Capturing the Interpersonal Process of Psychiatric Nurses: A Model for Engagement.

Staff members' engagement with patients is a critical element of inpatient psychiatric care, essential to safety, the hospitalization experience and the development of a culture of care. Currently broad concerns exist around the amount of time inpatient psychiatric nurses expend in patient engagement and the quality of these interactions. In this paper we present a model of engagement that clarifies necessary skills to support the engagement process. The model is based on Peplau's theory of interpersonal relations, patients' ideas on healing elements of psychiatric hospitalization and research on inpatient therapeutic relationships. We are currently using this model for a web-based teaching/learning course to cultivate interpersonal engagement, and to explicate how through operationalizing their inpatient role, nurses support patients in the development of their mental health and well-being.

Experiences of Military Spouses of Veterans With Combat-Related Posttraumatic Stress Disorder.

PURPOSE: To explore the experiences of military spouses living with veterans with combat-related posttraumatic stress disorder (PTSD). DESIGN: Husserlian phenomenology was chosen as the theoretical framework because it allowed a deeper understanding of the unfolding of the spouses' daily experience. METHODS: A purposive sample of 14 spouses living with veterans with symptoms of PTSD participated in unstructured interviews. Data were analyzed using a modification of the Colaizzi phenomenological method. FINDINGS: Spouses recognized that the veteran was no longer the same person, with life becoming one of living with the unpredictability of PTSD. The spouses bore the burden to maintain normalcy in the family and eventually created a new life. CONCLUSIONS: Military spouses endure psychological stress and strain, while living with a veteran with PTSD. There is a need for more programs to support the resilience of military spouses. CLINICAL RELEVANCE: Life for military spouses of veterans with PTSD is ever-changing and unpredictable. Practitioners need to be aware of the stress that spouses experience and develop programs and interventions that bolster the resilience of military families.

Development and testing of the combined assessment of psychiatric environments: a patient-centered quality measure for inpatient psychiatric treatment.

BACKGROUND: Inpatient psychiatric treatment satisfaction measures are not constructed from patients' perspective of hospitalization experiences that they deem meaningful and important. OBJECTIVE: To develop and conduct psychometric testing of a measure that evaluates person-centered care on inpatient psychiatric units, the Combined Assessment of Psychiatric Environments (CAPE). The measure is built on a theoretical framework holding that if optimal care is to be achieved, all major stakeholders (patients and staff) need to experience a positive environment. DESIGN: An instrument development design was used to create the patient/staff nurse versions of the CAPE and to test their dimensions. The pilot versions of the CAPE were tested on six inpatient psychiatric units to determine the psychometrics of the staff/patient versions. RESULTS: The overall reliability of both versions of the CAPE (staff/patient) was .91. The test-retest reliability for both versions was significant at the .01 level. Construct validity was established via factor analysis. Criterion-related validity was demonstrated by correlations of the two versions of the CAPE to instruments that were conceptually related. CONCLUSION: The CAPE is a valid and reliable instrument that can be used to examine practice and the patient experience on inpatient psychiatric units. The CAPE highlights that patient-centered environments of care are intertwined with staff experiences of support for their role.

Spiritual quality of life in advanced cancer patients receiving radiation therapy.

OBJECTIVE: The aim of this randomized controlled trial for patients with advanced cancer receiving radiation therapy was to determine the effect of a multidisciplinary intervention on spiritual quality of life (QOL) at the end of the intervention (week 4) and at two follow-up time points (weeks 26 and 52). METHODS: One hundred thirty-one persons were randomized to either the intervention or control (forms only) groups. The intervention included six 90-min in-person sessions based on the physical, emotion, social, and spiritual domains of QOL. Three sessions included the spiritual component. Caregivers were present for four sessions, one which included a spiritual component. Ten follow-up phone calls were made to the patients in the intervention group during the 6-month follow-up period. Patients completed the Functional Assessment of Cancer Therapy: General Scale, the Linear Analog Self-Assessment which includes an assessment of spiritual QOL, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being (FACIT-Sp) at enrollment, and weeks 4, 27, and 52. RESULTS: Following the intervention, the intervention group demonstrated improved spiritual QOL on the FACIT-Sp, whereas the spiritual QOL of the control group decreased, resulting in significant mean changes between groups (total score: 1.7 vs. -2.9; p < 0.01; meaning/peace subscale: 1.0 vs. -3.5; p < 0.01; faith subscale: 3.1 vs. -1.7; p = 0.04). CONCLUSIONS: The results indicate that a multidisciplinary intervention which includes a spiritual component can maintain the spiritual QOL of patients with advanced cancer during radiation therapy.

