Clinical exemplars demonstrate perioperative nurses' courage and commitment to quality patient care

AORN Journal, Jan, 1996 by Beverly P. Giordano

What's a clinical exemplar? must confess that until a few months ago, I'd never given the term much thought. When an AORN member handed me an article on this topic, my curiosity was piqued, and I began to think of ways in which perioperative nurses could use clinical exemplars.

Clinical exemplars are nurses, stories of situations that are outstanding examples of skilled nursing practice. Nurses share clinical exemplars informally every day, even though we may not recognize them as such. Think about the stories we swap by telephone, at lunch, or in workplace lounges. These are stories of courage and commitment to quality patient care. They illustrate our choices and decisions that influence patient outcomes.

REASONS TO USE

CLINICAL EXEMPLARS

Nurses can use clinical exemplars to

* recall instances of early warnings tie, recognition of subtle signs and symptoms of impending problems in patients) and successful interventions;

* demonstrate acquisition of new knowledge;

* describe effective teaching or coaching with patients or family members, and

* identify unrecognized aspects of nursing practice.(1)

Nurses in some facilities present clinical exemplars at formal celebration ceremonies and publish them in hospital nursing newsletters. In other settings, nurses write clinical exemplars as evidence of their readiness for promotion.(2)

Clinical exemplars are not intended to be self-congratulatory pats on the back. The purpose of writing clinical exemplars is to capture the interpersonal, ethical, and clinical judgments that nurses make in actual practice.

Clinical exemplars chronicle the quality and depth of expert nursing practice in ways that objective checklists cannot document.(3) They illustrate our critical thinking -- the processes by which we question the status quo, look for trends and patterns, view situations from broad perspectives, use intuition and follow hunches, and seek opinions from experienced peers when problem solving.(4)

By sharing stories of patient care experiences, we can help new nurses learn from our experiences (and mistakes!) so they will be successful early in their careers. In writing and sharing clinical exemplars, we can validate and document changes in nursing practice and describe our acquisition of skills and our professional advancement.(5) Using clinical exemplars, we can illustrate differences between the, "task-oriented, relying-on-rules" type of patient care that novice nurses or less-skilled personnel provide and the care that experienced nurses provide.

PERIOPERATIVE

EXEMPLARS

Two AORN members from Children's Hospital, Boston, recently published an article about their group's experience with clinical exemplars. Their exemplars illustrate the advanced skins and intuitive understanding of complex clinical situations that expert perioperative nurses possess.

Exemplar A. In this clinical exemplar, the perioperative nurse illustrates her ability to see beyond the immediate needs of patients in the OR and care for family members on a personal level. She describes her interventions in meeting the needs of the parents of a three-year-old girl who could not be weaned from cardiopulmonary bypass after undergoing a complicated repair of a congenital heart defect.

Based on her experience with similar surgical procedures, her assessment of the child's hemodynarnics, and the appearance of the child's myocardium after the first attempt to discontinue bypass, this nurse intuitively knew the child probably would not survive. She also recognized that the nurse acting in the surgical liaison role that day had little previous experience with crisis or death in the OR.

The nurse arranged for cardiology staff members who knew the family well to meet with the child's parents, and she called a chaplain and a staff psychiatrist to counsel the parents. Reflecting on this experience, the perioperative nurse realized that in helping the parents through their initial stage of grieving, she transformed what the surgical team members perceived as a failure into a positive challenge.(6)

This nurse demonstrated courage as she stepped beyond the familiar boundaries of the intraoperative nursing role and risked sharing the parents, emotional pain. Even as she dealt with the child's complex intraoperative care, this nurse demonstrated her commitment to family-entered care.

Exemplar B. This clinical exemplar describes a perioperative nurse's experience of being on call and coming in to coordinate a ventricular septal defect patch fenestration procedure On a three-year old patient. Although the nurse had not participated in this child's recent surgical procedure, she knew from experience with previous patients that the child would be in congestive heart failure and would be receiving inotropic medications. She also knew the child would be edematous and, therefore, would require special padding and extra care in positioning. What the nurse did not anticipate was that the attending anesthesiologist and anesthesia fellow would be new to the hospital and unfamiliar with the OR equipment and patient care routines. The nurse knew intuitively that she had to take charge of transfering the child, with all her invasive equipment, to the OR bed.(7)