct CoronaryArtery Bypass. Heather is currently onthe planning committee for Dynamics‘99 in Ottawa this fall.

As Heather moves from a regional tonational focus, she is looking forward tobeing part of a national association thatbrings nursing into the forefront byexpanding the voice that critical carenursing has across this country.

Lori Garchinski,RN, BSN, CNCC(C)

Western Region, Director

Newly elected to the CACCN boardof directors, Lori Garchinski began herfirst term in April 1999. Lori is currentlya staff nurse in the surgical intensive careunit at the General Hospital in Regina,Saskatchewan. She has been a criticalcare nurse for 10 years and enjoys thechallenges that this field has to offer. Aswell, Lori undertook the challenge andreceived her certification in critical carenursing, CNCC(C), in 1997.

For eight years now, Lori has beeninvolved with CACCN at the provinciallevel, and has been in the positions ofmember-at-large, president and currentlyas publications chairperson. Althoughthe Saskatchewan Chapter is a smallerchapter, she is very proud and pleased tohave been part of the excellent work thechapter has done in promoting criticalcare nursing in that province.

Lori is looking forward to workingwith the board of directors over the nexttwo years as critical care nursing entersthe new millennium - what an excitingtime to be a part of history and to

continue to strive to make the voice ofcritical care nursing heard nationally. Lorifeels that we not only need to be strongadvocates for the patients we serve, butalso for each other and our profession.

As Lori strives to fulfil theresponsibilities of the recruitment andretention portfolio, as well as helpCACCN fulfil its mission of maintainingand enhancing the quality of careprovided to critically ill patients and theirfamilies, she hopes to hear from manyCACCN members and welcomes allsuggestions, comments and issues thatneed to be addressed.

Brenda Morgan,RN, BScN, CNCC(C)

Central Region, Director

Brenda Morgan, who resides inLondon, Ontario, began her term on theboard in April 1998. During the next year,Brenda will continue to be responsible forthe certification portfolio, as well aschairperson for Dynamics ‘99 being heldSeptember 12-15 in Ottawa, Ontario.

Brenda graduated from the CentennialCollege diploma nursing program in1975, and from the University of WesternOntario, BScN program in April 1998.She is currently in the MScN program atMcMaster University. Brenda has workedin critical care at the London HealthSciences Centre for the past 20 years in avariety of roles, staff nurse, charge nurseand educator.

This is Brenda’s second time on theboard of directors. Her past activitiesinclude: London regional chapterpresident (1986-88), national president(1992-94), Dynamics chairperson 1991and 1994, and critical care representativeon the Canadian Nurses Association’sadvisory committee. Brenda is currentlya member of the critical care certificationcommittee and is the editor of the firstand second editions of the Study Guidefor the Critical Care NursingCertification Examination, published byCACCN.

Brenda is looking forward to thesecond year of her term on the board andhopes to see many CACCN members atDynamics ‘99 in Ottawa.

Lori Garchinski Brenda Morgan

NOTICE OF ANNUALGENERAL MEETING

The national board of directors of the Canadian Association of Critical Care Nurses (CACCN) would like to extend aninvitation to the membership to attend the 1999 Annual General Meeting of the CACCN. The CACCN Annual GeneralMeeting will be held on Monday, September 13, 1999 at 1630 hrs at the Crowne Plaza Hotel, Ottawa, Ontario inconjunction with Dynamics ‘99. Members unable to attend the Annual General Meeting are reminded that their proxy votemust be received in CACCN national office by 2400 hrs, September 1, 1999. The proxy vote form is printed on page 17 ofthis issue, and can also be obtained from your chapter president or CACCN national office.

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CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Sixteen

Where does all that money go?

The members of the board of directors(BOD) are accountable for answering aquestion sometimes asked by CACCNmembers regarding the use of the mem-bership fees. Accolades to the question-ers! We certainly agree that matters ofthis nature should be transparent for all,especially in a not-for-profit organizationsuch as ours.

Firstly, national representation isincluded in the membership fee for ourparticular professional organization. Thismeans that critical care nurses fromacross the country can have a voice thatis united; this voice should consequentlyalso be louder, more definite and moreeffective in developing critical care nurs-ing as a profession. This voice is used todevelop position papers that portray theviews of critical care nurses involvedwith an issue in question.

When CACCN members identified,for example, that “Withdrawal of LifeSupport” was an issue of significanceand variance in practice, the BOD askedfor volunteer members from critical careunits across the country to develop aposition paper draft for the issue. Thesecritical care nursing members wereselected according to their abilities,knowledge and experience. This draftwas then reviewed by the BOD as well asbeing considered for review request fromother potential groups, such as the CNAor the Critical Care Medicine Society.When the position paper is approved andfinal, all members benefit from its use.

Similarly, standards for critical carepractice have been developed byCACCN and used to develop the criticalcare nursing certification process.Critical care nurses interested in access-ing the best practices recommendednationally use these standards. When

approached by the ParliamentaryStanding Committee on Health for inputregarding the issue of organ donation,CNA asked CACCN to be involved. Theprocesses involved in examples such asthese can only occur in a national organi-zation with national representation.

Membership in CACCN means thatmembers receive the only Canadian crit-ical care nursing journal - one that is pub-lished quarterly with a professional criti-cal care nurse as its editor and profes-sional critical care nurses on its reviewboard. These nurses ensure that a blindreview process is used to assess articles,involving criteria that strive for excel-lence when published. In addition,CACCN members have an avenue toaccess this experienced group to assist indeveloping writing and publishing skills.

Every year, a national critical carenursing conference is offered in a citylocated in the western, central or easternregion of Canada. Planning for this con-ference commences more than two years

Question to the board

CRITICAL CARE NURSESLOOKING TO THE FUTUREWith development underway on a new critical care building atthe Health Sciences Centre, the critical care program is lookingto the future. Presently, however, we are looking for critical carenurses. 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 AboriginalHealth Care facility, the Health Sciences Centre has permanentfull 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 careerdevelopment within your profession, and would like toexplore your potential at the Health Sciences Centre, pleasesend a resume to:Mail: Human Resources, HEALTH SCIENCES CENTRE, 60 Pearl Street, Winnipeg, Manitoba, R3E 1X2Fax: (204) 787-1376; E-mail: SusanGoertzen@hsc.mb.ca; or call the Centre’s Nurse Recruiter at (204) 787-1842.

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CACCN 10-2 Summer 1999 Page Seventeen

in advance, involves critical care nursingexperts on its planning committee andprovides critical care nurses with oppor-tunities for continuing education, presen-tation skill development, networking,and observation of the latest technology.The final goal for attendees at such aconference is the development of “bestnursing practice”, a benefit for futurepatients and professional development.The budgets necessary for conferences ofthis nature can be surprising for thosewho are unfamiliar with the process.Request a sample budget if you are inter-ested in more details.

The board of directors is also respon-sible for establishment and maintenanceof initiatives that will benefit critical carenurses. These initiatives are sometimesfunded by money from membership fees;

frequently, our sponsoring corporationsdonate money. For example, awardsdeveloped in the past to recognize andreward our members need to be main-tained by collaborating with the sponsor,advertising the award and selecting therecipient according to established criteria.New initiatives, such as research awards,may be developed with the use of moneyfrom activities like Dynamics and frominterested sponsor corporations.

In addition to the benefits of belong-ing to a national organization, mostCACCN members also benefit fromlocal membership. Local chapters ofCACCN are able to work with local col-leagues to provide education and net-working opportunities. Many chaptersalso have developed similar initiatives tothe national organization. These initia-

tives provide for local variances andincreased development opportunities. Aportion of membership revenue goes tolocal chapters. As well, some funding isprovided for the executive of the localchapters for Chapter Connection Day.

Sometimes available money in anorganization’s account can be deceiving-ly high. A rule of thumb is to have twoyears operating budget at all times. TheAGM is another venue to ask questionsregarding membership fees and boardactivities. Even better, discover more byrunning for election to the board of direc-tors. It’s a great learning experience, achallenge and lots of fun.

