Caring through crisis: The professional quality of pediatric nurses during the COVID-19 pandemic.

PURPOSE: This study described pediatric nurses' professional quality of life during COVID-19 and explored demographic/clinical practice factors independently associated with compassion satisfaction (CS), burnout (BO), and secondary traumatic stress (STS). DESIGN AND METHODS: The Relational Caring Complexity Theory was used. This study employed a cross-sectional, descriptive, correlational design to describe professional quality of life of pediatric nurses (demographic questionnaire and ProQOL 5 measure) working during the COVID-19 pandemic. RESULTS: From 150 pediatric nurses, the mean scores were CS 40.8 (± 4.8), BO 22.6 (± 4.7), and STS 22.8 (± 5.8). Results of the multiple regression revealed that two variables, deployed to the same unit versus not deployed (ß = 2.424, p = .02) and currently practicing in perioperative/ambulation settings versus intensive care (ß = -0.272, p = .03), were independently associated with CS. Deployed to the same unit versus not deployed was found to be independently and significantly associated with BO (ß = -0.28, p = .005). The number of patients cared for with COVID-19 (ß = 0.196, p = .03) was significantly associated with STS. CONCLUSIONS: While the overall response was positive, these nurses were more likely to experience BO when deployed to the same area (likely a COVID-19 adult unit) and STS as they cared for more patients with COVID-19. PRACTICE IMPLICATIONS: Leaders should be aware of the impact of caring in times of crisis. Decentralized staffing may help meet emergent needs on a particular shift, but ensuring deployed nurses are well-supported is vital.

The Aggressive Incidents in Medical Settings (AIMS) Study: Advancing Measurement to Promote Prevention of Workplace Violence.

BACKGROUND: Rates of aggressive events and workplace violence (WPV) exposure are often represented by proxy measures (restraint, incident, injury reports) in health care settings. Precise measurement of nurse and patient care assistant exposure rates to patient aggression on inpatient medical units in acute care hospitals advances knowledge, promoting WPV prevention and intervention. METHODS: This prospective, multisite cohort study examined the incidence of patient and visitor aggressive events toward patient care staff on five inpatient medical units in a community hospital and an academic hospital setting in the northeastern United States. Data were collected with event counters, Aggressive Incident and Management Logs (AIM-Logs), and demographic forms over a 14-day period in early 2017. RESULTS: Participants recorded a total of 179 aggressive events using event counters, resulting in a rate of 2.54 aggressive events per 20 patient-days. Patient verbal aggression rates (2.00 events per 20 patient-days) were higher compared to physical aggression rates (0.85 events per 20 patient-days). The staff aggression exposure rate was 1.17 events per 40 hours worked (verbal aggression exposure rate: 0.92 events per 40 hours; physical aggression exposure rate: 0.39 events per 40 hours). The most common precipitants included medication administration (18.6%), waiting for care (17.2%), and delivering food/drinks (15.9%). Most events were managed with verbal de-escalation (75.2%). The number of patients assigned to patient care staff was significantly greater during a shift when an aggressive event occurred compared to when no event occurred (6.3 vs. 5.7, t = -2.12, df = 201.6, p = 0.0348). CONCLUSION: Event counters and AIM-Logs offer greater information about patterns of aggression and preventive interventions used and provide information on the need for debriefing and worker support after aggressive events. Additional studies of this methodology in other settings are needed to evaluate the value of this technology for improving worker and patient safety.

The Effect of an Educational Intervention on Nurses' Knowledge, Perception, and Use of Nursing Presence in the Perioperative Setting.

