How Should We Measure Temperature in Young Children?

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

Photo courtesy of Exergen Corporation. Photo courtesy of Exergen Corporation.

Do you dread taking rectal temperatures in pediatric patients, knowing that your action will leave you with a screaming, distrustful child as well as a distressed parent? Rectal temperature measurements have long been considered the “gold standard” for accuracy. But are they essential in very young children, especially when infection is not suspected?

Improving Pediatric Temperature Measurement in the ED” in our September issue relates how a group of ED nurses explored possible alternatives to routine rectal temperature measurements during triage. Their ED protocol had been to use this method in all children under the age of five. However, this practice extended the time needed for triage, was often upsetting to parents, and seemed potentially unnecessary when the reason for the ED visit did not suggest infection (where there would be a need for more careful fever assessment).

An existing emergency services committee made up of ED staff nurses from the hospital’s two campuses set out to explore their options. The committee’s first move was to clearly define the practice problem:

Using PICOT format (Patient population, Intervention of interest, Comparison intervention, Outcome, Time frame), the committee initially formulated the following clinical question: For pediatric patients younger than five years of age (P) who require temperature measurement (I), what is the safest method of measurement (C) to achieve consistently reliable temperature measurement (O) in the triage process (T)?

Under the guidance of an advanced practice nurse, they performed a literature search for relevant articles and guidelines and consulted local pediatric specialty hospitals about their practices. Nursing administrators provided paid release time to committee members so that part of the nurses’ work on this QI project could be done during work hours. […]

September 10th, 2015|Nursing, Patients|0 Comments

Editing a Journal: Not Bedside Nursing, But Still an Urgency to Get Things Right

By Maureen Shawn Kennedy, MA, RN, AJN editor-in-chief

‘Nurses practice based on what’s in the literature; we need editors who will draw lines and stand firm against publishing biased and inaccurate papers.’

Niklas Bildhauer/ Wikimedia Commons Niklas Bildhauer/ Wikimedia Commons

I recently returned from a meeting in Las Vegas, the land of lights and bells and six-story marquees—and heat (it hit 109 when I was there, but “a dry heat”). The long flight home gave me time to reflect on the meeting I’d attended (of editors of nursing journals) and on what I do.

When I began my nursing career, I always thought I would stay in the acute care setting. I found the fast pace of the ER challenging and never boring. When I moved into a clinical specialist position and then an administrative one, I could still get involved in challenging situations, from dealing with problems that occurred on clinical units or with staff to navigating the politics of hospital committees and community liaisons.

But time passes and paths twist and turn, and here I am the editor of AJN—and it’s the most challenging and professionally fulfilling job I’ve had.

The International Academy of Nursing Editors (INANE for short) meets annually. It’s a loose networking group, mainly held together through a Web site, blog, and listserv. There are no officers or bylaws, no dues. Each year someone volunteers to host the annual meeting and whoever would like to help joins in. Anyone can propose a project, and those who want to work on it volunteer. We pass the hat to raise funds to support the Web site and incidental expenses and to help new editors attend the INANE meeting.

But don’t accuse this laid-back group of being inactive or frivolous—serious issues are tackled on an ongoing basis. True, they are not as exciting as the situations one might encounter in the clinical arena, but they have an effect on what many nurses do and think and implement in practice.

In Las Vegas, sessions focused on some important topics, including

  • the retraction of articles, i.e., when a publisher basically admits that an article is flawed and should not have been published.
  • the ethics of authorship and what to do when authors don’t want to disclose who actually wrote the paper, thus leaving room for conflicts of interest, bias, and skewed results and conclusions.
  • when and how much to fact-check authors’ references.
  • how to ensure students are getting the correct information about scholarly writing and publishing.
  • how to help new authors get their articles published.


Evidence-Based Practice and the Curiosity of Nurses

By Betsy Todd, MPH, RN, CIC, AJN clinical editor

karen eliot/flickr by karen eliot/via flickr

In a series of articles in AJN, evidence-based practice (EBP) is defined as problem solving that “integrates the best evidence from well-designed studies and patient care data, and combines it with patient preferences and values and nurse expertise.”

We recently asked AJN’s Facebook fans to weigh in on the meaning of EBP for them. Some skeptics regarded it as simply the latest buzzword in health care, discussed “only when Joint Commission is in the building.” One comment noted that “evidence” can be misused to justify overtreatment and generate more profits. Another lamented that EBP serves to highlight the disconnect between education and practice—that is, between what we’re taught (usually, based on evidence) and what we do (often the result of limited resources).

There’s probably some truth in these observations. But at baseline, isn’t EBP simply about doing our best for patients by basing our clinical practice on the best evidence we can find? AJN has published some great examples of staff nurses who asked questions, set out to answer them, and ended up changing practice.

