Effects of a 12-Session Symptom Self-Management Course on Forensic Psychiatric Inpatients' Auditory Hallucinations and Anxiety.

The purpose of this clinical dissemination project was to evaluate changes in intensity of unpleasant auditory hallucinations (AH) and level of anxiety after forensic psychiatric inpatients attended an evidence-based symptom self-management course. The course was taught twice to patients with schizophrenic disorders. Data were collected using five self-rating measures. Seventy percent of participants reported reduced AH and anxiety; 100% reported helpfulness of being with others with similar symptoms; 90% would recommend the course to others. The course facilitator reported: improved communication, comfort, and effectiveness working with people with AH, plans to teach the course again and recommend it to colleagues.

Integrating Anxiety Reduction into an Existing Self-Management of Auditory Hallucinations Course.

High levels of anxiety were found to interfere with voice hearers' ability to benefit from a 10-Session Behavioral Management of Auditory Hallucinations Course. The 10-session course was revised, adding anxiety reduction strategies to the first four classes and reinforcing those strategies in the remaining eight classes. A multi-site study (N = 27) used repeated measures to determine whether the new 12-session course would significantly reduce anxiety. Ten course leaders were trained and taught the course six times at three different outpatient mental health sites. Three measures of anxiety were used. The 12-session course was found to significantly reduce anxiety after the first four classes with further reduction at the end of the course. Eighty-eight percent of course participants reported the course was moderately to extremely helpful. They also reported that being in a group with others with similar symptoms was valuable. Course leaders reported learning about the prevalence and importance of treating voice hearers' anxiety. [Journal of Psychosocial Nursing and Mental Health Services, 55(5), 29-39.].

Insufflation using carbon dioxide versus room air during colonoscopy: comparison of patient comfort, recovery time, and nursing resources.

The standard of practice for colonoscopy is room air insufflation. Recent research demonstrates safety and significant decrease in postcolonoscopy discomfort from distention when carbon dioxide (CO2) is used during insufflation. Reducing abdominal pain after colonoscopy may lead to increased acceptance of colonoscopy screening for colorectal cancer. This study aims to compare patient comfort intra- and postprocedure, length of recovery, and nursing time in patients undergoing colonoscopy using room air vs. CO2 insufflation. This study uses an experimental design with patients randomly assigned to either room air or CO2 during colonoscopy. Physician endoscopists, postprocedure nurses, and patients were blinded to assignment. Prior bowel surgery, inflammatory bowel disease, or inability to consent excluded participants. Outcome measures included discomfort assessment, nursing tasks, and recovery time.Of 191 participants, 177 were men and 14 were women; 94 received room air; 97 received CO2. Patients insufflated with room air reported higher levels of some measures of discomfort: (a) during colonoscopy (p = .02), (b) on admission to recovery (p = .001), and (c) on discharge from recovery (p = .001). Patients receiving room air required more nursing tasks in recovery (p = .001) and more total nursing time (p = .001).Compared with room air, CO2 insufflation increases patient comfort and decreases nursing tasks and time.

Auditory hallucinations interview guide: promoting recovery with an interactive assessment tool.

The Auditory Hallucinations Interview Guide (AHIG) is a 32-item tool that helps psychiatric-mental health (PMH) nurses assess past and current experiences of voice hearers so they can provide more individualized care. The AHIG was developed as a research tool but has also been found to be clinically useful in both inpatient and outpatient settings to help voice hearers and nurses develop a shared terminology of auditory hallucinations (AH). Using the AHIG, voice hearers are able to tell their stories in a structured and safe environment, thus encouraging recovery. Through respect and active listening, PMH nurses can communicate unconditional acceptance, caring, and hope for recovery, which helps develop rapport and promote trust in the nurse-patient relationship. Once trust is developed, voice hearers and PMH nurses can work together to find effective strategies for managing AH, including commands to harm self and others.

Disseminating an evidence-based course to teach self-management of auditory hallucinations.

This multi-site project extended course dissemination of the 10-session Behavioral Management of Auditory Hallucinations Course to U.S. Department of Veterans Affairs (VA) mental health outpatient settings. The VA Quality Enhancement Research Initiative (QUERI) model and Rogers' theory of diffusion of innovations served as the theoretical framework. The course was taught to mental health professionals using teleconferencing, electronic media, and monthly conference calls across 24 VA mental health outpatient sites. Twenty course leaders provided feedback. One hundred percent reported being better able to communicate with patients about their voices and 96% reported improved understanding of the voice-hearing experience. Thirty-three course participants provided feedback. Ninety-four percent would recommend the course, 85% reported being better able to communicate with staff about their voices, and 66% reported being better able to manage their voices. Facilitators and barriers to course implementation are described.