PURPOSE: Explore the effect of a nursing presence educational intervention on nurse circulators' perceptions, knowledge, and use of nursing presence with patients undergoing surgical procedures. DESIGN: One group, pretest-posttest design. METHODS: Nursing presence is an intentional-reflective way of being with patients that was operationalized using four domains (Attention-to-Environment, Interaction Quality, Focus-of-Energy, and Active Engagement). Data collection involved observations of participants in practice and completion of surveys to examine 34 randomly selected nurse circulators' knowledge, perception, and use of nursing presence before and after participating in a nursing presence educational intervention. Dependent t tests and McNemar tests were used to examine relationships between the independent and three dependent variables - knowledge, perceptions, and use of nursing presence. FINDINGS: The educational intervention significantly enhanced participants' nursing presence knowledge, but not perceptions, which were very high at baseline. Participants' significantly increased their use of 3 of 4 nursing presence domains with the exception of the Attention-to-Environment domain, which is related to promoting a healing environment. CONCLUSIONS: Lack of attention to promoting a healing environment by the surgical team created a barrier to circulators' ability to successfully use all four nursing presence domains. Embracing nursing presence as a practice framework involves cooperation from the surgical team and a shift in perioperative environment from a chaotic to healing one.

A Focus Group Study of Retirement-Age Nurses: Balancing Tension and a Love of Nursing in a Changing Healthcare Environment.

OBJECTIVE: The aims of this study were to explore the experience of retirement-age nurses and identify decision-making factors and innovations to enhance retention. BACKGROUND: A national shortage of nurses has created challenges to preserving quality patient care and level of nursing competency and managing turnover costs. METHODS: A qualitative study using focus groups was conducted of nurses 55 years or older who were working or recently retired. Data were audiotaped and transcribed verbatim, with content analysis used to code in an iterative process until consensus was reached. RESULTS: The tension of balancing the love of patient care within a changing healthcare system was described. Patient acuity, competing roles, and the centrality of computers were stressors and integrally related. Flexibility in work schedules and new practice models were important to retirement decision making for work-life balance and retention. CONCLUSION: Passion for patient care dominated decisions to continue working. Innovations in practice models and scheduling offer opportunities to enhance the retention of experienced nurses.

Using a teach-back intervention significantly improves knowledge, perceptions, and satisfaction of patients with Nurses' discharge medication education.

BACKGROUND: Evidence indicates that patients desire medication information, but clinicians often fail to teach this information in an understandable way. Teach-Back promotes effective clinician-patient communication and enhances medication adherence, satisfaction with education, and hospital experiences. AIMS: This study examined effects of a nurse-led Teach-Back intervention, Teaching Important Medication Effects (TIME), compared with usual care on patients' knowledge, experiences, and satisfaction with medication education before and after discharge. The aims were to examine patients' priority learning needs, group differences in new medication knowledge before and after discharge, and post-discharge experience and satisfaction with medication instruction. METHODS: A longitudinal pretest/post-test, 2-group design was used with 107 randomly selected medical-surgical patients from an academic hospital. After receiving medication instructions, patients were interviewed before and within 72 h after discharge. Bivariate analyses were used to assess group differences in demographic and outcome variables. RESULTS: Usual care (n = 52) and TIME (n = 55) groups' characteristics were equivalent. Knowing new medication names and side effects were top learning priorities. Medication side effect knowledge was better in TIME versus usual care groups at discharge (94.3% vs. 72.5%, p = .003) and follow-up (93.9% vs.75.8%, p = .04). TIME positively influenced patients' medication education experiences; specifically, nurses always explained why a new medication was needed and its side effects. TIME was associated with patients being very satisfied with nurses' education versus usual care (97% vs. 46.9%, p < .001). LINKING EVIDENCE TO ACTION: TIME was significantly and positively associated with knowledge of new medication side effects over time and experiences and satisfaction with nurses' medication education. Teach-Back was effective in educating patients about new medications. It is an essential approach for patient education, requiring clinicians to confirm patients' retention and understanding of new information with each encounter.

A Nurse-Led Voiding Algorithm for Managing Urinary Retention After General Thoracic Surgery.

