Adaption of the Casey-Fink Survey Tool for Nurse Residency Programs: Making It Relevant for Hospice and Palliative Care Nurse Residency Programs.

OBJECTIVE: This evaluation project focused on assessing the content validity of an adapted version of the Casey-Fink (CF) Graduate Nurse Experience Survey, which is aimed at measuring role transitions in nursing. BACKGROUND: Registered nurses in the hospice and palliative care field need training and confidence to be proficient in core skills including communication, interprofessional competence, and clinical skills required to care for the dying patient. However, a review of the literature revealed a gap in the availability of survey instruments to measure the confidence of nurses entering the field of hospice and palliative care. METHODS: Ten items from the CF survey were revised by the project team and then evaluated for relevance by a group of 7 national hospice and palliative experts. The content validity index (CVI) was used to determine item relevance. RESULTS: Item-level CVI (I-CVI) calculations ranged from 0.57 to 1.0. The 8 items scored between 0.80 and 1.0 were retained as written. One item required further revision (I-CVI, 0.71), and 1 item revision was eliminated (I-CVI, 0.57). Experts also suggested 5 additional items in the original CF-survey need modification. CONCLUSION: The adapted CF-survey tool is ready for further psychometric testing, and next steps include administration to a new sample of nurse residents to determine construct validity.

Clinicians' perceptions of usefulness of the PubMed4Hh mobile device application for clinical decision making at the point of care: a pilot study.

BACKGROUND: Although evidence-based practice in healthcare has been facilitated by Internet access through wireless mobile devices, research on the effectiveness of clinical decision support for clinicians at the point of care is lacking. This study examined how evidence as abstracts and the bottom-line summaries, accessed with PubMed4Hh mobile devices, affected clinicians' decision making at the point of care. METHODS: Three iterative steps were taken to evaluate the usefulness of PubMed4Hh tools at the NIH Clinical Center. First, feasibility testing was conducted using data collected from a librarian. Next, usability testing was carried out by a postdoctoral research fellow shadowing clinicians during rounds for one month in the inpatient setting. Then, a pilot study was conducted from February, 2016 to January, 2017, with clinicians using a mobile version of PubMed4Hh. Invitations were sent via e-mail lists to clinicians (physicians, physician assistants and nurse practitioners) along with periodic reminders. Participants rated the usefulness of retrieved bottom-line summaries and abstracts and indicated their usefulness on a 7-point Likert scale. They also indicated location of use (office, rounds, etc.). RESULTS: Of the 166 responses collected in the feasibility phase, more than half of questions (57%, n = 94) were answerable by both the librarian using various resources and by the postdoctoral research fellow using PubMed4Hh. Sixty-six questions were collected during usability testing. More than half of questions (60.6%) were related to information about medication or treatment, while 21% were questions regarding diagnosis, and 12% were specific to disease entities. During the pilot study, participants reviewed 34 abstracts and 40 bottom-line summaries. The abstracts' usefulness mean scores were higher (95% CI [6.12, 6.64) than the scores of the bottom-line summaries (95% CI [5.25, 6.10]). The most frequent reason given was that it confirmed current or tentative diagnostic or treatment plan. The bottom-line summaries were used more in the office (79.3%), and abstracts were used more at point of care (51.9%). CONCLUSIONS: Clinicians reported that retrieving relevant health information from biomedical literature using the PubMed4Hh was useful at the point of care and in the office.

Learning by doing: observing an interprofessional process as an interprofessional team.

New competencies exist for interprofessional education, which are centered on the goal of improving quality of care and patient safety through improved interprofessional collaboration. Interprofessional education and effective interprofessional collaboration are cornerstones of the Veterans Affairs Quality Scholars fellowship program. The purpose of this project was to evaluate an innovative interprofessional education strategy in which teams of physicians and nurses were "learning by doing" as they observed and analyzed the functioning of an interprofessional process, specifically, inpatient discharge. Fellows completed voluntary, anonymous surveys seeking their perspectives about the project. Fellows' feedback revealed several themes, with both positive and negative characteristics related to team functioning, interprofessional understanding, microsystem knowledge, pooled knowledge and assignment challenges. The strength of this strategy is exemplified by the fact that fellows not only learned from each other's separate professional observations, but also observed the emergence of a shared interprofessional perspective through working together.