Metasynthesis of research on the role of psychiatric inpatient nurses: what is important to staff?

BACKGROUND: Inpatient psychiatric nurses are a large workforce, but their work is poorly articulated and thus poorly understood outside of the professional inpatient community. OBJECTIVE: To learn how inpatient psychiatric nurses depict their work, define important aspects of their role, and view the impact of the unit environment on their clinical practice. DESIGN: Metasynthesis of research that has focused on the ideas and perceptions of inpatient psychiatric nurses around their role and practice on inpatient psychiatric units. RESULTS: Three themes emerged from the analysis; the first was an umbrella for three important aspects of nursing work: the nurses' efforts to forge engagement with patients; their activities which maintained the safety of the unit and interventions nurses viewed as educating/empowering patients. The second theme captures the conditions that enabled nurses to do this work such as a cohesive nursing team and their sense of self-direction in their role. The final theme centers on difficulties nurses encountered in enacting their role which included multiple responsibilities for patient care and management of the milieu; intense work often with low visibility and scant support within the organization. CONCLUSIONS: Nurses need to articulate their practice so they can assert for the staffing and resources needed to keep units safe and promote patients' well-being, strive toward quality, and promote the development of the specialty.

Randomized controlled trial of maintaining quality of life during radiotherapy for advanced cancer.

BACKGROUND: Psychosocial interventions often address only 1 domain of quality of life (QOL), are offered to patients with early-stage cancer, do not include the caregiver, and are delivered after cancer treatment has been completed. METHODS: In the current randomized controlled trial, 131 patients with advanced cancer who received radiotherapy and their caregivers were randomly assigned to either a 6-session, structured, multidisciplinary intervention arm or a standard care arm. The average age of the patients was 58 years, the majority were male (63%), and tumor types varied (gastrointestinal [37%], brain [22%], head and neck [16%], lung [13%], and other [12%]). The six 90-minute sessions addressed the 5 domains of QOL: cognitive, physical, emotional, social, and spiritual. The in-person intervention was followed by 10 brief telephone counseling sessions that took place over the next 6 months. RESULTS: Of the 117 patients who completed the study, overall QOL (assessed by Functional Assessment of Cancer Therapy-General [FACT-G]) at week 4 was significantly higher in the intervention group (n = 54) compared with the standard arm control group (n = 63) (75.2 vs 68.7; P = .02). The 10 brief telephone contacts did not appear to impact QOL because at week 27 the groups had identical QOL (means of 77.6 and 77.7, respectively). There was no effect of the intervention noted on caregiver QOL. CONCLUSIONS: Participating in a 6-session multidisciplinary intervention was found to be effective in maintaining the QOL of patients with advanced cancer who were actively receiving radiotherapy. The QOL and symptom burden of this population is striking, making it important to identify effective QOL strategies to implement in conjunction with cancer care.

Spiritual well-being in lung cancer survivors.

PURPOSE: Spiritual well-being (SWB) among lung cancer survivors has not been well-delineated. Additionally, little is known about how SWB is affected over the trajectory of the disease process. The aims of this study were to examine the SWB of individuals with a diagnosis of lung cancer, to assess the stability of SWB over time, and to identify the factors associated with SWB. METHODS: A prospective cohort of patients with lung cancer first seen at the Mayo Clinic over a 10-year period of time was included in this study. Study entry was at the time of diagnosis or referral to the Mayo Clinic, and participation involved annual survey using the Functional Assessment in Chronic Illness Therapy-Spiritual Well-being, Medical Outcome Short Form 8, and Quality of Life (QOL) Linear Analog Scale Assessment. Associations were explored using Fisher's exact test, chi-squared test, Kruskal-Wallis test, and Spearman correlations. Linear regression was used to explore multivariate relationships. RESULTS: There were 1,578 participants over a 10-year period of time. Group SWB scores were relatively high and stable over a 10-year period of time ([Formula: see text], standard deviation = 14.47-18.46, possible scale of 0-100). However, individual scores varied widely across almost the entire scale (2.1-100) and revealed a chaotic trajectory for SWB. Males, current smokers, and those with higher pack-years experienced lower SWB compared to females, nonsmokers, and those with lower pack-years (p < 0.0001, 0.0455, and 0.0004, respectively). SWB was strongly associated with overall QOL. CONCLUSIONS: SWB is an individualistic experience that can change dramatically over time for cancer survivors. Ongoing assessments are important.