Self-management of unpleasant auditory hallucinations: a tested practice model.

Individuals who experience auditory hallucinations (AH) frequently report hearing unpleasant voices saying disturbing things to them, making derogatory remarks about them, or commanding them to do something, including harming themselves or someone else. The Self-Management of Unpleasant Auditory Hallucinations Practice Model was developed to help psychiatric-mental health nurses in both inpatient and outpatient settings implement evidence-based nursing care for voice hearers who are distressed by unpleasant voices. The model's utility extends to nursing education, administration, and research. The model is comprised of three parts: (a) Assessment of Voice Hearer's Experience, (b) Nursing Interventions, and (c) Voice Hearer's Expected Positive Outcomes. These three parts of the model describe nursing assessments conducted with an interview guide and two self-report tools, nursing interventions that teach strategies to manage unpleasant AH in a 10-session course or individually, and evaluation of voice hearer outcomes with two self-report tools.

Comprehensive evidence-based program teaching self-management of auditory hallucinations on inpatient psychiatric units.

Patients hearing command hallucinations to harm whose only self-management strategies are to obey these commands, can represent serious safety concerns on inpatient psychiatric units. A comprehensive evidence-based program teaching self-management of auditory hallucinations on inpatient psychiatric units is described that includes five components: suggestions for staff education; patient self-assessment tools; an interview guide and safety protocol; a course to teach strategies for managing distressing voices and commands to harm; suggestions to improve staff communication; and a plan to extend the program from inpatient care settings into the community by sharing materials with community case managers and caregivers when patients are discharged.

Responding to command hallucinations to harm: the unpleasant voices scale and harm command safety protocol.

Command hallucinations are relatively common in voice hearers and are taken seriously because of the potential threat to self and others. Many variables mediate the relationship between hearing commands and acting on them. This article describes the implementation of the Harm Command Safety Protocol and the Unpleasant Voices Scale to respond to command hallucinations to harm in the context of the dissemination of a multisite, evidence-based behavioral management course for patients with auditory hallucinations.

Behavioral management of auditory hallucinations.

A 10-session behavioral course for self-management of auditory hallucinations in patients with schizophrenia has demonstrated positive outcomes. This article evaluates both the course's implementation and benefits to patients attending the course. Teleconferencing, electronic media, and 26 monthly conference calls were used to educate six advanced practice nurses (APNs) at six sites about the course implementation. Thirty-two patients within the U.S. Department of Veterans Affairs participated in the course. All of the APNs reported course helpfulness, improved communication with patients about voices, and improved harm assessment. Of the patients, 96% found the course helpful: 67% no longer heard voices to harm self or others, and 60% had improved auditory hallucination intensity scores. The project demonstrated successful implementation and practice integration with APNs' activities corresponding to Rogers' stages of innovation adoption. Facilitators and barriers to implementation are also described.

A music intervention to reduce anxiety before vascular angiography procedures.

Patients scheduled for vascular angiography are often anxious and frightened. High levels of anxiety may result in more difficult and painful procedures. Past research has reported mixed results for anxiety reduction techniques in other procedures settings, such as education, cognitive-behavioral skills, coping and relaxation skills, combinations of techniques, and music. Music as an intervention for pre-procedural anxiety prior to vascular angiography has not been studied. A randomized controlled trial of 170 patients was undertaken to determine whether 15 minutes of self-selected music reduced pre-procedure anxiety. The State Trait Anxiety Inventory was used to measure patients' anxiety. One-hundred sixty-six men and 4 women comprised the sample with an average age of 66.8 years (SD 9.95, range 37 to 85 years). Patients who listened to music (n=89) reduced their anxiety score from 38.57 (SD 10.46) to 35.2 (SD 9.7), while those who did not listen to music (n=81) reduced their anxiety score from 36.23 (SD 10.54) to 35.1 (SD 10.59); the difference between the groups was statistically significant (t=1.95, df 161, p=0.05). Pulse achieved a statistically significant reduction in the music group (t=2.45, df 167, p=0.02). Music is a noninvasive nursing intervention that patients enjoy and reduces their anxiety and their pulse rate. Further research should address using music to reduce anxiety in other interventional vascular angiography settings with equal numbers of men and women and comparing self-selected versus investigator-selected music.

Handoffs and Patient Safety: Grasping the Story and Painting a Full Picture.