Rosella Jefferson, Vice-President,CACCN Board of Directors

Recently I have been receiving a number of e-mailscontaining inspirational sayings, “rules” to live a fuller life,and personal affirmations. There is one statement that struckme in particular: “Share your knowledge. It’s a way toachieve immortality.” I thought of that idea as I waspreparing the manuscripts for this issue of the journal. Whatbetter way to share knowledge than to write and publish yourideas, innovations, and nursing practices?

Sharing our knowledge through the printed medium hasmany advantages. One great advantage relates to the processof disseminating information about critical care nursing acrossthe country. Because we live in such a large geographic area itis more important than ever that we share our knowledge,research findings, and experiences to help our colleaguesdealing with similar issues across the country. We are greatresources for each other. Every nurse I speak with has more todo than there are hours in the day. As a friend once remindedme, it does not make sense that everyone should need to startfrom scratch on so many of the same policies and practices.Practices and protocols already exist and work well.

I would like to acknowledge and thank all those who haveshared their knowledge through publishing in the journal.Your words and thoughts will exist forever. So let us not keepreinventing the wheel and share our knowledge with ourcolleagues.

This issue of the journal contains two very interestingarticles. Sharon Chow challenges us to reconsider restrictedvisitation policies in our ICUs. The findings of her literaturereview give us information on the alternative for restrictedvisiting and give us direction for practice and further nursingresearch. Stacey Dalgleish shares with us the results of herreview of neonates experiencing pain and the use of sucroseas an analgesic. The implications of this article are applicablein neonatal critical care units as a possible strategy forassisting neonates who are experiencing mild pain.

Paula Price RN, MN, Clinical Editor

Letter fromthe clinical editor

Annual General MeetingProxy Vote 1999Every active member may, by means of proxy, appoint a person(not necessarily a member of the association), as his/her nomineeto attend and act at the annual general meeting in the manner andto the extent and with the power conferred by the proxy. Theproxy shall be in writing under the hand of the member or his/herattorney, authorized in writing, and shall cease to be valid afterthe expiration of one (1) year from the date thereof.Proxy votes must be received in the national officeno later than midnight, Wednesday, September 1, 1999.Proxy votes may be mailed/faxed to:Canadian Association of Critical Care NursesP.O. Box 25322, London, Ontario N6C 6B1(Fax) 519-668-2499The following shall be a sufficient form of proxy:

I, ______________________, of ______________________,

an active member of the Canadian Association of Critical CareNurses hereby appoint

______________________ of ______________________,or failing her/him,______________________ of ______________________,

as my proxy to vote for me and on my behalf at the meeting ofmembers of the association to be held on the 13th day ofSeptember 1999, and at any adjournment thereof.

Dated at ____________________, this _____ day

of ____________________, 1999.

Signature of Member: ____________________

CACCN Membership Number: ____________________

CACCN 10-2 Summer 1999Page Eighteen

Sucrose asanalgesia for neonatesexperiencing “mild” pain

By Stacey Dalgleish, RN, MN

AbstractHealth care professionals who care

for neonates have few treatment optionsfor the management of mild, sporadicpainful events, such as those associatedwith venipuncture. A number of researchstudies have demonstrated sucrose to bean efficacious analgesic for mildprocedural pain in neonates. Thehistorical therapy of the “sugar nipple”has even been replaced with sucrose. Adiscussion of the pharmacologicprinciples, available research regardingdose-response relationships andimplications for nursing care ispresented in this article to allow thereader to consider how this adjunctivetherapy may be incorporated into care ofthe neonate.

Rather than considering sucrose as areplacement for traditional analgesics,this easily administered and seeminglysafe intervention could be used asanother adjunctive therapy in treatingmild pain for neonates. Future directionsof research may identify the precisemechanism of action that sucrose takesin the neonate, the gestational andchronological ages when sucrose is mostefficacious, and the consequences offrequent or repeated dosing with termand low birth weight infants.

Clinical caseBaby Boy Blue is a 34-week baby in

the neonatal intensive care unit (NICU)who is to be kept NPO for the next 24hours. He has no respiratory distress andwould generally be considered a “well”premature baby in the NICU; however,even this “well” baby requires bothcapillary lab work and his interstitialintravenous (IV) to be restarted in thenext hour.

You likely will use consolinginterventions such as non-nutritivesucking and bundling to soothe himduring these painful procedures. Butwhat else could you do to guard thisinfant against the adverse effects of pain?

Consider the limited choicesavailable to you. The attendingphysician in the NICU will not orderoral acetaminophen drops for this NPObaby. Acetaminophen suppositories, thatyou would have to cut to achieve anappropriate dose, are notorious for theirunpredictable absorption and imprecisedrug dosage delivery (Truog & Anand,1989). As you scroll through a list ofother medications in your NICUformulary, you know that none of theother medications available are suitablefor this baby. EMLA (a topicalanesthetic mixture of lidocaine andprilocaine) is not yet approved inCanada for neonates. Opioids are notsuitable for “mild”, sporadic, proceduralpain. Sedatives have no analgesicproperties (Stevens, 1996; Truog &Anand, 1989). Sound like an all toofamiliar, frustrating clinical experience?There may be a solution.

Consider a new, safe analgesic forneonates who are undergoing a mildlypainful procedure such as an IV initiationor heel prick for capillary laboratorycollection. This analgesic has none of thepotentially serious adverse drug reactionsassociated with other commonly usedanalgesics in the NICU, and it could begiven transmucosally, so it would notmatter if the baby was NPO or without IVaccess at the time of the procedure. Soundlike every neonatal nurse’s dream?According to a growing body of neonatalresearch, this “new analgesia” may bemore reality than fantasy.

Sucrose has been demonstrated to be asafe, efficacious therapy for prematureand term infants. A discussion of thepharmacologic principles, availableresearch regarding dose-responserelationships and implications for nursingcare will allow the reader to consider howthis adjunctive therapy may beincorporated into care of the neonate.

Clinical importanceNurses who care for infants have

slowly developed an attitude of growingconcern about the lack of accurate and

adequate treatment for neonatal pain.Over the past decade, the literature haswarned that unmediated neonatal pain ornociception, the sensation of pain thatoriginates in the peripheral nervoussystem with sensory stimulation, isassociated with both short and long termconsequences. Rather than the transient,inconsequential and forgotten event itwas once thought to be, pain is nowknown to cause a significant stressresponse in both term and preterm babies.

The stress response leads to a rangeof physiologic, behavioral, hormonal,and metabolic consequences thatimpact negatively upon the newborn(Stevens, 1996). Of equal concern isthe suggestion that unmanaged painmay lead to permanent alterations inthe neonate’s neuroanatomy, andincreased somatization to painfulevents in later childhood (Franck,1993). Neonates are also known tobehave unpredictably when faced withpainful procedures; a response can bedelayed, cumulative, or absent simplybecause they do not have thephysiologic reserve to respond to pain(Bell, 1994). With this knowledge,many health care providers areabandoning the assumption thatabsence of a typical response to apotentially painful event issynonymous with a lack of painperception.

Great strides have been made inassessing neonatal pain, and treatingmoderate to severe types of pain such asthose often experienced in the intensivecare unit. However, for those babies whoare not critically ill, or are having whatwould generally be considered minor,sporadic procedures such as IVinitiations, modalities aimed at treatingmild pain secondary to those eventsremain elusive. With our knowledge ofthe potential short- and long-termconsequences of unmediated nociceptionin the neonate, it is unethical to ignorepain relief measures for any baby.

continued on page 20...

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“Total Care”

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Twenty

Sucrose as analgesiacontinued from page 18...

BackgroundThe ‘sugar nipple’ was used many

decades ago during all types ofprocedures before there was safe,effective analgesia and anesthesia forneonates (Bruck, 1991; “Pacifiers,”1992). From these historical discussions,interest among researchers and cliniciansalike was piqued as to why this techniqueseemed to work so effectively beforetechnology afforded us other choices ofpain management.