Spiritual well-being and quality of life of women with ovarian cancer and their spouses.

BACKGROUND: There is little research on the quality of life (QOL) and spiritual well-being (SWB) of women diagnosed with ovarian cancer and their spouses. OBJECTIVE: We compared the SWB and QOL of these women and their spouses over a 3-year period. METHODS: This is a descriptive, longitudinal study involving 70 women with ovarian cancer and 26 spouses. Questionnaires were completed postoperatively and by mail 3, 7, 12, 18, 24, and 36 months later. All participants completed the Functional Assessment of Chronic Illness Therapy (FACIT)-Spiritual Well-Being-Expanded Version, Symptom Distress Scale, and open-ended questions about changes in their lives. Diagnosed women completed the FACIT-Ovarian and spouses the Caregiver Burden Interview and Linear Analog Self-Assessment scales. RESULTS: Women reported a high level of SWB over time. Spouses' SWB was significantly worse than the women's at 1 and 3 years (P ≤ .05). Insomnia, fatigue, and outlook/worry were problematic across time, with no significant differences between women and spouses except that women experienced more insomnia through 3 months (P = .02). Emotional well-being was compromised over time for the women but not their spouses until year 3. Physical and social well-being were compromised in spouses across time, while women's social well-being remained high and physical well-being was problematic only for the first year. LIMITATIONS: Limitations include a small spouse sample and, due to the disease process, attrition over time. CONCLUSIONS: Ovarian cancer has significant, but different, effects on women and spouses. Some effects are static, while others are not, which underscores the need for continual monitoring.

The Chicago Breathe Project: a regional approach to improving education on asthma inhalers for resident physicians and minority patients.

BACKGROUND: Asthma affects minority citizens in Chicago disproportionately. Policy changes introducing hydrofluroalkane (HFA) inhalers may worsen already-existing health disparities related to asthma. AIMS: To teach internal medicine residents about the transition to HFAs so they can better counsel their patients on asthma self-management. To provide minority community members with interactive educational sessions. SETTING: Internal medicine residents at 5 Chicago programs. Community workshops in primarily Spanish-speaking (Cicero) Latino population and a primarily African American population from the south side of Chicago. PROGRAM DESCRIPTION: The Chicago Breathe Project provides residents with education and tools necessary to counsel patients with asthma on inhaler use and provides minority community members with interactive educational sessions on asthma and inhaler use. PROGRAM EVALUATION: Eleven workshops were held across 5 academic institutions, with a total of 161 residents. Resident knowledge regarding HFA inhalers improved dramatically (5% pre vs. 91% post, p < .001). Six months post education, residents were more likely to assess inhaler technique (44% vs. 11%, p = .046) and discuss new HFA inhalers (69% vs. 24%, p = .011) with their asthma patients. Community members provided feedback after the workshops that they would come again, found the session helpful ,and enjoyed the session. DISCUSSION: The Chicago Breathe Project resulted in improved resident knowledge and skill on inhaler use during HFA transition. Regional educational approaches targeting internal medicine residencies in urban areas may be helpful to address future changes in chronic disease management. This training can be taken into minority communities to provide high-quality interactive educational workshops directly to patients and their families.

Point-of-care technology supports bedside documentation.

As the conversion to an electronic health record intensifies, the question of which data-entry device works best in what environment and situation is paramount. Specifically, what is the best mix of equipment to purchase and install on clinical units based on staff preferences and budget constraints? The authors discuss their evaluation of stationary personal computers, workshops on wheels, and handheld tablets related to timeliness of data entry and their use of focus groups to ascertain the pros/cons of data-entry devices and staff preferences. An assessment of the implications for costs related to the timeliness of data entry is also presented.

Violence and restraint reduction efforts on inpatient psychiatric units.