BACKGROUND: Untreated postoperative urinary retention (POUR) leads to bladder overdistension. Treatment of POUR involves urinary catheterization, which predisposes patients to catheter-associated urinary tract infections. The hospital's rate of POUR after lobectomy was 21%, exceeding the Society of Thoracic Surgeons' benchmark of 6.4%. Nurses observed that more patients were being catheterized after implementation of a newly revised urinary catheter protocol. OBJECTIVE: To reduce the incidence of POUR by implementing a thoracic surgery-specific nurse-led voiding algorithm. METHODS: Experts validated the voiding algorithm that standardized postoperative assessment. It was initiated after general thoracic surgery among 179 patients in a thoracic surgery stepdown unit of a large Magnet hospital. After obtaining verbal consent from patients, nurses collected demographic and clinical data and followed the algorithm, documenting voided amounts and bladder scan results. Descriptive statistics characterized the sample and the incidence of POUR. Associations were determined between demographic and clinical factors and POUR status by using the t test and χ2 test. RESULTS: The POUR-positive group and the POUR-negative group were equivalent with regard to demographic and clinical factors, except more patients in the POUR-positive cohort had had a lobectomy (P = .05). The rate of POUR was 8%. Society of Thoracic Surgeons reports revealed a rapid and sustained reduction in the hospital's rates of POUR after lobectomy: from 21% to 3%. CONCLUSION: The use of this nurse-led voiding algorithm effectively reduced and sustained rates of POUR.

Nurses' Perceptions of Barriers to Out-of-Bed Activities Among Patients Receiving Mechanical Ventilation.

BACKGROUND: Delays in early patient mobility are common in critical care areas. Oral intubation with mechanical ventilation is negatively associated with out-of-bed activities. OBJECTIVES: To explore nurses' mobility practices for patients with oral intubation and mechanical ventilation and identify barriers related to patient, nurse, and environment-of-care factors specific to this population. METHODS: In this cross-sectional, descriptive study in a medical intensive care unit, mobility was defined as standing, sitting in a chair, or walking. A total of 105 patients who met predefined mobility criteria and their 48 nurses were enrolled. Nurses were interviewed about mobility practices at the ends of shifts. Descriptive statistics summarized nurse and patient characteristics and mobility barriers. RESULTS: Patients were deemed ready to begin mobility within a mean (SD) of 41.5 (34.8) hours after oral endotracheal intubation. Two-thirds of nurses reported that they never or rarely got these patients out of bed. Only 12.4% of patients had a clinician's activity order. Common patient-related barriers were uncooperative behavior (21.9%) and active medical issues (15%), even in patients who met mobility criteria. Nurse-related barriers were concerns for patient safety, specifically falls (14.3% of patients) and harm (9.5%). The environment of care posed very few barriers; nurses rarely mentioned that lack of help (13.3% of patients) or lack of clinician's activity order (5.7%) impeded mobility. CONCLUSIONS: Mobility practices were nonexistent in these patients despite patients' being deemed ready to begin out-of-bed activities. Nurses must be attentive to their unit's mobility culture to overcome these barriers.

Development, Validation, and Implementation of a Guideline to Improve Clinical Event Debriefing at a Level-I Adult and Level-II Pediatric Trauma Center.

OBJECTIVE: Clinical event debriefing is recommended by the American Heart Association and the European Resuscitation Council, because debriefings improve team performance. The purpose here was to develop and validate tools needed to overcome barriers to debriefing in the emergency department. METHOD: This quality improvement project was conducted in 4 phases. Phase 1: Current evidence related to debriefing in the emergency department was reviewed and synthesized to inform an iterative process for drafting the debriefing guideline and instrument for documentation. Phase 2: Content Validity Index of the tools was evaluated by obtaining ratings of items' clarity and relevance from 5 national experts in 2 rounds of review. On the basis of experts' feedback, tools were revised, and a Facilitators' Guide was created. Phase 3: The validated debriefing tools were implemented. Phase 4: Debriefing facilitators completed a survey about their experience with using the new tools. RESULTS: The Content Validity Index of 71 debriefing tool items (guideline, instrument, Facilitators' Guide) was 0.93 and 0.96 for clarity and relevance, respectively. Of the 32 debriefings conducted during the first 8 weeks of implementation, 53% described patient safety concerns, and 97% described recommendations to improve performance. Most (94%) facilitators agreed that the guideline clarified debriefing requirements. CONCLUSION: The use of debriefing tools validated by computation of the Content Validity Index led to the identification of safety threats and recommendations to improve care processes. These tools can be used in ED settings to promote team learning and aid in identifying and resolving safety concerns.

