Reflective practice: a framework for case manager development.

PURPOSE/OBJECTIVES: The role of a nurse case manager (NCM) incorporates practice that is built upon knowledge gained in other roles as well as components unique to case management. The concept of reflective practice was used in creating a framework to recognize the developmental stages that occur within community based case management practice. The formation of this framework and its uses are described in this article. PRIMARY PRACTICE SETTING: The practice setting is a community based case management department in a large midwestern metropolitan health care system with Magnet recognition. Advanced practice nurses provide care for clients with chronic health conditions. FINDINGS/CONCLUSIONS: Twenty-four narratives were used to identify behaviors of community based case managers and to distinguish stages of practice. The behaviors of advanced practice found within the narratives were labeled and analyzed for similarities. Related behaviors were grouped and descriptor statements were written. These statements grouped into 3 domains of practice: relationship/partnership, coordination/collaboration, and clinical knowledge/decision making. The statements in each domain showed practice variations from competent to expert, and 3 stages were determined. Reliability and validity of the framework involved analysis of additional narratives. The reflective practice process, used for monthly case review presentations, provides opportunity for professional development and group learning focused on improving case manager practice. The framework is also being used in orientation as new case managers acclimate to the role. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Reflective writing has unveiled the richness and depth of nurse case manager practice. The depth of knowledge and skills involved in community-based case management is captured within this reflective practice framework. This framework provides a format for describing community based case manager practice development over the course of time and has been used as a tool for orientation and peer review.

Respiratory depression in adult patients with intravenous patient-controlled analgesia.

Patient-controlled analgesia (PCA) has been widely implemented to provide better pain relief and increased patient satisfaction with relatively few side effects. However, patients using intravenous (i.v.) PCA are at increased risk for specific adverse effects, especially respiratory depression. A review of the literature from 1990 to present was done to identify the incidence and risk factors for respiratory depression and recommendations for care. Several studies have documented the incidence of respiratory depression with i.v. PCA; rates ranged from 0.19% to 5.2%. Variation in incidence existed because authors defined respiratory depression differently. Methods for monitoring oxygenation include sedation; respiratory rate, depth, and rhythm, and oxygen saturation using pulse oximetry. No single parameter is the single indicator for respiratory depression. Risk factors for respiratory depression with i.v. PCA include age greater than 70 years; basal infusion with i.v. PCA; renal, hepatic, pulmonary, or cardiac impairment; sleep apnea (suspected or history); concurrent central nervous system depressants; obesity; upper abdominal or thoracic surgery; and i.v. PCA bolus > 1 mg. Structures and processes should be in place to guide appropriate dosing, identify risk factors, and activate pertinent monitoring and frequency. Finally, respiratory depression occurs infrequently in comparison to the 10% of patients who are undertreated for pain.