Effective handoff communication is critical for patient safety. Research is needed to understand how information processes occurring intra-shift impact handoff effectiveness. The purpose of this qualitative study was to examine medical-surgical nurses' (n = 21) perspectives about processes that promote and hinder patient safety intra-shift and during handoff. Results indicated that offgoing nurses' ability to grasp the story intra-shift was essential to convey the full picture during handoff. When oncoming nurses understood the picture being conveyed at the handoff, nurses jointly painted a full picture. Arriving and leaving the handoff with this level of information promoted patient safety. However, intra-shift disruptions often impeded nurses in their processes to grasp the story thus posing risks to patient safety. Improvement efforts need to target the different processes involved in grasping the story and painting a full picture. Future research needs to examine handoff practices and outcomes on units with good and poor practice environments.

A clinical trial of the effectiveness of regularly scheduled versus as-needed administration of acetaminophen in the management of discomfort in older adults with dementia.

OBJECTIVES: To determine in a sample of nursing home patients with dementia and a painful condition whether the regularly scheduled administration of acetaminophen (650 mg four times a day (qid)) was more or less effective than as-needed (prn) administration of acetaminophen in reducing discomfort. DESIGN: Double-blind, double-dummy, placebo-controlled, crossover study. One arm consisted of 650 mg of acetaminophen administered qid with placebo prn; the other arm consisted of placebo administered qid with acetaminophen prn. SETTING: Two community and one Veterans Affairs nursing homes in the San Francisco Bay area. PARTICIPANTS: Thirty-nine nursing home patients with a mean+/-standard deviation Mini-Mental State Examination score of 4.3+/-5, a mean Global Deterioration Scale score of 5.7+/-0.4, and a mean Discomfort Scale score of 10.7+/-6.8. Approximately 84% had degenerative joint disease. RESULTS: Mean Discomfort Scale scores of 7.4+/-3.7 during the prn arm and 7.2+/-2.1 during the qid arm (t=0.249, nonsignificant) were within the range previously shown to indicate substantial discomfort. No significant differences in discomfort scores were found between the trial arms after controlling for baseline discomfort and prn use of acetaminophen. CONCLUSION: Although this trial was negative in terms of the analgesic effects of acetaminophen, the findings have important implications for clinical practice. Prn administration of acetaminophen is sometimes the standard of care for pain management in nursing homes or is offered as an intervention to assess effectiveness. Findings from this study suggest that a 2,600-mg/d dose of acetaminophen is inadequate for elderly nursing home patients with degenerative joint disease, fractures, or back pain who have significant discomfort.

Changing practice to prevent contrast-induced nephropathy.

Based on updated evidence, a radiology nurse systematically engaged a multidisciplinary staff in testing a protocol to prevent contrast-induced nephropathy related to computed tomography. In a quality improvement project, the protocol combined preprocedure oral hydration with postprocedure intravenous saline. This protocol safely improved kidney function, reduced postprocedure time, and decreased annual cost. By applying theory, being persistent, presenting sound evidence, and unifying the team, one concerned staff nurse profoundly affected patient care and policy in an entire medical center.

Moving to new settings: pilot study of families' perceptions of professional caregivers' pain management in persons with dementia.

Persons with advanced dementia often have pain that is underrecognized and undertreated primarily because they cannot clearly communicate their needs. Consequently, they receive fewer analgesics than cognitively intact persons with the same conditions. Several assessment methods have been developed in the past decade, yet pain assessment and management problems persist in all care settings. These problems are likely to persist when patients move between levels of care. In this study, we determined from family caregivers whether pain was problematic when their family members with dementia moved to different care settings (e.g., admission or transfer). A total of 34 family caregivers responded to an anonymous survey; 50% reported that pain was not discussed at admission or after entry into a new care setting, and 67% were not confident that staff could detect pain. Respondents' recommendations for improving pain management included regular observation and assessment, timely and consistent pain medication administration, communication with family caregivers, and staff education.

Cognitive impairment and pain management: review of issues and challenges.

The assessment and treatment of pain in persons with cognitive impairments pose unique challenges. Disorders affecting cognition include neurodegenerative, vascular, toxic, anoxic, and infectious processes. Persons with memory, language, and speech deficits and consciousness alterations are often unable to communicate clearly about their pain and discomfort. Past research has documented that persons with cognitive impairments, particularly dementia, are less likely to ask for and receive analgesics. This article provides an overview of the assessment, treatment, and management of pain in adults with cognitive impairments. We review types of cognitive impairment; recent work specific to best practices for pain management in patients with dementia, including assessment-tool development and pharmacological treatment; challenges in patients with delirium and in medical intensive care and palliative care settings; and directions for future research.