  • In a June 2013 article, nurses describe how they devised a nurse-directed protocol that resulted in fewer catheter-associated urinary tract infections (CAUTIs).
  • A 2014 article relates how oncology nurses discovered the lack of evidence for the notion that blood can only be transfused through large-bore needles. These nurses were able to make transfusions safer and more comfortable for their patients. […]

AJN Collections of Note: From Women’s Health Issues to Assessment Tools for Older Adults

By Jacob Molyneux, senior editor

'Nuff Said by ElektraCute / Elektra Noelani Fisher, via Flickr. Elektra Noelani Fisher/ Flickr

It’s easy to miss, but there’s a tab at the top of the AJN home page that will take you to our collections page. There you can delve more deeply into a wide range of topics—and find many options for obtaining continuing education credits in the process.

For example, you’ll find a collection of recent continuing education (CE) feature articles devoted to women’s health issues, such as menopausal hormone therapy, cardiovascular disease prevention for women, and issues faced by young women who are BRCA positive.

The patient population in the U.S. continues to age. To gain confidence in meeting the needs of these patients, nurses can consult our practical collection of articles and videos devoted to the use of evidence-based geriatric assessment tools and best practices.

For the more creative side of nursing, we have a collection of 20 visual works and poems from our Art of Nursing column.

For those concerned with potential legal issues, it’s a good idea to have a look at the three CE articles from our Legal Clinic column on protecting your nursing license.

For would-be authors and those interested in applying knowledge to practice more effectively, there are step-by-step series on conducting a systematic review and on how nurses can implement evidence-based practice at their institutions. […]

Cochrane Reviews: An Oft-Overlooked Evidence Source for Nurses at the Bedside

By Amanda Anderson, a critical care nurse and graduate student in New York City currently doing a graduate placement at AJN.

“Research holding the torch of knowledge” (1896) by Olin Levi Warner. Library of Congress, Thomas Jefferson Building, Washington, D.C./Photo by Carol Highsmith, via Wikipedia

Long ago, in an ICU far away, I picked up the habit of saying, during rounds, “Well, you know, research suggests the practice…” I have trouble remembering who taught me this tactic, but it has always been a highly effective way of advocating for my patients.

The eyes of doctors, never ones to be silenced by a nurse who reads research, usually light up at the challenge.

I’ll admit that, for a while, many of my conversational citations came from ‘clinical pearls’ or tidbits I read from certifying organizations via social media. While my knowledge was based on credible sources, my analysis was topical, at best.

Then I started graduate school. Although my program isn’t a clinical one, the need to seek out evidence for class assignments intensified my practice of trying to apply research evidence at the bedside.

It’s tricky to find and discuss credible research as a bedside nurse. Services like Lexicomp and UpToDate, which most hospitals hold subscriptions to, compile current research for clinician use and provide comprehensive information that’s far more credible than Wikipedia. But they’re exhaustive and often require a pretty hefty chunk of time to really analyze and understand. Printing out a 37-page document to hand to an attending on rounds isn’t a practice I’d recommend.

So how do we get reliable, evidence-based information efficiently when it’s needed? It wasn’t until deep into grad school that I started to realize that Cochrane Reviews were sometimes the best bedside research translator out there. The Cochrane Collaboration is an international, nonprofit organization that performs systematic reviews on peer-reviewed journal articles. The reviews are considered, by my professors at least, often the best form of evidence. Short summaries and abstracts are free to all users and are easy to find via PubMed and print. (Full access is subscription based, at least in the U.S.)

‘Sedation vacations’: yes, no, maybe? A topic I’ve always loved to use my research line on is the practice of ‘sedation vacations.’ When patients are deathly ill and ventilated, their lives depend on the use of sedatives. However, studies have linked lengthy use of sedative agents to serious complications—drug bioaccumulation, postextubation delirium, decreased quality of life, and adverse events, to name a few. Hence, the daily sedation vacation was born.

Most ICUs these days require a daily sedation vacation for intubated, sedated patients. There’s little doubt that patients are often oversedated, and the practice of pausing the sedation to see if they wake up and then readjusting their sedation according to policy can cut excess use. Some units allow nurses to perform the practice without input from an attending physician. Others rely on a case-by-case method. I’ve worked in both, and in both have said the words, “You know, research calls for daily sedation vacations, and this patient meets the criteria. Should I move forward?”

In most such instances, a sedation vacation was authorized for the patient, and sometimes a discussion of current practices was stimulated by my reference to research. I’d always thought that sedation vacations were a validated, proven, evidence-based practice, and had always advocated for them when my patients met clinical criteria. […]