As with many pharmacologicalconcepts, initial research was performedon rat models. Neonatal rats were foundto have decreased pain sensitivity whengiven an intraoral infusion of sucrose(Blass, Fitzgerald & Kehoe, 1987).Sucrose, a disaccharide, was chosen as anaturally occurring, sweet-tastingsubstance. The rats’ response washypothesized to be one of endogenousopioid mediation because the increasedpain threshold could be normalized withadministration of a narcotic antagonist(Shide & Blass, 1989). Thus, there wasinitial support for the concept that sweet-tasting solutions given orally maysomehow link with the endogenousopioid pathways.

From animal models to human models,the hypothesis that sucrose may mediateminor procedural pain has resulted in anumber of studies with both term andpreterm baby populations. Sucrose andother sweet-tasting solutions given bymouth in small volumes have beenconsistently associated with calming andrelief of procedural pain such as thatexperienced with a heel stick or avenipuncture (Blass & Hoffmeyer, 1991;Bucher et al., 1995). Common measures ofpain used in the studies have includedduration of crying, pain scores, andphysiological parameters such as heart rate(Stevens, Taddio, Ohlsson & Einarson,1997). Researchers consistently reportedthat heart rate elevation, duration of cryingand pain scores were significantly reducedin study groups of neonates who receivedsucrose (Bucher, et al., 1995; Haouari,Wood, Griffith & Levene, 1995;Ramenghi, Wood, Griffith & Levene,1996a). Early study designs that combinedsucrose and non-nutritive sucking werecriticized because both endogenous opioidand other non-opioid mechanisms mayhave mediated the antinociceptive resultsachieved. To control for the behaviours ofsucking, licking and swallowing, allconsidered to be activities that could be

incompatible with infant crying, furtherstudies removed the non-nutritive suckingvariable and administered sucrose into themouth by way of syringe or dropper.Again, researchers found significantlyfewer pain responses in sucrose treatedneonates (Haouari et al., 1995; Ramenghiet al., 1996a).

Pharmacologyof sucrose

Pharmacokinetics, or the study of howa drug moves through the body over time,is not available for sucrose. Rememberthat opioid release appears to be activatedby the tasting of sucrose, not by thetransmittal of sucrose to some other part ofthe body. Following this current thinkingabout how sucrose achieves its analgesiceffect, it is not necessary and would not beappropriate to measure blood levels ofsucrose (A. Taddio, personalcommunication, March 26, 1998).

Pharmacodynamics, or the study ofthe dose-response relationship, isavailable for sucrose. The initialcalculations were performed with animalmodels; further testing with humanmodels has provided support that theavailable pharmacodynamic informationis correct (Blass, et al. 1987; Blass &Shah, 1995). Throughout the currentresearch, the dose-response time that hasbeen most efficacious remains a two-minute time period, an interval thoughtto coincide with endogenous opioidrelease associated with sweet taste(Haouari et al., 1995; Stevens et al.,1997). Although only trace amounts ofsugar could be detected by chemicalanalysis of the saliva within one minuteafter termination of the intraoral sucroseinfusion (Blass & Hoffmeyer, 1991), theefficacy of sucrose as an antinociceptiveagent lasted for at least five to 10 minutesafter its administration had beencompleted (Stevens et al., 1997).

To date, there have been no adverseeffects reported in any study examiningthe effects of sucrose in the neonatalpopulation. However, the long-term risksassociated with sucrose administration toneonates, particularly very low birthweight infants, are unknown. Of interest,infants who receive sucrose are notsimply sleepier or less aware of externalstimulation; in most cases they arereported to be in calm, alert states ratherthan drowsy or asleep (Blass &Hoffmeyer, 1991).

The research involving sucrose andneonates has involved a variety ofdosages, routes of administration, times

of administration and outcomes assessed.In a meta-analysis of these data, Stevensand associates (1997) have determinedthe optimum sucrose concentration,amount, dosing interval and route ofadministration. The meta-analysisincluded neonatal research studies thatwere prospective, randomized, placebo-controlled trials involving sucrose.Studies that had used other non-pharmacological interventions such asnon-nutritive sucking or bundling werenot included. The outcome of interestwas the proportion of time crying for thethree-minute period after the painfulstimulus began or ended. Stevens et al.(1997) determined that sucrosedecreased the crying time in neonateswho had undergone mildly painfulprocedures such as heel stick orvenipuncture. Sucrose doses of 0.24 g (2ml of 12% weight/volume [w/v] sucrose)or greater were effective in diminishingthe proportion of cry and, in some cases,heart rate when administered by mouthtwo minutes prior to the start of aprocedure. There was little differencebetween 0.24 g and larger doses; inparticular, there did not appear to be anybenefit in administering doses greaterthan 0.50 g (>2 ml of 25% w/v solution).Weak solutions, or those less than 12%w/v, seemed to have insignificantantinociceptive properties and are notrecommended for clinical use (Haouariet al., 1995).

Nursing implicationsFrom the data available, it seems clear

that sucrose has efficacy as an analgesicfor mild procedural pain. Sucrose is notintended to replace traditional analgesicssuch as opioids that are used withcritically ill patients. Rather, it could beused as another adjunctive therapy intreating mild procedural pain.

Clinicians with a research-basedpractice may wish to integrate theavailable data regarding oral sucrose intotheir clinical practice. To do so, it will benecessary to formulate practicalguidelines for the use of oral sucrosebased upon the research findings. TableOne is an example of how this importantresearch may be used in clinical practice.

Recommendationsfor the future

In light of the research completed todate, it is difficult to dispute the fact thatsucrose has some antinociceptive effect forneonates. However, the effect that is seenwith sucrose does not seem to fit into any

CACCN 10-2 Summer 1999 Page Twenty-One

of the present theories of antinociception(Lindahl, 1997). The question that remainsto be answered is how oral sucroseinteracts with the neonate’s body tomodulate mildly painful experiences.

Most of the studies have looked atduration of cry either as a single variableor in combination with some otherphysiological or behavioural variables.Although these findings lend support tothe concept that sucrose is an effectiveantinociceptive, they do not fullyappreciate the complexity of the neonatalresponse to pain. The use of amultivariate approach includingphysiological, behavioral and contextualindices would be a more valid measureof neonatal pain for all infants includingthe very low birth weight and criticallyill (Stevens et al., 1997).

To date there have been only twopublished studies of preterm babies of 27-36 weeks gestational age (Abad, Diaz,Domenech, Robayna & Rico, 1996;Bucher et al., 1995). Therefore, we arelacking knowledge about what theappropriate dosing or risks associated withthe intervention may be for very low birthweight infants. A concern exists that anyhyperosmolar solution given frequently(eight to 12 times per day) may increasethe risk of necrotizing enterocolitis inpreterm babies (Willis, Chabot, Radde &Chance, 1977). One may argue the volumeof sucrose given is small and theantinociceptive effect is obtained throughtasting; however, there are no dataavailable to completely dispute thisconcern. There remains uncertainty as tothe appropriate use of sucrose with infantswho are very low birth weight or moremature and unstable (Stevens et al., 1997).

These neonatal results do not appearto be transferable to older populationsof infants. Allen, White and Walburn(1996) reported that orallyadministered sucrose minimized cryingin one study group of two-week-oldbabies who were having immunizationinjections. However, other study groupsof babies who ranged in age from twomonths to 18 months received novisible benefit from the sucrosepretreatment. More research will needto be completed to determine the exactgestational age, and equally importantin the NICU, the chronological age,when sucrose loses its efficacy as anantinociceptive agent.