The oncology acuity tool: a reliable, valid method for measuring patient acuity for nurse assignment decisions.

BACKGROUND AND PURPOSE: Matching nurse assignments with patient acuity has critical implications for providing safe, effective, and efficient care. Despite this, we lack well-established methods for accurate assessment of acuity. This study aimed to evaluate the reliability and validity of the Oncology Acuity Tool (OAT), which is used for determining nurse assignments. METHODS: Inter-rater reliability and concurrent validity were assessed via surveys of current users of the tool. Content validity data were collected from expert oncology nurses. Predictive validity was assessed by tracking patients who sustained either of two acute events. RESULTS: Findings included high inter-rater reliability, moderately strong concurrent validity, and moderate content validity. Acuity significantly predicted rapid response team consults but not falls. CONCLUSIONS: The OAT demonstrated sufficient reliability and validity for measuring acuity prospectively in this population.

Patient acuity: a concept analysis.

AIM: This paper is a report of a concept analysis of patient acuity. BACKGROUND: Patient acuity is a widely-used term in the health sciences literature, but often without specification of its exact meaning. Concept clarification is therefore needed to delineate the meaning of patient acuity. DATA SOURCES: A review of the Pubmed, CINAHL, MEDLINE and PsychInfo databases for the keyword 'acuity' in the title or abstract of papers in English language journals, as well as searches for the term 'acuity' and 'acute' in the Merriam-Webster and Oxford English Dictionaries were the data sources for this concept analysis. Papers were excluded if 'acuity' was not present in the title or abstract. Publication dates of the literature included in the review ranged from 1974 to 2008. FINDINGS: The attributes of acuity are severity, intensity and the pairing of acuity measurements with another concept. These attributes were organized according to Holzemer's Outcomes Model for Health Care Research as patient-, provider- or system-related. The sub-categories of attributes identified were physical, psychological, nursing care needs, workload, complexity, case-mix, patient classification systems, urgency/triage scales and other uses. CONCLUSION: Researchers are encouraged to specify which attribute of acuity they are studying and to develop measurement tools specific to that attribute, in order to move the science towards standardization of the concept of acuity and its measurement.

The impact of personalized prenotification on response rates to an electronic survey.

The purpose of this post-hoc investigation was to determine the difference in response rates between respondents who received personalized prenotification prior to receiving an electronic survey and those who did not. An electronic survey was e-mailed to 236 program directors or other designated individuals from nurse practitioner (NP) programs around the United States. Seventy six percent of the NP program directors were personally contacted about the survey in advance, and 97.5% agreed to participate. The remaining 24% were sent e-mails with a link to the survey without prenotification. Response rates for those in the prenotification group who had agreed to participate versus those who did not receive prenotification were 49% and 45%, respectively. Personalized prenotification did not affect the electronic survey response rates. Electronic research methodology offers a unique opportunity to potentially survey an entire population (e.g., nursing faculty), thus further investigation regarding factors associated with electronic survey response rates and ways to improve these rates is warranted.

Translation and Preliminary Validation of the Oncology Acuity Tool-French (for Switzerland).

BACKGROUND AND PURPOSE: Few tools exist to measure real-time patient demands for care and match them with the supply of available nurses. We translated the Oncology Acuity Tool into a French version (for Switzerland) and conducted preliminary validation. METHODS: The setting was two French-speaking Swiss hospitals. Methods included translation and harmonization by experts. Content validity was assessed among nine oncology nurses. Inter-rater reliability was evaluated based on case studies. RESULTS: Content validity results met or exceeded pre-set cut-points and inter-rater reliability results were moderate. Several indicators were changed, added or removed. CONCLUSION: The Swiss tool may improve real-time estimates of patients' nursing care needs and assist with efficient resource allocation. Additional validation studies are recommended.

Patient Acuity Related to Clinical Research: Concept Clarification and Literature Review.

In research settings, clinical and research requirements contribute to nursing workload, staffing decisions, and resource allocation. The aim of this article is to define patient acuity in the context of clinical research, or research intensity, and report available instruments to measure it. The design was based on Centre for Reviews and Dissemination recommendations, including defining search terms, developing inclusion and exclusion criteria, followed by abstract review by three members of the team, thorough reading of each article by two team members, and data extraction procedures, including a quality appraisal of each article. Few instruments were available to measure research intensity. Findings provide foundational work for conceptual clarity and tool development, both of which are necessary before workforce allocation based on research intensity can occur.