Keeping Nurses Engaged in Nursing Professional Governance During the COVID-19 Pandemic:: Nursing Professional Governance Structure at Yale New Haven Hospital.

In 2020, during the COVID-19 pandemic, nursing professional governance (NPG) clinical nurse leaders at Yale New Haven Hospital developed an innovative way to engage nurses in their practice. Utilizing an electronic platform, NPG leaders established a way to harvest best practices, innovations, and resources from clinical nurses and reputable sources to share with all nurses in every practice area. Support for NPG leaders to have dedicated time for this work accelerated the process and allowed them to engage with nursing leaders to enhance communication and support clinical nurses. This work demonstrated the value of NPG during a time of crisis.

Comparison of Point-of-Care Testing Methods and Laboratory Analysis for Assessing Urine Specific Gravity and pH of Children Undergoing Chemotherapy.

BACKGROUND: To reduce the risk of renal toxicity, urine specific gravity (SG) and pH (potential of hydrogen) parameters should be met before nephrotoxic chemotherapeutic agents are administered. The purpose of this study was to compare laboratory urine SG and pH values with those obtained with urine point-of-care (POC) testing methods commonly used when caring for children receiving nephrotoxic chemotherapeutic agents. METHOD: A method-comparison design was used to compare the values of three POC methods for SG (dipstick, automated dipstick reader, refractometer) and three pH (dipstick, automated dipstick reader, litmus paper) methods with laboratory analysis of 86 urine samples from 43 children hospitalized on a pediatric hematology oncology unit in a large academic medical center. The Bland-Altman method was used to calculate bias and precision between POC and laboratory values. RESULTS: Except for the SG refractometer, bias values from Bland-Altman graphs demonstrated poor agreement between POC and laboratory urine SG and pH results. The precision values between these methods indicated overestimation or underestimation of hydration or urine pH status. Compared with laboratory methods, 31% of POC visual reading of dipstick SG values were falsely low-putting the patient at risk of not receiving necessary hydration and subsequent nephrotoxicity. DISCUSSION: In conclusion, most POC urine testing methods for SG and pH are not accurate compared with laboratory analysis. Because laboratory analyses can take longer than POC methods to obtain results, clinicians need to collaborate with laboratory medicine to ensure that an expedited process is in place in order to prevent chemotherapy administration delays.

"Finding the Balance": A Qualitative Study of the Experience of Nurses and Patients with Diabetes on an Insulin Pump in the Hospital.

PURPOSE: The purpose of this study was to explore experiences of hospitalized patients as they transition insulin pump self-management from home to hospital and the experience of nurses caring for them. Patients are often more knowledgeable about the pump than their nurses, which could lead to undiscovered challenges. Little is known about the hospital experience related to insulin pump therapy from nurses' and patients' perspectives. METHODS: A qualitative approach with interpretive descriptive design and purposive sampling was used. Eligible patients were ≥18 years of age, able to read and speak English, and admitted to non-ICU settings ≥20 hours. Eligible nurses cared for at least 1 patient using an insulin pump. Patients and nurses were interviewed separately. Interviews were audiotaped and transcribed verbatim. Data were analyzed using a constant comparative method. Coding was performed independently and jointly to reach consensus on emerging themes. RESULTS: Hospitalized patients and nurses had an array of perceptions highlighting challenges and adaption to "finding the balance" in managing diabetes when patients wore their insulin pumps. There were 4 interrelated themes representing a continuum of trust to lack of trust, control versus lack of control, effective communication to limited communication, and staff knowledge to lack of knowledge. CONCLUSIONS: Results of this study provide valuable insights into the challenges for both patients and nurses. A standardized approach to caring for this population is necessary. These findings can inform the development of nursing education programs and policies aimed at improving their experiences.