Efforts to reduce aggression and violence and the use of restraint and seclusion have traditionally been through some form of educational program. This paper presents an integrative review of research and quality improvement projects that aimed to reduce aggression/violence or restraint/seclusion through the use of an educational program. Forty-six papers are included in this review. This paper presents summaries and comparisons of the research designs, the content and length of programs, and the outcomes of these programs. From these summaries, trends in relation to design, content, and outcomes are identified, and recommendations for clinicians and researchers are given.

The design of adult acute care units in U.S. hospitals.

PURPOSE: To describe the current state of design characteristics determined to be desirable by the Agency for Health Research and Quality (AHRQ) in U.S. adult medical, surgical, and intensive care units (ICUs). DESIGN: Descriptive study of patient visibility; distance to hygiene, toileting, charting, and supplies; unit configuration; percentage of private rooms; and presence or absence of carpeting in 56 ICUs and 81 medical-surgical units in six metropolitan areas. METHODS: Data were collected via observation, measurement, and interviews. Unit configurations were classified via an iterative process. Descriptive data were analyzed according to ICU and non-ICU status using SPSS (Version 15). FINDINGS: Analysis of unit configurations indicated eight unit designs. Statistical analysis showed inter- and intrahospital variation in unit configurations, percentage private rooms, carpeting, visibility, and distance to supplies and charting. Few units met the AHRQ designated design elements studied. CONCLUSIONS: A wide gap exists between desirable characteristics in ICUs and medical-surgical units. Future research is needed to explore operationalization of unit design elements as risk adjustments, how design elements contribute to patient outcomes, and how design elements influence one another. CLINICAL RELEVANCE: There is room for improvement on almost every design variable, particularly on medical-surgical units. Future planning should take into consideration the interaction of bed capacity and unit configuration.

Hospital chaplains' involvement in a randomized controlled multidisciplinary trial: implications for spiritual care and research.

Chaplains' involvement in spirituality and health research can contribute something vital and unique to these investigations. It can also provide opportunity for professional growth and increased effectiveness. This article describes the authors' experience as co-investigators in a randomized controlled trial involving patients with a life expectancy of less than five years receiving radiation therapy for advanced cancer. It also discusses the application to clinical settings and other research.

Urology resident training with an unexpected patient death scenario: experiential learning with high fidelity simulation.

PURPOSE: Communicating unexpected news of a patient death is rarely encountered in urology. We evaluated resident performance during an unexpected patient death scenario involving high fidelity simulation. We also studied simulation as a tool to teach and assess nontechnical skills in urology. MATERIALS AND METHODS: An unexpected patient death scenario was developed at a simulation center using high fidelity mannequins, urology residents, critical care fellows, nurses, hospital chaplains and actors. Scenario objectives addressed Accreditation Council for Graduate Medical Education core competencies. The 19 urology residents in training years 2 to 6 participated in the scenario. Performance was evaluated using 5-point Likert scale questionnaires and checklists completed by residents, faculty and actors. RESULTS: Overall resident performance was satisfactory in the simulation scenario. Verification of code status was identified as an area requiring improvement. Euphemisms for death were more commonly used in the initial delivery (16 residents or 84.2%) than the preferred words died or death (3 or 15.8%). After completing the scenario the perceived competency of residents increased from 73.7% before to 94.7% after the scenario. In addition, all residents agreed that the simulation experience was useful and overall realistic, and it should be part of the training curriculum. CONCLUSIONS: Evaluation of urology resident performance was possible during an unexpected patient death scenario. Upon completion of the scenario perceived competency of the simulation task was increased. High fidelity simulation was found to be an effective method for teaching and assessing the acquisition of nontechnical skills. All residents agreed that the simulation was useful and should be included in urological training.

Patients' expectations of hospital chaplains.