Characteristics of nurse practitioner curricula in the United States related to antimicrobial prescribing and resistance.

PURPOSE: The purpose of this study was to examine current nurse practitioner (NP) curricula in the United States with regard to antibiotics and antimicrobial resistance and assess the need for a web-based module for instruction on antimicrobial resistance and appropriate prescribing of antibiotics. DATA SOURCES: A 22-item, anonymous, self-administered, web-based survey was sent to 312 NP programs; 149 (48%) responded. Survey items included questions related to NP specialties offered, program accreditation, format of pharmacology course(s), lecture hours related to antimicrobial therapy, and whether the participant would use a Web-based module to teach NP students about antimicrobial resistance, if one were available. CONCLUSIONS: Most NP programs (99.3%) required a pharmacology course, and 95% had lectures dedicated to antimicrobial therapy. Half of the programs (53.5%) devoted >or=4 lecture hours to antimicrobial therapy in the pharmacology course, and most (84.8%) reported covering antimicrobial therapy in nonpharmacology courses as well. Approximately half of the programs (45.3%) reported <4 h of lecture on antimicrobial therapy in nonpharmacology courses. Many programs (51.9%) did not offer a microbiology course; 39.2% required microbiology as a prerequisite. Most respondents (86.7%) were familiar with the Centers for Disease Control and Prevention antimicrobial resistance program, and 92.6% reported that they would use an electronic module regarding resistance. IMPLICATIONS FOR PRACTICE: NP curricula generally include <10 h of content on antimicrobial therapy. An electronic module regarding antimicrobial resistance is likely to be a useful and relevant adjunct to current curricula.

Feasibility of Automating Patient Acuity Measurement Using a Machine Learning Algorithm.

BACKGROUND AND PURPOSE: One method of determining nurse staffing is to match patient demand for nursing care (patient acuity) with available nursing staff. This pilot study explored the feasibility of automating acuity measurement using a machine learning algorithm. METHODS: Natural language processing combined with a machine learning algorithm was used to predict acuity levels based on electronic health record data. RESULTS: The algorithm was able to predict acuity relatively well. A main challenge was discordance among nurse raters of acuity in generating a gold standard of acuity before applying the machine learning algorithm. CONCLUSIONS: This pilot study tested applying machine learning techniques to acuity measurement and yielded a moderate level of performance. Higher agreement among the gold standard may yield higher performance in future studies.

Improving Palliative Care Team Meetings: Structure, Inclusion, and "Team Care".

Increasing demands on palliative care teams point to the need for continuous improvement to ensure teams are working collaboratively and efficiently. This quality improvement initiative focused on improving interprofessional team meeting efficiency and subsequently patient care. Meeting start and end times improved from a mean of approximately 9 and 6 minutes late in the baseline period, respectively, to a mean of 4.4 minutes late (start time) and ending early in our sustainability phase. Mean team satisfaction improved from 2.4 to 4.5 on a 5-point Likert-type scale. The improvement initiative clarified communication about patients' plans of care, thus positively impacting team members' ability to articulate goals to other professionals, patients, and families. We propose several recommendations in the form of a team meeting "toolkit."

Methodological challenges of validating a clinical decision-making tool in the practice environment.

Validating a measurement tool intended for use in the practice environment poses challenges that may not be present when validating a tool intended solely for research purposes. The aim of this article is to describe the methodological challenges of validating a clinical decision-making tool, the Oncology Acuity Tool, which nurses use to make nurse assignment and staffing decisions prospectively each shift. Data were derived from a larger validation study, during which several methodological challenges arose. Revisions to the tool, including conducting iterative feedback cycles with end users, were necessary before the validation study was initiated. The "true" value of patient acuity is unknown, and thus, two approaches to inter-rater reliability assessment were used. Discordant perspectives existed between experts and end users. Balancing psychometric rigor with clinical relevance may be achieved through establishing research-practice partnerships, seeking active and continuous feedback with end users, and weighing traditional statistical rules of thumb with practical considerations.

