Operational Readiness: Redesigning Advanced Practice Registered Nurse (APRN) Curriculum for an Evolving Battlefield.

INTRODUCTION: The Global War on Terror and the ensuing Overseas Contingency Operations has rapidly transformed the U.S. military's strategic philosophy for warfare. The paradigm shift to unconventional warfare has forced military medicine to adapt with the rapidly evolving battle space. To this end, large fixed facility hospitals are being replaced with highly mobile and austere medical platforms that serve farther forward. The transition in operational health care has challenged the role of all health care team members.Through the evolution of the modern battlefield, nursing roles have grown and expanded beyond the traditional roles and peacetime practice. Nurses are seeing greater autonomy and scope of practice in operational settings while caring for patient pathologies that are often different than at home. The expansion of practice extends beyond the registered nurse at the bedside to the Advanced Practice Registered Nurse (APRN) that serves in the provider role. Through anecdotal reports, and a growing body of literature, that APRN operational practice is different than in the traditional health care setting. MATERIALS AND METHODS: Although a variety of organizations have codified knowledge, skills and attitudes (KSAs) relevant to operational practice, no formal APRN operational curriculum currently exists. Using an adaptation of Kern's Six-Step Model of curriculum design, we describe a curriculum development process used to improve and focus educational experiences to better prepare APRNs for evolving operational roles. RESULTS: Through deliberate approaches the GSN has reimagined its operational readiness curriculum for the preparation of the military APRN on the evolving battlefield. The GSN has operationalized APRN operational readiness through the integration of operationally relevant curriculum designed around interprofessional education experiences. Through this curricular design, GSN APRN students are provided with operationally relevant experiences in the context of authentic military scenarios. Through these encounters, we believe, allows our students to successfully develop the clinical, operational and teamwork skills to successfully perform care in austere and operational settings. CONCLUSIONS: This manuscript describes a novel approach to provide operational readiness education to military APRN students. Through an evaluation of the current literature, expert reports and information of the current operational requirements, the USU GSN has developed a model and curricula for APRN operational readiness that lie beyond the traditional skills in the peacetime setting. Through this plan of instruction, USU GSN APRN students will have the requisite skills to meet the evolving operational needs of the Department of Defense.

Compassion fatigue in military healthcare teams.

Since the onset of the Iraq war and Afghanistan conflicts, military healthcare teams have had increasing exposure to the traumatic effects of caring for wounded warriors, leading to a phenomenon termed compassion fatigue. The purpose of this integrative review was to develop a proposed definition for compassion fatigue in support of these teams. There is no current standardized formal definition, and this lack of clarity can inhibit intervention. Seven main themes evolved from the literature review and were integrated with the core elements of the Bandura Social Cognitive Theory Model as the first step in developing a uniformed definition.

Implementing AORN recommended practices for medication safety.

Medication errors in the perioperative setting can result in patient morbidity and mortality. The AORN "Recommended practices for medication safety" provide guidance to perioperative nurses in developing, implementing, and evaluating safe medication use practices. These practices include recognizing risk points in the medication use process, collaborating with pharmacy staff members, conducting preoperative assessments and postoperative evaluations (eg, medication reconciliation), and handling hazardous medications and pharmaceutical waste. Strategies for successful implementation of the recommended practices include promoting a basic understanding of the nurse's role in the medication use process and developing a medication management plan as well as policies and procedures that support medication safety and activities to measure compliance with safe practices.

Perioperative pharmacology: patient-controlled analgesia.

Patient-controlled analgesia (PCA) is an effective treatment option for reducing pain, but PCA errors can be quite serious. Opioid analgesics are among the most effective pain relievers available, but all have contraindications and can have adverse effects, including respiratory depression and other effects on the central nervous system. Practitioners must weigh the potential benefits of PCA use against the risks. Errors associated with the PCA process have been documented in each phase of the medication-use process; therefore, practice improvements in prescribing, transcribing, dispensing, administering, and monitoring PCA may reduce the likelihood of errors. Perioperative nurses can make important contributions to safe PCA use by establishing standardized processes to help ensure positive patient outcomes in pain management.

Perioperative pharmacology: blood coagulation modifiers.