Research studies are now diversifyingto study other sweet substances such asglucose (the solution normally used forintravenous infusions in the NICU) andbreast milk, which are more commonly

Table One: Clinical guidelines for mild pain management

Guideline Rationale

• Consider adding sucrose as analgesic • Other analgesics such as opioidsmodality to your nursery will remain the therapy of choicepharmaceutical formulary for critically ill infants or those who

• Do not use sucrose to replace other are experiencing procedures that more appropriate analgesia for the would be considered more thancritically ill neonate or the neonate mildly painful (“Pacifiers”, 1992)who is undergoing frequent painfulevents or experiencing severeprocedural pain

• Prepare sucrose in amounts of • This concentration and amount has 0.24 g - 0.50 g (2 ml of 12 % w/v, been identified as the most 1 ml of 25 % w/v; 2 ml of 25 % w/v) efficacious to mediate painful

events for neonates(Stevens et al., 1997)

• Administer intraoral dose two • This timing allows sucrose to be minutes before starting procedure most efficacious for neonates

during a 5-10 minute procedure (Stevens et al., 1997)

• Administer mainly to the • 90% of the taste buds are locatedanterior part of the tongue on the anterior part of the tongue,

resulting in enhanced opioid release(Ramenghi et. al., 1996a)

• Sucrose may be used as an • When appropriate, offer other adjunctive therapy along with consoling co-interventions traditional soothing techniques (bundling, soother) during the

procedure (Campos, 1988)

• Plan to use sucrose as an • Using sucrose less than eight times antinociceptive management fewer each day may decrease the hypo-than eight times each day in thetical risk of NEC (necrotizing pre-term babies. This should not enterocolitis) secondary to thebe an issue; a neonate requiring hyperosmolar solution (Willis,minor procedural intervention more Chabot, Radde & Chance, 1977)than eight times per day requires • One may ask the questions: Is thisreassessment of the total plan of care baby an appropriate candidate for

another type of intervention or analgesia? Does this neonate require all of these procedures?

• Complete and document a neonatal • Consider such neonatal pain scores as:pain score during and after the • NIPS. Neonatal Infant Pain procedure to evaluate the efficacy Score (Lawrence et al., 1993)of your intervention • PIPP. Premature Infant Pain

Profile (Stevens, Johnston, Petryshen & Taddio, 1996)

• DSVNI. Clinical Distress Scalefor Ventilated Newborn Infants(Sparshott, 1996)

• Review new research • New information being generated findings regularly will further refine your clinical

practice that includes sucrose asan analgesic therapy

CACCN 10-2 Summer 1999Page Twenty-Two

available in the nursery than sucrose.Skogsdal, Eriksson and Schollin (1997)used a cohort of well preterm babies tomeasure a variety of solutions that wereadministered two minutes before apainful event. Breast milk was found tobe ineffective for mediating cryingassociated with a painful event, but 30%w/v glucose in the amount of 1.0 ml wasfound to significantly diminish the cryresponse in babies undergoing heel pricksand lab collections. These researchfindings will clarify for clinicians thatthere is no reason to enhance therelationship between the pleasurable actof feeding and a noxious pain experience.

Another research study compared asweet-tasting “sugar-free” solution withsucrose (Ramenghi, Wood, Griffith &Levene, 1996b). The sugar-free solutionwas found to be equally efficacious withsucrose solutions in reducing crying timeand pain scores three minutes after thepainful stimulus of blood sampling viaheel stab.

We are clearly at the ‘tip of theiceberg’ of understanding how and whysucrose is efficacious as an analgesicagent. Carefully planned and executedclinical trials and studies will only serveto further develop the knowledge thatwill guide clinical management of mildprocedural pain for the neonatalpopulation.

ConclusionsJust as the pharmacokinetics and

pharmacodynamics of each drug areunique for the neonatal population(Patrick, 1995), sucrose provides aunique therapy for this particular group ofinfants. For many nurses with a clinicalpractice in the NICU, neonatalnociception is recognized andacknowledged. There remain gapsbetween adequate assessment techniquesand appropriate treatment modalities forwhat has been assessed. The body ofresearch exploring sucrose and neonatalpain responses that has been generatedover the last 10 years adds anotherweapon into the nurse’s arsenal to addressunmediated neonatal pain. Sucrose wouldseem to provide another safe analgesicfor mild procedural pain.

About the authorStacey Dalgleish is a member of theneonatal transport team for the CalgaryRegional Health Authority and aninstructor in the maternal infant childnursing post-basic program at MountRoyal College, Calgary, Alberta.

References

Abad, F., Diaz, N., Domenech, E., Robayna, M., & Rico, J. (1996). Oral sweetsolution reduces pain-related behavior in preterm infants. Acta Paediatrica, 85, 854-858.

Allen, K., White, D., & Walburn, J. (1996). Sucrose as an analgesic agent forinfants during immunization injections. Archives of Pediatrics and AdolescentMedicine, 150, 270-274.

Bell, S. (1994). The national pain management guidelines: Implications forneonatal intensive care. Neonatal Network, 13, 9-17.

Blass, E., Fitzgerald, E., & Kehoe, P. (1987). Interactions between sucrose, painand isolation distress. Pharmacological Biochemical Behavior, 26, 483-489.

Blass, E., & Hoffmeyer, L. (1991). Sucrose as an analgesic for newborn infants.Pediatrics, 87, 215-218.

Blass, E., & Shah, A. (1995). Pain-reducing properties of sucrose in humannewborns. Chemical Senses, 20, 29-35.

Bruck, E. (1991). Sucrose as an analgesic for newborn infants [Letter].Pediatrics, 88, 655.

Bucher, H., Moser, T., Von Siebenthal, K., Keel, M., Wolf, M., & Duc, G.(1995). Sucrose reduces pain reaction to heel lancing in preterm infants: A placebo-controlled, randomized and masked study. Pediatric Research, 38, 332-335.

Campos, R. (1988). Comfort measures for infant pain. Zero to Three, 6-13.Franck, L. (1993). Identification, management, and prevention of pain in the

neonate. In C. Kenner, C. Brueggemeyer, & L. Gunderson (Eds.), Comprehensiveneonatal nursing: A physiologic perspective (pp. 913-925). Philadelphia: W.B.Saunders.

Haouari, N., Wood, C., Griffiths, G., & Leven, M. (1995). The analgesic effectof sucrose in full term infants: A randomized controlled trial. British MedicalJournal, 310, 1498-1500.

Lawrence, J., Alcock, D., McGrath, P., Kay, J., MacMurray, S., & Dulberg, C.(1993). The development of a tool to assess neonatal pain. Neonatal Network, 12,59-66.

Lindahl, S. (1997). Calming minds or killing pain in newborn infants? ActaPaediatrica, 86, 787-788.

Pacifiers, passive behavior and pain. (1992). Lancet, 339, 275-276.Patrick, C. (1995). Therapeutic drug monitoring in neonates. Neonatal

Network, 14, 21-26.Ramenghi, L., Wood, C., Griffith, G., & Levene, M. (1996a). Reduction of pain

response in premature infants using intraoral sucrose. Archives of Disease inChildhood, 74, F126-F128.

Ramenghi, L., Wood, C., Griffith, G., & Levene, M. (1996b). Effect of non-sucrose sweet tasting solution on neonatal heel prick responses. Archives of Diseasein Childhood, 74, F129-F131.

Shide, D., & Blass, E. (1989). Opioid-like effects of intraoral infusions of cornoil and polycose on stress reactions in 10-day-old rats. Behavioral Neuroscience,103, 1168-1175.

Skogsdal, Y., Eriksson, M., & Schollin, J. (1997). Analgesia in newborns givenoral glucose. Acta Paediatrica, 86, 217-220.

Sparshott, M. (1996). The development of a clinical distress scale for ventilatednewborn infants: Identification of pain and distress based on validated behavioralscores. Journal of Neonatal Nursing, 2, 5-10.

Stevens, B. (1996). Pain management in newborns: How far have weprogressed in research and practice? Birth, 23, 229-235.

Stevens, B., Johnston, C., Petryshen, P., & Taddio, A. (1996). Premature infant pain profile:Development and initial validation. Clinical Journal of Pain, 12, 13-22.

Stevens, B., Taddio, A., Ohlsson, A., & Einarson, T. (1997). The efficacy ofsucrose for relieving procedural pain in neonates - a systematic review and meta-analysis. Acta Paediatrica, 86, 837-842.