Safety and Effectiveness of Early Oral Hydration in Patients After Cardiothoracic Surgery.

BACKGROUND: Patients fast after cardiothoracic surgery because of concerns for nausea, vomiting, dysphagia, and aspiration pneumonia; fasting, however, causes thirst, a distressing symptom. To our knowledge, no studies exist to guide hydration practices in this population. OBJECTIVE: To determine the effect of early oral hydration on adverse events and thirst in patients after cardiothoracic surgery. METHODS: This study applied a prospective 2-group design in which 149 patients from an 18-bed cardiothoracic intensive care unit were randomized to either usual care (a 6-hour fast) or early oral hydration after extubation. The research protocol involved nurses evaluating patients' readiness for oral hydration and then offering them ice chips. If patients tolerated the ice chips, they were allowed to drink water 1 hour later. RESULTS: Most patients (91.3%) had undergone coronary artery or valve surgery, or both. Demographic and clinical variables were similar in both groups. No significant between-group differences were found for the incidence of nausea, vomiting, or dysphagia, and no aspiration pneumonia occurred. Significantly more patients with a high thirst level were in the usual care group (81.2%) than in the early oral hydration group (56.5%; P = .002, r2 test). After adjustment for demographic and clinical variables by using logistic regression, early oral hydration was independently and negatively associated with a high thirst level (odds ratio, 0.30 [95% CI, 0.13-0.69]; P = .004). CONCLUSION: This research provides new evidence that oral hydration (ice chips and water) soon after extubation is safe and significantly reduces thirst in particular patients.

Using Quality Improvement Methods to Understand Incidence, Timing, and Factors Associated With Unplanned Intensive Care Unit Transfers of Patients With End-Stage Liver Disease.

INTRODUCTION: Patients with end-stage liver disease are at risk for clinical deterioration, often requiring hospital admissions while awaiting transplantation. Nurses observed that many patients were or became unstable soon after arrival, requiring transfers to the medical intensive care unit. OBJECTIVE: To explore the incidence, timing, and factors associated with unplanned intensive care transfers. DESIGN: We conducted a quality improvement project using plan-do-study-act methods to explore administrative data from adult patients admitted to the hepatology service's medical-surgical unit. Chi-square and t-tests were used to examine associations between demographic, clinical, and temporal factors and unplanned transfers. Data were analyzed at the hospital encounter level. RESULTS: Unplanned transfers occurred in 8.6% of 1418 encounters. The number of transfers during these encounters ranged from 1 to 6. Most unplanned transfers (65.9%) occurred during the evening shift. On average, there was a 4.2-hour delay to the transfer. Fifty-one percent of these encounters required support from clinicians outside the unit while waiting for a bed. Factors associated with unplanned intensive care unit transfer were male sex (P = .02), self-referral to the emergency department (P < .001), and lower initial mean Rothman Index (P < .001). DISCUSSION: Results validated nurses' concerns about the patients' severity of illnesses at the time of admission and frequent need for transfer to intensive care soon after admission. We now have actionable data that are being used by leaders to assess unit admission criteria and develop operating budgets for human and material resources needed to care for this challenging population.

Incidence, Timing, and Factors Associated with Postoperative Nausea and Vomiting in the Ambulatory Surgery Setting.

PURPOSE: To examine incidence, timing, and factors associated with postoperative nausea and vomiting (PONV) in patients recovering in the ambulatory postanesthesia care unit (PACU). DESIGN: Descriptive correlational, cross-sectional. METHODS: Data were collected prospectively, including patient, surgery, anesthesia, and postoperative factors associated with PONV. Independent predictors of nausea were determined using logistic regression. FINDINGS: In 139 randomly selected patients, 10.8% had nausea and 2.9% vomited. On arrival to the PACU, 3 patients had nausea, which increased incrementally to 10 during the next 90 minutes, declining to 3 by 150 minutes. These patients had significantly more hydration and longer PACU stays. Fifty-three percent had nausea at discharge. Younger age and gastroesophageal reflux disease were significantly and independently associated with nausea. CONCLUSIONS: PONV is relatively infrequent, but remains a distressing problem resulting in negative surgical experiences and increased cost. Future research is warranted to examine gastroesophageal reflux disease as a novel risk factor.