OBJECTIVE: To evaluate patients' expectations of hospital chaplains. PATIENTS AND METHODS: From April 6, 2006, through April 25, 2006, we surveyed by mail 1500 consecutive medical and surgical patients within 3 weeks of their discharge from the hospital. The survey included questions related to demographics, duration and area of hospitalization, awareness of chaplain availability, expectations regarding chaplain visits, and reasons for wanting to see a chaplain. Measured characteristics were summarized by calculating means and SDs for continuous variables and proportions for categorical variables. Proportions were statistically compared via Fisher exact tests or Monte Carlo estimates. RESULTS: Surveys were returned by 535 of the 1500 patients to whom they were sent. Most of those who returned surveys had been hospitalized for less than 1 week (398/514 [77.4%]) and were male (265/510 [52.0%]), married (396/528 [75.0%]), 56 years or older (382/532 [71.8%]), or affiliated with either the Lutheran (177 [33.3%]) or Catholic (133 [25.0%]) churches. Most (78.9%) were aware of the availability of chaplains, and 62.3% would have appreciated chaplain visitation at least every few days. More than half (52.9%) reported that they were visited, and 86.4% reported that this visit was important to them. The primary reason selected for wanting to see a chaplain was "to be reminded of God's care and presence." Items related to ritual, prayer, and pastoral support were also highly endorsed. Some results were dependent on sex, age, religious affiliation, or duration of stay. CONCLUSION: Hospitalized patients value visitation by chaplains and appreciate both religious and supportive interventions. Opportunities for patient care, education, and research are apparent.

Losing one's memory in early Alzheimer's disease.

A Heideggerian hermeneutical phenomenological research method was used to investigate the experience of memory loss in twelve individuals with early Alzheimer's disease or mild cognitive impairment. Data analysis proceeded as described by Diekelmann, Allen, and Tanner (1989), and incorporated the methods of Benner (1994), Thomas and Pollio (2002), and van Manen (1990). Three constitutive patterns with relational themes were identified. The first pattern, experiencing breakdown, consisted of two themes: awakening to breakdown and living with forgetting. The second pattern, temporality, consisted of three themes: being in the nothing, forgetting the past, and looking ahead. The third pattern, managing forgetting, consisted of the themes: remembering with cues, writing things down, recognizing what made remembering better or worse, and using laughter. The finding show that early Alzheimer's disease is more than an illness of cognitive losses and that forgetting is significant in light of the meaning that it has within everyday life.

Emotional Availability Scale Among Three U.S. Race/Ethnic Groups.

This study used a cross-sectional design to conduct a subgroup psychometric analysis of the Emotional Availability Scale among matched Hispanic ( n = 20), African American ( n = 20), and European American ( n = 10) English-speaking mother-child dyads in the United States. Differences by race/ethnicity were tested ( p < .05) among (a) Emotional Availability Scale dimensions with ANOVA, and (b) relationships of Emotional Availability Scale dimensions with select Dyadic Parent-Child Interaction Coding System variables with Pearson correlation and matched moderated regression. Internal consistency was .950 (Cronbach's α; N = 50). No significant differences in the six Emotional Availability Scale dimension scores by race/ethnicity emerged. Two Dyadic Parent-Child Interaction Coding System behaviors predicted two Emotional Availability Scale dimensions each for Hispanic and African American mother-child dyads. Results suggest emotional availability similarity among race/ethnic subgroups with few predictive differences of emotional availability dimensions by specific behaviors for Hispanic and African American subgroups.

Measuring spiritual quality of life in patients with cancer.

There is no one established approach to the measurement of spiritual quality of life (QOL). Available instruments are based on various theoretical components. We used a multi-instrument approach to measure the spiritual domain of QOL that adds to our understanding of a participant self-definition of spiritual QOL. In total, 103 participants with advanced cancer receiving radiation therapy were enrolled in this study. Most were Caucasian, male, and had advanced lung, head and neck, or gastrointestinal cancer. Two instruments, the Spiritual Well-Being Linear Analogue Self Assessment (SWB LASA) and the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual (FACIT-Sp-12), were used to measure spiritual QOL at enrollment and 4, 8, and 27 weeks after enrollment. Analyses included descriptive statistics, Spearman correlations, stepwise multiple regression, and repeated measures analysis of variance. There was a strong association between SWB LASA and FACIT-Sp-12 total scores. However, FACIT-Sp-12 items defining SWB LASA scores varied over time. Two to three of the FACIT-Sp-12 items explained approximately two thirds of the variance in the SWB LASA scores at each time point with the exception of 4 weeks after enrollment. SWB scores were strongly associated with all QOL domains. In research and clinical care, SWB must be treated as a complex concept that has the potential to change over time. Although a single-item measure of SWB provides valuable information and is strongly associated with the multiple item FACIT-Sp-12, our more detailed inquiry using the FACIT-Sp-12 provides additional guidance for the design and timing of spiritual support interventions.