Truog, R., & Anand, K. (1989). Management of pain in the postoperativeneonate. Clinics in Perinatology, 16, 61-78.

Willis, D., Chabot, J., Radde, I., & Chance, G. (1977). Unsuspectedhyperosmolality of oral solutions contributing to necrotizing enterocolitis in very-low-birth-weight infants. Pediatrics, 60, 535-538.

Smith and Nephew AdNew four colour film supplied

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Twenty-Four

Challengingrestricted visitingpolicies in critical care

By Sharon M. Chow,RN, MN(c), CNCC(C)

AbstractThe need for family members to visit

their loved ones when they have beenadmitted into the critical care unit wasidentified in 1979 by Molter in thecritical care family needs inventory(CCFNI). This need has been the centreof controversy for critical care units formany years. This article provides anoverview of literature that refutes someof the rationales that have been used torestrict family visiting in the criticalcare unit. An overview of a liberalized(open, contract, inclusive or structured)visiting policy is discussed as an optionto the restricted visiting policy.

The admission of a family memberinto a critical care unit often occurswithout warning, allowing very littletime for adjustment by both the familyand the patient. Family members mayconsider the admission to a critical careunit a crisis or, at best, a stressful time.

Molter (1979) identified needs offamily members following theadmission of their loved one into acritical care unit in her study onfamilies. Forty-five needs wereidentified through family assessmentsand self-reporting. These needs wereincorporated into the critical care familyneeds inventory (CCFNI). Through theuse of factor analysis, the 45 needs havebeen clustered into the five categories:support, comfort, information, proximityand assurance. Only the proximitycategory will be addressed in thisarticle.

The proximity category encompasseseight specific needs that reflect, fromthe family’s perspective, personalcontact and a sense of being near,physically and emotionally, to theirloved one (Table One). Research byFisher (1994), Kirschbaum (1990),Leske (1991) and Titler and Walsh(1992) support the need of family

members to visit their critically ill lovedone. The need of family members to benear their loved one challenges criticalcare units to review their visitationpolicies to ensure that the proximityneeds are met for the families.

In 1982, Kirchhoff reported that inthe United States visitors were restrictedto visiting their loved one every twohours for 10 minutes at a time and onlytwo visitors were permitted at a time.Eleven years later Dracup (1993)reported that restricted visitation stillappeared to be the norm in the majorityof intensive care units in the UnitedStates but was a policy that was beingexamined. Messner (1996) recognizedthat the examination of visiting policiesin the United States was being driven byeconomics as consumer satisfaction wasencouraged to ensure loyalty to thehealth care facility. Recently, Carlson,Riegel and Thomason (1998) reported adecrease in restricted visiting incoronary care units.

The terms restricted, rigid and closedvisitation are used interchangeably inthe literature. (In this article, the termrestricted visiting will be used.)Lewandowski (1994) and Moseley andJones (1991) stated that these terms areall used to describe policies that restrict

visiting by imposing times andfrequencies. Moseley and Jones (1991)referred to flexible or liberal visitationpolicies (common in pediatric andneonatal critical care units) as policiesthat allowed an increased frequency inthe number and length of visits. Liberalvisitation practices such as open,contract, structured or inclusive will bediscussed later in this article.

Rationale forrestricted visiting

Lewandowski (1994) reported thefollowing reasons for restricted visitingin adult critical care units as stated bynurses:• only immediate family members are

those best able to provide support to the patient

• patients need rest and visitors are too fatiguing

• visitors create adverse hemodynamic responses in patients

• family members are disruptive to unit functioning, and

• rules must apply equally to everyone if the system is to be fair. These reasons often serve as the

basis for restricted visiting in criticalcare units. In the following discussion,

Table One: Proximity needs of family members of critically ill patients

To visit any time.To see the patient frequently.To receive information about the patient once a day.To have visiting hours changed for specific conditions.To be told about transfer plans while they are being made.To have the waiting room near the patient.To have visiting hours start on time.To talk to the same nurse every day.

(Titler & Walsh, 1992, p. 624).

CACCN 10-2 Summer 1999 Page Twenty-Five

it will be evident the above rationalesfor restricted visiting are not supportedby research and should challenge anycritical care unit which has a restrictedvisiting policy.Only Immediate Family Members.The traditional 1950s view of the“normal” family structure is no longer auseful conceptualization of the family.Lewandowski (1994) defined the familyas “the patient’s description of who heor she considers family and whosepresence would be most supportive” (p.56). Moseley and Jones (1991)concurred with this definition andexpanded it to include significant othersand those who are not related by blood.These definitions acknowledge thefamily to include sexual orientation,marital status, blended families, closefriends, and cultural and ethnicbackgrounds. Therefore, the rationalethat only the immediate family is bestable to provide the best support is nolonger valid as it is dependent on thepatient’s definition of their family.According to Titler, Bombei and Schutte(1995), the supportive role to thecritically ill patient can only be fulfilledby the persons that the patient considersto be family and this may includepersons other than the immediatefamily.

The “family” members of thecritically ill patient who is unable toverbalize due to intubation, sedation orthe result of an injury, must bedetermined by the nursing staff incollaboration with members of thefamily and friends who may be present.These family members and friendswould be the primary source ofinformation to identify who would be asupport to their loved one.

Traditionally, children have not beenpermitted to visit in the intensive careunit even though they are members ofthe immediate family. Youngner,Coulton, Welton, Juknialis, and Jackson(1984) reported survey results thatindicated 77% of the intensive careunits (ICU) rarely or never allowedchildren under age 12 to visit. Inaddition, less than 20% of ICUs have apolicy for children to visit their familymember. No current results have beenfound to compare whether changes haveoccurred in the last 15 years.

Johnson (1994) identified someassumptions made by nurses that limitedthe ability for children to visit in thecritical care unit. These include thepossibility of children causing adversepsychological effects on themselves,

increased incidence of infections, and anincrease in the number of negativeincidents by unsupervised children. It isimportant to remember that children arean integral part of a parent’s life.Although a person becomes a patientwith a critical illness, they do not stopbeing a parent. The parent, who is nowthe critically ill patient, will miss theirchildren. Short but important andmeaningful visits from their childrencan provide the ill parent with hope forrecovery, memories of their life as afamily and be a diversion for the illparent. Children may provide a positivepsychological influence on the patientand promote healing.

Other studies refute the aboveassumptions made by nurses. Kowbaand Schwirian (1985) found that therewas no increase in infection rates ofnewborns after the newborns received avisit from a sibling. A pilot study byNicholson et al. (1993) supportedchildren visiting adult family membersin critical care. These researchers founda greater reduction of negativebehaviours in the group of children whovisited their family than in the group ofchildren who did not visit their lovedone. As research continues to supportchildren visiting adult critical care units,this will require a change in visitationpolicies and practices.

A family member or significant otherin someone’s life may not always behuman. This may be a pet they have hadfor many years. Will restricted visitingpermit these family members to visit?Probably not! Cole and Gawlinski(1995) reported the implementation ofan animal assisted therapy program in acardiac care unit in Los Angeles. Coleand Gawlinski (1995) found that boththe patients and family members haveresponded positively to having dogsvisiting in the unit.

In summary, it is clear from theresearch that family visiting is importantto patients. The family must be definedby each patient in order to meet theneeds of the patient and his or herfamily. Patients need rest. Lazure (1997)found that critical care nurses wereconcerned about visitors tiring patients;however, in contrast, the patientsperceived that they had more rest whenthey had control of visiting than whenvisiting was controlled by the nurse.Comptom (1991) and Simpson (1991)found that, according to patients, theircontact with their families was ‘nottiring’ but was an important and

meaningful factor enabling them to copewith critical illness.

McHugh, Clark and Pierson (1992)identified that restricting visitation maycontribute to sensory deprivation, whichcould lead to delirium in critical carepatients. Sensory deprivation is definedas “not simply due to a reduction instimulation of the patient’s senses. It isrelated to a reduction in meaningfulstimuli, the lack of familiar stimuli andthe misinterpretation of stimuli” (p.1223). These authors support familyvisits as being beneficial in themanagement of sensory deprivation byproviding stimulation, orientation, andreassurance to patients regardless of thepatients’ level of consciousness. In astudy by Bay, Kupferschmidt,Opperwall and Speer (1988), thepatient’s orientation to time, place andperson was improved significantly afterreceiving visits.