Safety and Patients' Response to Ambulation With a Pulmonary Artery Catheter in the Cardiac Intensive Care Unit.

BACKGROUND: Early mobilization of patients in the intensive care unit can be beneficial, but evidence is insufficient to indicate whether allowing patients with an indwelling pulmonary artery catheter to walk is safe. OBJECTIVE: To describe the physiological and emotional responses to ambulation in patients with heart failure and a pulmonary artery catheter. METHODS: This prospective, descriptive study included 19 patients with heart failure monitored with a pulmonary artery catheter in a cardiac intensive care unit. Each patient, accompanied by a nurse, walked with continuous observation of heart rate and rhythm and pulmonary artery tracing on a transport monitor. Pulmonary artery catheter position and waveform, arrhythmias, and perceived levels of exertion and fatigue were recorded before and after each walk. The distance ambulated was documented. One to 3 times per week, nurses administered a questionnaire addressing patients' sense of well-being. RESULTS: The 19 patients had 303 walks (range, 1-68; median, 7). During 7 patient walks (2.4%), catheter migration of 1 to 5 cm occurred, but no arrhythmias or waveform changes were observed. Changes in exertion and fatigue were significant (P < .001, paired t test), but levels of both were minimal after walking. Patients expressed physical and emotional benefits of walking. CONCLUSIONS: This study provides preliminary evidence that for hemodynamically stable patients with heart failure, ambulating with a pulmonary artery catheter is safe and enhances their sense of well-being. The presence of an indwelling pulmonary artery catheter should not preclude walking.

Factors Associated With Timely Blood Glucose Testing and Insulin Administration in Patients Receiving Mealtime Insulin Coverage in Medical Surgical Units.

Purpose The purpose of the study was to identify the rate and factors associated with timely mealtime capillary blood glucose (CBG) testing and insulin coverage in hospitalized patients with diabetes. Methods A descriptive-correlational design was used with a random sample of patients (n = 77) and nurses (n = 36) on a medicine and a neuroscience unit of a large Magnet hospital. After written consent was obtained, post-meal patient and nurse interviews were conducted to collect information about patient, nurse, and situational factors known to influence timely mealtime diabetes care. Results Timely CBG testing occurred on 85.7% of the patient participants, and 71.4% received timely insulin coverage. Timely CBG testing was associated (unadjusted) with telling the patient care associate to obtain a finger stick (FS) prior to meals and patient off the unit during mealtime. The odds of having insulin administered on time was significantly and independently associated with the nurse caring for fewer patients, patients waiting for insulin prior to eating, and patients knowing pre-meal FS was high. Conclusions One situational factor and 2 patient factors were independently associated with timely insulin coverage prior to meals. Interventions aimed at raising staff awareness of these factors and providing tailored education to patients may improve the odds of having insulin administered on time.

Perceptions of Adult Hospitalized Patients on Family Presence During Cardiopulmonary Resuscitation.

BACKGROUND: Family presence during cardiopulmonary resuscitation in acute care is not widespread. Patients are not likely to be asked about their wishes for family presence or if they wish to be the decision makers about who should be present. OBJECTIVE: To explore the perceptions of patients on general medical units and to find factors independently associated with family presence during cardiopulmonary resuscitation. METHODS: A cross-sectional study of 117 randomly selected adult patients was conducted at an academic medical center. Participants were interviewed via a survey to obtain information on demographics, knowledge of cardiopulmonary resuscitation, sources of information on resuscitation, and preferences for family presence. RESULTS: About half of the participants agreed or strongly agreed that family presence during cardiopulmonary resuscitation was important (52.1%), that the participant should be the decision maker about who should be present (50.4%), and that the patient should give consent ahead of time (47.0%). Participants indicated that they would want an adult sibling, parents, or others (20.5%); spouse (14.5%); adult child (8.5%); close friend (5.1%); or companion (4.3%) present during cardiopulmonary resuscitation. Younger participants (20-45 years old) were 6.28 times more likely than those ≥ 66 years old (P = .01) and nonwhite participants were 2.7 times more likely than white participants (P = .049) to want family presence. CONCLUSION: Patients have strong preferences about family presence during cardiopulmonary resuscitation, and they should have the opportunity to make the decision about having family present.