Organization of nursing and quality of care for veterans at the end of life.

CONTEXT: The Veterans Health Administration (VA) has improved the quality of end-of-life (EOL) care over the past several years. Several structural and process variables are associated with better outcomes. Little is known, however, about the relationship between the organization of nursing care and EOL outcomes. OBJECTIVES: To examine the association between the organization of nursing care, including the nurse work environment and nurse staffing levels, and quality of EOL care in VA acute care facilities. METHODS: Secondary analysis of linked data from the Bereaved Family Survey (BFS), electronic medical record, administrative data, and the VA Nursing Outcomes Database. The sample included 4908 veterans who died in one of 116 VA acute care facilities nationally between October 2010 and September 2011. Unadjusted and adjusted generalized estimating equations were used to examine associations between nursing and BFS outcomes. RESULTS: BFS respondents were 17% more likely to give an excellent overall rating of the quality of EOL care received by the veteran in facilities with better nurse work environments (P ≤ 0.05). The nurse work environment also was a significant predictor of providers listening to concerns and providing desired treatments. Nurse staffing was significantly associated with an excellent overall rating, alerting of the family before death, attention to personal care needs, and the provision of emotional support after the patient's death. CONCLUSION: Improvement of the nurse work environment and nurse staffing in VA acute care facilities may result in enhanced quality of care received by hospitalized veterans at the EOL.

Identifying Previously Undetected Harm: Piloting the Institute for Healthcare Improvement's Global Trigger Tool in the Veterans Health Administration.

BACKGROUND: Adverse event (AE) surveillance may be enhanced by the Institute for Healthcare Improvement's Global Trigger Tool (GTT). A pilot study of the GTT was conducted in one Veterans Health Administration (VA) facility to assess the rates, types, and harm of AEs detected and to examine the overlap in AE detection between the GTT and existing surveillance mechanisms. METHODS: GTT guidelines were followed and medical records were reviewed for 17 weeks of acute care hospitalizations. Investigators met monthly, first to adjudicate discordant reviewer categorizations of harm and later to categorize the AEs detected using standardized definitions. GTT-detected AEs were compared with incident reports, Patient Safety Indicators, and the VA Surgical Quality Improvement Program. RESULTS: Medical records were reviewed for 273 of 1980 eligible cases. Using the GTT, a total of 109 AEs were identified. More than 1 of 5 hospitalizations (21%) were associated with an AE. The majority of AEs detected (60%) were minor harms; there were no deaths attributable to medical care. Ninety-six of the 109 AEs (88%) were not detected by other measures. CONCLUSIONS: The GTT identified previously undetected AEs at one VA. The GTT has the potential to track AEs and guide quality improvement efforts in conjunction with existing AE surveillance mechanisms.

State of the science: the relationship between nurse staffing and patient outcomes.

Over a decade of research on the relationship between nurse staffing and patient outcomes has demonstrated the important role of nurses in the provision of high-quality, safe care, yet currently, no evidence-based nurse staffing guidelines exist. A systematic review of reviews was conducted to explore reasons why this is the case and recommend directions for future research to improve upon this gap. Authors of the 29 included reviews reported variability in methods and measurement approaches, lack of incorporation of nurse processes and system factors that potentially affect relationships among variables, and overall inconsistencies in results across primary studies. We propose use of an Integrated Framework for a Systems Approach to Nurse Staffing Research to inform the development of applicable conceptual models. Future studies that use a systems approach and focus on establishing causal relationships among variables will potentially strengthen the evidence and advance the science in this area.

Providing a "good death" for oncology patients during the final hours of life in the intensive care unit.

Cancer is a leading cause of death in the United States. Aggressiveness of cancer care continues to rise in parallel with scientific discoveries in the treatment of a variety of malignancies. As a result, patients with cancer often require care in intensive care units (ICUs). Although growth in hospice and palliative care programs has occurred nationwide, access to these programs varies by geographic region and hospital type. Thus, critical care nurses may be caring for patients with cancer during the final hours of life in the ICU without the support of palliative care experts. This article provides an overview of the meaning of the final hours of life for cancer patients and uses principles of a "good death" and the tenets of hospice care to organize recommendations for critical care nurses for providing high quality end-of-life care to patients with cancer in the ICU.