In summary, the stimulation causedby family visits does not detract fromthe rest of patients but may promote restfor some patients. In the situation ofpatients who are able to regulate theirown rest times, the control of visitationshould be monitored by the patientswhenever possible.Visitors create adverse hemodynamicresponses in patients. The belief thatvisitors can create adversehemodynamic responses in patients isbased on several studies of patients whoexperienced adverse physiologicaleffects during visits from familymembers. Brown (1976) concludedfrom her study that family visits shouldonly be limited to 10 minutes everyhour because of an adverse effect onblood pressure and heart rate. Lazure(1997) found that the initial increase inthe patient’s vital signs returned tobaseline after 10 minutes.

Thomas, Lynch and Mills (1975)reported that patients had two times asmany ectopic heartbeats during clinicalinteractions. These interactions includedfamily visits and nursing interventions.Fuller and Foster (1982) found thatfamily visits were no more stress-provoking than nurse-patientinteractions or the patients observingprocedures performed on other patientsin the unit.

Adverse hemodynamic responsesfrom nursing interventions have beenrecorded in several studies (Clark,Winslow, Tyler & White, 1990; Copel &Stolarik, 1991; Tidwell, Ryan,Osguthorpe, Paull & Smith, 1990; Tyler,Winslow, Clark & White, 1990;

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Twenty-Six

Winslow, Clark, White & Tyler, 1990).These researchers have all identifiedthat various nursing interventions suchas endotracheal suctioning, positionchanges and a one-minute back rub allproduce an increase in oxygenconsumption of 10-50% in patients. Ifpatients become excited and anxiouswhen they interact with their visitors, anincrease in oxygen consumption canoccur and may not be a desiredoutcome. However, researchers have notidentified any adverse effects fromhaving a family member at the bedsidestroking the arm or holding the hand oftheir loved one.

The effect of visitors on patients’intracranial pressure has beeninvestigated by Prins (1989) andTreolar, Nalli, Guin and Gary (1991).Prins (1989) found that family visits didnot have a significant effect onintracranial pressure. Treolar et al.(1991) found that the intracranialpressure was not affected by familiarand unfamiliar verbal stimulation.

In summary, the research ofphysiological effects of family visitingdoes not reveal any detrimental effectsto the patients. Families disrupt unit functioning.Lewandowski (1994) identified thatnurses perceived that families disruptthe unit functioning by disrupting thecontrolled atmosphere of a critical careunit and by distracting nurses fromnursing care. Moseley and Jones (1991)found the disruption to the unit or fromnursing care can be avoided throughcareful planning of treatments andprocedures with the patient and familymembers. O’Malley et al. (1991)reported that family members were a“source of stress for critical care nurseswho were not prepared to meet theneeds of the families” (p. 190). Becauseof this stress a disruption in the caremay occur as the nurse is faced with anexternal stressor with which he or she isnot ready to deal.Rules must apply equally to everyone.Despite the rationale of applying rulesequally to everyone, Lewandowski(1994) identified that some nursesaltered the rules for families who werevisiting their loved ones because thenurses experienced discomfort withofficial policies, peer pressure fromcolleagues, or personal feelings towardsthe family. Dracup (1993) supported thisposition by stating that “what worksbest for families also works best fornurses” (p. 8) and that the restrictedenvironment may cause families further

frustration and hostility. The application of rules portrays a

paternalistic model as nurses assume theresponsibility for determining what isthe best for the patient. By restrictingvisiting in the critical care units,families are all treated in the samerestrictive manner.

Options for visitingThe rationales for restricting visiting

are not supported in the literature andthus, the identification of options torestricted visiting is necessary toprovide the best care to patients andtheir families. Henneman, McKenzie &Dewan (1992) found that theimplementation of an open visitingpolicy increased family satisfaction. Thevarious types of liberalized or openvisiting policies that will be discussedare: open, contract, structured, andinclusive visiting.Open Visiting. Titler and Walsh (1992)defined open visiting as imposing norestrictions in frequency, time, or lengthof visits on the family members;however, restrictions may still be placedon the number and type of visitors. Therestrictions imposed would bedependent on the physical environmentof the critical care unit. Open visitingmay be the ideal option in units withprivate rooms where families maycommunicate openly and privately.Doors may be closed to promote familyvisits instead of limiting them due to theclose proximity of other patients in theunit. Contract Visitation. Contract visitationis implemented by developing a visitingcontract with the family members,patient and the nurse regarding thetimes, frequency, and length of visitsand number, age, and type of visitors. Inaddition to identifying the visitors andthe visitation of the family, Moseley andJones (1991) suggested that the contractcan also identify if the family wouldlike to participate in the care of theirloved one and what they would like todo. In addition, reasons for alteringpredetermined visiting times can beidentified and explained to the familymembers (e.g., a cardiac arrest situationin the unit).

Gurley (1995) reported that contractvisiting resulted in an increased sense ofcontrol for the nurse, the family andpatient. The predetermined times ofvisiting for the family would enable thenurse to plan patient care around thevisiting times. Family members andpatients’ frustrations could be avoided,

as they are aware of the designatedvisiting times as outlined in the contract.Structured Visiting. The onlydifference between structured visitingand restricted visiting is in the length oftime visitors may stay. Visitors may beable to stay 30 to 60 minutes versus therestricted visiting time of five to 10minute visits. The main disadvantageTitler and Walsh (1992) identified instructured visiting is a lack of controlfor the family over the frequency ofvisits, number of visitors and who canvisit as visitors are limited to two at atime only.Inclusive Visiting. Inclusive visitingwould permit visiting at any time exceptat standardized times specified by thenursing staff. The most common timethat family members are not permittedto visit is during shift change to ensureconfidentiality. Inclusive visiting hoursshould be determined to facilitate familyvisiting in the mornings when thefamily member is on their way homeafter night shift or in the evenings whena family member may be going homeafter an extended day shift.

Concluding thoughtsThe issue of visiting in the critical

care setting continues to be acontroversial one. Rationales forrestricted visiting are not supported bythe research. Patients need to identifythe members of their family and whomthey would like to visit. When patientshave the power to determine theirvisitors and the times for visiting, theyreport a greater sense of control andincreased sense of being rested. Earlystudies that identified visitors as asource of adverse hemodynamic effectsare not supported by current research.In fact, nursing interventions have beenidentified as causing adversehemodynamic effects on our patientsalso. Disruptive family visits have notoccurred when family members wereallowed to determine a plan forvisiting. Children and pet visiting havebeen shown to be an asset to patientsand not cause a disruption or adverseeffects.

Open visiting offers options to anycritical care unit that has a restrictedvisiting policy. As nurses, we have beeneducated that caring for the patientincludes caring for the family. Open,contract, structured and inclusive are alltypes of liberalized visiting that enablenurses to care for the needs of thefamily members and the needs of ourpatients to be near their family. In

CACCN 10-2 Summer 1999 Page Twenty-Seven

challenging the restricted visiting policyand the rationales for the restriction,nurses can be advocates for the needs ofour patients and their families.

References

Bay, E., Kupferschmidt, B., Opperwall, B., & Speer, J.(1988). Effect of the family visit on the patient’s mentalstatus. Focus on Critical Care, 15(10), 10-16.

Brown, A.J. (1976). Effect of family visits on the bloodpressure and heart rate of patients in the coronary-care unit.Heart & Lung, 5, 291-296.

Carlson, B., Riegel, B., & Thomason, T. (1998).Visitation: Policy versus practice. Dimensions of CriticalCare Nursing, 17(1), 40-47.

Clark, A.P., Winslow, E.H., Tyler, D.O., & White, K.M.(1990). Effects of endotracheal suctioning on mixed venousoxygen saturation monitoring and heart rate in critically illpatients. Heart & Lung, 19, 552-556.