Getting used to being a patient: the postoperative experience of living liver transplant donors.

CONTEXT: Living donor liver transplant is a viable option for eligible persons in need of a liver transplant, but little is known about the hospitalization experience of patients undergoing hepatectomy for transplant donation. OBJECTIVE: To explore the hospital experience of patients recovering from donor hepatectomy. DESIGN: A qualitative interpretive descriptive design was used to understand the hospital experience of patients recovering from donor hepatectomy. Semistructured interviews, conducted before discharge, were audiotaped and transcribed verbatim. Coding was performed independently, then jointly by investigators to reach consensus on emerging themes. Setting-Major university hospital in the Northeastern United States. Sample-Adults (>18 years of age) whose primary language was English or Spanish and who could provide written informed consent. RESULTS: The sample consisted of 15 participants who had a mean age of 34.6 years; half were women. Most were white and college educated. The relationship of the donors to recipients varied from immediate family to altruistic donors. "Getting used to being a patient" was the major theme that captured the patients' postoperative experience. Four subthemes explained the experience: regaining consciousness, all those tubes, expecting horrible pain, and feeling special and cared for. These were described in the context of an "amazing and impressive" transplant team. CONCLUSION: As healthy donors are getting used to being patients, these results provide clinicians with a deeper understanding of the transplant experience from the donor's perspective so that care can be tailored to meet their unique needs.

An infrastructure to advance the scholarly work of staff nurses.

The traditional role of the acute care staff nurse is changing. The new norm establishes an expectation that staff nurses base their practice on best evidence. When evidence is lacking, nurses are charged with using the research process to generate and disseminate new knowledge. This article describes the critical forces behind the transformation of this role and the organizational mission, culture, and capacity required to support practice that is based on science. The vital role of senior nursing leaders, the nurse researcher, and the nursing research committee within the context of a collaborative governance structure is highlighted. Several well-known, evidence-based practice models are presented. Finally, there is a discussion of the infrastructure created by Yale-New Haven Hospital to advance the scholarly work of the nursing staff.

Improvements in time to reperfusion: do women have an advantage?

Several studies demonstrate that women have greater delays in primary percutaneous coronary intervention (PCI). To improve care for women, the Women's Heart Advantage at Yale-New Haven Hospital (YNHH) developed patient- and physician-level interventions to improve knowledge about chest pain syndromes to promote early presentation, diagnosis, and timely management of ST-elevation myocardial infarction (STEMI) in women presenting to the emergency department. Specifically, we analyzed chart-abstracted data from all patients undergoing PCI for STEMI at YNHH from January 2004 to July 2007 and assessed quality of care for STEMI and trends in time to reperfusion. Women's Heart Advantage and YNHH orchestrated several clinical initiatives and instituted hospital-wide systems to improve STEMI care over this period. Both men and women had declines in time to reperfusion (91-73 minutes for men and 120-74 minutes for women). Notably, improvements in time to reperfusion were more substantial in women; the greatest improvement was reduction in door-to-table time (50% decrease in women vs. 19% decrease in men [P < 0.05]). In this single-site study of men and women undergoing primary PCI at a large, urban teaching hospital, where ongoing interventions to increase both patient and physician awareness regarding heart disease in women were initiated, time to reperfusion for women improved to a greater degree than in men. These results are encouraging, showing that significant improvements can be made over a relatively short time frame. It is hoped these reductions in time to reperfusion are associated with improved outcomes; however, further studies are needed to verify this potential benefit.