Blood coagulation is the process that results in the formation of a blood clot to stop bleeding from a damaged blood vessel. Various pharmacologic agents can affect the coagulation process. The American College of Chest Physicians' evidence-based practice guidelines for perioperative management of antithrombotic therapy provide guidance for anticoagulant or antiplatelet therapy and bridge therapy. Perioperative nurses must understand the pharmacologic principles of the most common blood coagulation modifiers related to perioperative use. The perioperative nurse's responsibilities regarding administration of blood coagulation modifiers include reviewing the patient's pertinent laboratory results (eg, prothrombin time, partial thromboplastin time, international normalized ratio), recognizing the underlying conditions that require blood coagulation therapy, and documenting all pertinent information. Perioperative nurses also should participate in development of detailed storage and retrieval policies related to heparin.

Perioperative pharmacology: antibiotic administration.

Accurate and timely administration of antibiotics is a crucial element of perioperative patient care but, often, pharmacologic implications of antibiotics are overlooked or misunderstood. Preventable medication errors that involve antimicrobials occur throughout the perioperative continuum. Examples of errors associated with antimicrobial use include omitted doses, duplicate doses, incorrect doses, and antimicrobial products given to patients with preexisting allergies. Perioperative nurses can contribute to safe antibiotic administration through education and improved communication. Perioperative managers should ensure that practitioners have access to standards for antibiotic administration and accurate information and assistive technologies. Numerous resources, including measurement tools and published guidelines, are available to support adherence to surgical site infection prevention requirements and assist in ensuring effective and safe perioperative antibiotic use.

Perioperative pharmacology: pharmacotherapeutics, pharmacokinetics, and pharmacodynamics.

Results of current research into perioperative medication errors have revealed that more than half of medication errors occur during the administration phase of the medication-use process. The administration phase is the point at which the medication and the patient intersect and the medication imposes its pharmacological effect. During this phase, the only safety net between the patient and the medication is the health care provider's attention and care when administering the medication. To help mitigate these errors, perioperative nurses must understand pharmacotherapeutics: the use of medications to prevent, treat, cure, or alleviate symptoms of disease. Pharmacotherapeutics incorporates pharmacokinetics (ie, what the body does to a medication after it enters the system) and pharmacodynamics (ie, how a medication acts on the body to achieve a desired therapeutic effect).

Perioperative pharmacology: a framework for perioperative medication safety.

Learning pharmacology is a critical element of any health care practitioner's education to ensure quality and safety in perioperative care. The medication-use process and safe medication use are two important principles that contribute to the safe use of pharmacological agents in perioperative clinical practice. The medication-use process consists of procuring, prescribing, transcribing, dispensing, administering, and monitoring; however, variations in the medication-use process result from demands unique to the perioperative environment, and these variations can sometimes bypass the safety nets within the system. Understanding these variances will help perioperative practitioners recognize threats to patient safety and help ensure the patient's well-being. Responsibilities of a safe medication-use system include assuring the public that practitioners use medications efficiently, safely, and effectively, and fully document all medications administered.

An evidence-based process for evaluating infection control policies.

The purpose of this study was to identify and describe evidence-based criteria for evaluating the appropriateness of policies for decontamination of noncritical equipment. An integrated literature review, guided by the Stetler Research Utilization Model and Bibb-Wanzer Identifying, Organizing, and Synthesizing strategy, provided the framework. A confirmatory search and document review process guided identification of documents and data extraction. Data synthesis was conducted using manifest content analysis. Five major criteria for disinfecting noncritical items were identified: use of personal protective equipment, removal of contamination, cleaning items before disinfecting, low-level disinfectant use, and following manufacturers' recommendations for disinfectants.

Medication safety within the perioperative environment.

With the widespread patient safety movement comes an increased public awareness of the risks inherent within the health care setting. More specifically, the highly publicized medication error cases that hit the media demonstrate the effect mediation errors have on patient safety within the perioperative environment. This awareness, however, has triggered limited research across the continuum of care within this complex environment. A current review of the state of the science related to medication safety within this setting reveals research primarily focused on the anesthesia domain of practice. Although application to the perioperative environment can be extrapolated from this research, there is a notable lack of nursing-initiated research that focuses on improved systems or processes related to medication safety within the perioperative continuum of care. This knowledge gap in the literature presents an excellent opportunity for nursing to grow a research program to improve medication safety within the perioperative environment in support of evidence-based practice.

Microbial flora on operating room telephones.

Approximately 500,000 surgical site infections (SSIs) occur each year in the United States. The purpose of this study was to determine if the bacteria most frequently involved in SSIs could be found on telephones in the OR. Twenty-six cultures were taken from telephones in 14 ORs and two substerile rooms at a large teaching medical center. Using standard laboratory procedures, the researchers identified coagulase-negative staphylococci in the cultures. The study found that telephones in the OR can serve as reservoirs for SSI-causing bacteria.