Cole, K.M., & Gawlinski, A. (1995). Animal-assistedtherapy in the intensive care unit: A staff nurse’s dream cometrue. Nursing Clinics of North America, 30(3), 529-537.

Comptom, P. (1991). Critical illness and intensive care:what it means to the client. Critical Care Nurse, 11, 50-56.

Copel, L.C., & Stolarik, A. (1991). Impact of nursingcare activities on SvO2 levels of postoperative cardiac surgerypatients. Cardiovascular Nursing, 27(1), 1-6.

Dracup, K. (1993). Challenges in critical care nursing:helping patients and families cope. Critical Care Nurse, 13(Suppl. Aug), 4-9.

Fisher, M.D. (1994). Identified needs of parents in apediatric intensive care unit. Critical Care Nurse, 14(3),82-90.

Fuller, B., & Foster, G. (1982). The effect offamily/friend visits vs. staff interaction on stress/arousal ofsurgical intensive care patients. Heart & Lung, 11, 457-463.

Gurley, M.J. (1995). Determining ICU visiting hours.MEDSURG Nursing, 4(1), 40-43.

Henneman, E.A., McKenzie, J.B., & Dewan, C.S.(1992). An evaluation of interventions for meeting theinformation needs of families of critically ill patients.American Journal of Critical Care, 1(3), 85-93.

Johnson, D.L. (1994). Preparing children for visitingparents in the adult ICU. Dimensions of Critical CareNursing, 13, 152-165.

Kirchhoff, K. (1982). Visiting policies for patients withmyocardial infarction: a national survey. Heart & Lung, 6,571.

Kirschbaum, M.S. (1990). Needs of parents of criticallyill children. Dimensions of Critical Care Nursing, 9, 344-352.

Kowba, M.D., & Schwirian, P.M. (1985). Direct siblingcontact and bacterial colonization in newborns. Journal ofObstetric, Gynecologic and Neonatal Nursing, 14, 412-417.

Lazure, L.L.A. (1997). Strategies to increase patientcontrol of visiting. Dimensions of Critical Care Nursing, 16,11-19.

Leske, J.S. (1991). Internal psychometric properties ofthe critical care family needs inventory. Heart & Lung, 20,236-244.

Lewandowski, L.A. (1994). Nursing grand rounds.Journal of Cardiovascular Nursing, 9(1), 54-60.

McHugh, L.G., Clark, K.G., & Pierson, D.J. (1992).Psychosocial aspects of critical care. In D.J. Pierson & R.M.Kacmarek (Eds.), Foundations of Respiratory Care (pp.1221-1236). New York, NY: Churchill Livingstone.

Messner, R.L. (1996). Visiting hours: What’s reallybest? RN, 59(10), 27-30.

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Moseley, M.J., & Jones, A. (1991). Contracting forvisitation with families. Dimensions of Critical CareNursing, 10, 364-371.

Nicholson, A.C., Titler, M., Montgomery, L.A., Kleiber,C., Craft, M.J., Halm, M., Buckwalter, K., & Johnson, S.(1993). Effects of child visitation in adult critical care units: apilot study. Heart & Lung, 22, 36-45.

O’Malley, P., Favaloro, R., Anderson, B., Anderson,M.L., Siewe, S., Benson-Landau, M., Deane, D., Feeney, J.,Gmeiner, J., Keefer, N., Mains, J., & Riddle, K. (1991).Critical care nurse perceptions of family needs. Heart &Lung, 20, 189-201.

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About the authorSharon M. Chow, RN, MN(c), CNCC(C), is a Masters of Nursing Graduate Studentat the University of Saskatchewan in Saskatoon, Saskatchewan.

CACCN 10-2 Summer 1999CACCN 10-2 Summer 1999Page Twenty-Eight

Membership Why CACCN?The voice for Canadian critical care nurses involved inpractice, education, research and administration in:• Medical ICU • Surgical ICU• Cardiovascular ICU • Neurosurgical ICU• Neonatal and Paediatric ICU • CCU• Burn Units • Recovery Room• Trauma UnitsMission

StatementThe Canadian Association ofCritical Care Nurses is a non-profit, specialty organizationdedicated to maintaining andenhancing the quality of careprovided to critically ill patientsand their families.We serve the public, ourmembers and the critical carenursing community by meetingthe professional and educationalneeds of critical care nurses.These needs are met by:• developing and implementingstandards of critical care nursingpractice• providing educationalopportunities• supporting and facilitatingcritical care nursing research• providing opportunities fornetworking• identifying and addressingpolitical and professional issues• collaborating with otherprofessional organizations

Objectivesi) to provide informed guidancein shaping the delivery systemas it relates to the care of thecritically illii) to determine standards forcritical care nursingiii) to determine certificationstandards for national testing forthe specialty of critical carenursingiv) to promote and provideeducational opportunitiesv) to improve the quality ofpatient care through thepromotion of nursing research incritical carevi) to promote membership andchapter development.

Application for membershipName: ____________________________________________________________

Address: __________________________________________________________

_________________________________________________________________

W (____) ____ - ________ H (____) ____ - ________ F (____) ____ - _______

Employing Agency: _________________________________________________

Position: __________________________________________________________

Area of Employment: _______________________________________________

Nursing Registration No.: ______________________ Province: _____________

Chapter Affiliation: _________________________________________________

Sponsor’s Name: ___________________________________________________

Please check one:o New Member $64.20 (includes 7% GST)o Renewal $64.20 (includes 7% GST) - Present Number _______________

Are you a CNA member? o Yes, o No

Signature: ________________________________________________________

Date: ____________________________________________________________

Please Note: This application is for both national and chapter membership.

Make cheque or money order payable to:Canadian Association of Critical Care Nurses (CACCN)Mail to: CACCN, P.O. Box 25322, London, Ontario, N6C 6B1Telephone: (519) 649-5284

(Street)

(City) (Province) (Postal Code)

(If applicable)

CACCN 10-2 Summer 1999 Page Twenty-Nine

AwardsAwards availableto CACCNmembers

COBE Chapter of theYear Award ProgramPurpose

To recognize the effort, contributionsand dedication of a chapter of CACCN incarrying out the purposes and goals of theassociation.A. Criteria for the award program1. The award program will be for the periodof July 1 to June 30 each year.2. Chapters may win the award for one yearfollowed by a two-year lapse beforeentering again.3. A point system has been developed toevaluate chapter activities during the year.The chapter with the most points will be thewinner of the Chapter of the Year Award.CACCN reserves the right to adjust pointsdepending upon supporting materialssubmitted.4. The award winner will be announced atChapter Connections Day.B. Conditions for the award program1. All chapters of CACCN are eligible toparticipate provided they have on file atnational office all of their financial(quarterly) and activity (bi-yearly) reportsrequired for the qualifying period.2. Chapters must submit their entry formand accompanying binder to nationaloffice, postmarked by July 31 of that year.3. Each chapter is required to record theiractivities and their total points awarded foreach activity.4. Supporting materials are to betypewritten in a looseleaf binder, separatedby category.5. Each entry must contain a cover sheetlisting the points accrued in each categoryand the total overall points.

If the above conditions are not met, theentry will be disqualified.

The winning chapter will receive aplaque and cheque for $500.00 that will bepresented at that year’s Dynamics.Announcement of the winner will bepublished in CACCN publications. Thewinning chapter’s binder will be displayedat that year’s Dynamics.C. Categories and their correspondingpoints1. List the educational programs, with anaccompanying brochure or pamphlet, thatoccurred during the period of July 1 - June 30.

Programs between:1-3 hours... 25 points each3-8 hours... 50 points each> 8 hours... 100 points each

2. Submit the minutes of business meetingsheld during the qualifying period.10 points for each meeting to a maximum of5 meetings.3. Provide member attendance sheets foreach program and/or meeting, and calculateyour points based on percentage ofmembers that attend the program and/ormeeting out of the total chaptermembership.

e.g., 100 members in chapter,25 attend a program/meeting,therefore 25 ÷ 100 x 100% = 25%(30 points)

1-10%....10 points 51-60% .....60 points11-20%... 20 points 61-70%... 70 points21-30%... 30 points 71-80%... 80 points31-40%... 40 points 81-90%... 90 points41-50%... 50 points 91-100%...100 points

4. Submit a list of new members recruitedfrom July 1 to June 30 during thequalifying period, and include nationalCACCN membership numbers. Calculateyour points based on the percentage of newmembers recruited as compared to the totalmembership of July 1 (prior to thequalifying period).

1-10%....10 points 51-60% .....60 points11-20%... 20 points 61-70%... 70 points21-30%... 30 points 71-80%... 80 points31-40%... 40 points 81-90%... 90 points41-50%... 50 points 91-100%...100 points

5. Submit a sample of each newsletterpublished for the membership. A minimumof three are required to qualify for thepoints. Special announcements are not tobe included.100 points6. List each chapter member who hascontributed an article (excluding executivereports) to the chapter newsletter for thequalifying period. Please provide thenewsletter with the articles in it.25 points for each member7. Submit a copy of a written paper(s)authored or co-authored by at least one

member of the chapter that is published inthe Official Journal of the CanadianAssociation of Critical Care Nurses forthe qualifying period.100 points/paper8. List projects that provide publiceducation, community service and/orpromote the image of critical care nursing.These projects must be presented under theauspices of the CACCN chapter.

i.e., participating in blood pressureclinics, teaching CPR to the public,participating in health fairs.

Validation must be provided that theevent was a CACCN-sponsored project by,for example, submitting a letter from thereceiving group or a picture of the event,etc.50 points for each project9. List each chapter member your chapterhas funded to attend Dynamics in thequalifying period. The points will becalculated on a percentage of money spenton that member in relation to the currentfinancial account at that time. Pleaseprovide proof that the member attended.

i.e., $350 spent on a member; total infinancial account at that time= $3,500; therefore$350 ÷ $3,500 x 100% = 10%(10 points)

1-10%....10 points 51-60% .....60 points11-20%... 20 points 61-70%... 70 points21-30%... 30 points 71-80%... 80 points31-40%... 40 points 81-90%... 90 points41-50%... 50 points 91-100%...100 points

In the case of a tie, CACCN reserves theright to determine the winner.Good luck in your endeavours!

Johnson & JohnsonEditorial AwardsThe awardThe Johnson & Johnson Editorial Awardswill be presented to the author(s) of twowritten papers in the Official Journal ofthe Canadian Association of CriticalCare Nurses which demonstrate theachievement of excellence in the area ofcritical care nursing. A $750.00 awardwill be given to the author(s) of the bestarticle, and $250.00 given to the

CACCN 10-2 Summer 1999Page Thirty

author(s) of the runner-up article. It isexpected that the money will be used forprofessional development. Morespecifically, the funds must be used bythe recipient:1) within 12 months following theannouncement of the winners, or within areasonable time;2) to cover and/or allay costs incurredwhile attending critical care nursing-relatededucational courses, seminars, workshops,conferences or special programs or projectsapproved by the CACCN, and3) to further one’s career development inthe area of critical care nursing.Eligibility1) The author(s) is a Canadian citizen2) The primary author(s) is an activemember of the Canadian Association ofCritical Care Nurses (minimum of oneyear).3) The author(s) is prepared to present thepaper at Dynamics of Critical Care(optional).4) The paper contains original work, notpreviously published by the author(s).5) The award may not be presented to thesame author(s) two consecutive years.6) Members of the CACCN board ofdirectors, awards committee or editorialcommittee of the OJCACCN are excludedfrom participation in these awards.Criteria for evaluation1) The topic is approached from a nursingperspective.2) The paper demonstrates relevance tocritical care nursing.3) The content is readily applicable tocritical care nursing.4) The topic contains information or ideasthat are current, innovative, unique and/orvisionary.Style

The paper is written according to theestablished guidelines for writing amanuscript for the Official Journal of theCanadian Association of Critical CareNurses.Selection1) The papers are selected by the awardscommittee in conjunction with the CACCNboard of directors.2) The awards committee reserves the rightto withhold the awards if no papers meetthe criteria.Presentation1) The awards are presented by arepresentative of Johnson & Johnson at theDynamics of Critical Care Conference.

SIMS Educational AwardsThe CACCN Educational Awards have

been established to provide funds ($750.00each) to assist critical care nurses to attendcontinuing education programs at thebaccalaureate and masters nursing levels.All critical care nurses in Canada are

eligible to apply, except members of theCACCN board of directors and the awardscommittee.Criteria for application• be a Canadian citizen• be an active member of CACCN in goodstanding for a minimum of one (1) year.• demonstrate the equivalent of one (1) fullyear of recent critical care nursingexperience in the year of the application.• be an active member (minimum of one [1]year) of a CACCN committee(s) and/orparticipate in other chapter-relatedactivities. Past participation is acceptable.• submit a letter of reference from his/hercurrent employer.• be accepted to an accredited school ofnursing or recognized critical care programof direct relevance to the practice,administration, teaching and research ofcritical care nursing.• contribute to CACCN in return for theaward - successful applicant must submitan article to the official journal within thenext year after receipt of the award.• incomplete applications will not beconsidered; quality of application will be afactor in selecting winners.Application process• submit completed CACCN educationalaward application forms to national office(forms package can be requested fromnational office).• obtain a minimum of 200 merit points(preference will be given to members withthe highest number of merit points).• keep a record of his/her own merit points(form included in forms package).• submit all required documentationoutlined in criteria - candidate will bedisqualified if documentation is notsubmitted with application.Post-application process• all applications will be acknowledged inwriting from awards committee.• unsuccessful applicants will be notifiedindividually by awards committee.• winners will be acknowledged atDynamics of Critical Care and published inthe official journal.Deadlines for receipt of applications innational office are: September 1 andJanuary 31 of each year.

The Johnson & JohnsonInnovative Project Award

The Johnson & Johnson InnovativeProject Award will be presented to a groupof critical care nurses who develop aproject that will enhance their professionaldevelopment. The primary contact personfor the project must be an active member ofCACCN (for at least one year).Applications must be received in CACCNnational office on or before July 1.Presentation of the award will be made atDynamics.

Applications will be judged accordingto the following criteria:1) the number of nurses that will benefitfrom the project,2) the uniqueness of the project, and3) the relevance to critical care nursing.

Within one year, the winning group ofnurses is expected to publish a report thatoutlines their project in the OfficialJournal of the Canadian Association ofCritical Care Nurses.

Do you have a unique idea?Recognition, Recruitmentand Retention Award

This CACCN initiative was establishedto recognize members and the chapters fortheir outstanding achievements withrespect to recruitment and retention.Individual members will be recognized forlong-standing service to the association aswell.Recognition Initiative

Members will receive recognition atDynamics for their long service toCACCN. This will be in the form of apin that will be given to people withfive years, 10 years, 15 years and 20years of continuous membership in theassociation. Membership must berenewed within a two-month window inorder to qualify for continuousmembership. Note: In the new nationalmembership database, all members’“date of joining” is March 1996 orafter.

In addition, new members from theprevious 12 months prior to each Dynamicswill be given ribbons on their name tags ifthey attend Dynamics that year.Recruitment Initiative

This initiative will benefit the chapter ifthe following requirements are met:• If the chapter recruits 25-49 new membersfrom April 1 to March 31 of the next year,they receive one full tuition to Dynamics ofthat year.• If the chapter recruits 50-100 newmembers from April 1 to March 31 of thenext year, they receive one full tuition plus$100.00 to Dynamics of that year.Retention Initiative

This initiative will benefit the chapter ifthe following requirements are met:• If the chapter has 100% renewal of itsprevious year’s members, the chapter willreceive $250.00.• If the chapter has greater than 80%renewal of its previous year’s members, thechapter will receive $150.00.• If the chapter has greater than 60%renewal of its previous year’s members, thechapter will receive $100.00.

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