Diversity dynamics: The experience of male Robert Wood Johnson Foundation nurse faculty scholars.

BACKGROUND: Managing diversity dynamics in academic or clinical settings for men in nursing has unique challenges resulting from their minority status within the profession. PURPOSE: The purpose of this study was to share challenges and lessons learned identified by male scholars in the Robert Wood Johnson Foundation Nurse Faculty Scholars program and suggest strategies for creating positive organizations promoting inclusive excellence. METHODS: Multiple strategies including informal mentored discussions and peer-to-peer dialogue throughout the program, formal online surveys of scholars and National Advisory Committee members, and review of scholar progress reports were analyzed as part of the comprehensive evaluation plan of the program. DISCUSSION: Diversity dynamic issues include concerns with negative stereotyping, microaggression, gender intelligence, and differences in communication and leadership styles. CONCLUSION: Male nurse faculty scholars report experiencing both opportunities and challenges residing in a predominately female profession. This article attempts to raise awareness and suggest strategies to manage diversity dynamics in service of promoting the development of a culture of health that values diversity and inclusive excellence for both men and women in academic, research, and practice contexts.

Defining attributes of patient safety through a concept analysis.

AIM: The aim of this study was to report an analysis of the concept of patient safety. BACKGROUND: Despite recent increase in the number of work being done to clarify the concept and standardize measurement of patient safety, there are still huge variations in how the term is conceptualized and how to measure patient safety data across various healthcare settings and in research. DESIGN: Concept analysis. DATA SOURCES: A literature search was conducted through PubMed and Cumulative Index to Nursing and Allied Health Literature, Plus using the terms 'patient safety' in the title and 'concept analysis,' 'attributes' or 'definition' in the title and or abstract. All English language literature published between 2002-2014 were considered for the review. METHODS: Walker and Avant's method guided this analysis. RESULTS: The defining attributes of patient safety include prevention of medical errors and avoidable adverse events, protection of patients from harm or injury and collaborative efforts by individual healthcare providers and a strong, well-integrated healthcare system. The application of Collaborative Alliance of Nursing Outcomes indicators as empirical referents would facilitate the measurement of patient safety. CONCLUSION: With the knowledge gained from this analysis, nurses may improve patient surveillance efforts that identify potential hazards before they become adverse events and have a stronger voice in health policy decision-making that influence implementation efforts aimed at promoting patient safety, worldwide. Further studies are needed on development of a conceptual model and framework that can aid with collection and measurement of standardized patient safety data.

Pressure ulcer care and public policy: exploring the past to inform the future.

Over the last 25 years, the quality of pressure ulcer (PrU) care has significantly changed because of sweeping public policy changes from the federal government. In fact, how clinicians think about PrU prevention and treatment can be traced back to several landmark changes made by the federal government that affect the continuum of healthcare. Moreover, the types of reimbursements for providers and institutions have dramatically changed in the last 25 years. The purpose of this article is to briefly review some of the major changes in long-term care, acute care, and home healthcare that have been impacted by public policy over the last 25 years.

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

BACKGROUND: Although there is extensive evidence of racial disparities in processes and outcomes of medical care, there has been limited investigation of disparities in patient safety. OBJECTIVE: To determine whether there are racial disparities in the frequency of adverse events studied in the Medicare Patient Safety Monitoring System. DESIGN AND SUBJECTS: Abstraction of 102,623 randomly selected charts from hospital discharges of non-Hispanic white and black Medicare patients between January 1, 2004 and December 31, 2007 to assess frequency of patient safety events in 4 domains: general (pressure ulcers and falls), selected nosocomial infections, selected procedure-related adverse events, and adverse drug events due to anticoagulants and hypoglycemic agents. MEASURES: Racial disparities in risk of patient safety events, and differences in adverse event rates among hospital groups stratified by percentage of black patients. RESULTS: Blacks had higher adjusted risk than whites of suffering one of the measured nosocomial infections (1.34; 95% confidence interval, 1.17-1.55; P < 0.001) and one of the measured adverse drug events (1.29; 95% confidence interval, 1.19-1.40; P < 0.001). After adjustment for patient and hospital factors, patients in hospitals with the highest percentages of black patients were at increased risk of experiencing one of the measured nosocomial infections (1.9% vs. 1.5%; P < 0.001) and adverse drug events (8.7% vs. 7.8%; P < 0.01). CONCLUSIONS: Hospitalized blacks are at higher risk than whites of experiencing certain patient safety events. In addition, hospitals serving high percentages of black patients have higher risk-adjusted rates of selected patient safety events.

Improving the detection of pressure ulcers using the TMI ImageMed system.

OBJECTIVE: The aim of the study was to evaluate a novel infrared imaging device coupled with an intelligent software interface that may provide a more objective means of identifying anatomical sites at risk for pressure ulcer (PrU) development as compared with the Braden Scale for Predicting Pressure Sore Risk. DESIGN: Repeated-measures design. SETTING: Duke University Medical Center. PARTICIPANTS: One hundred patients admitted to a medical unit at risk for PrUs. MAIN RESULTS: Only 5 participants developed early stage PrUs (Stages I and II). However, the infrared imaging device not only predicted all 5 participants to be at risk, but also predicted the anatomical location where the ulcer would develop. The Braden Scale correctly identified 3 of 5 participants who developed PrUs. It was also determined that a temperature variance of 1.5° C was able to accurately predict PrU development. CONCLUSION: Infrared imaging using intelligent software may become a promising, objective method for identifying incipient PrUs and provide clinicians with specific anatomical locations for increased preventive interventions.

Nursing research and participant recruitment: organizational challenges and strategies.

Hospitals as research environments are crucial in advancing evidence-based practice and translational research. The authors discuss issues related to hospital-based nursing research such as institutional review board approval, the HIPAA, structure, unit characteristics, and nurse staffing as well as research-related issues such as study purpose and design, participant recruitment, and research personnel. Strategies and suggestions for nurse executives to assist researchers in overcoming recruitment challenges are presented.

Annual checkup: the CMS pressure ulcer present-on-admission indicator.

PURPOSE: To provide the wound care practitioner with information about the Centers for Medicare and Medicaid Services (CMS) pressure ulcer present-on-admission (POA) indicators. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After reading this article and taking this test, the reader should be able to: 1. Describe the history and rationale for the CMS financial incentives for pressure ulcer (PrU) prevention. 2. Identify the CMS Pressure Ulcer POA indicators and 2009 ICD-9 coding for PrU staging. 3. Discuss the implications of the new CMS reimbursement for PrUs on healthcare organization practices with examples of successful interventions for PrU reduction.

Dilemmas in measuring and using pressure ulcer prevalence and incidence: an international consensus.

Pressure ulcer prevalence and incidence data are increasingly being used as indicators of quality of care and the efficacy of pressure ulcer prevention protocols. In some health care systems, the occurrence of pressure ulcers is also being linked to reimbursement. The wider use of these epidemiological analyses necessitates that all those involved in pressure ulcer care and prevention have a clear understanding of the definitions and implications of prevalence and incidence rates. In addition, an appreciation of the potential difficulties in conducting prevalence and incidence studies and the possible explanations for differences between studies are important. An international group of experts has worked to produce a consensus document that aims to delineate and discuss the important issues involved, and to provide guidance on approaches to conducting and interpreting pressure ulcer prevalence and incidence studies. The group's main findings are summarised in this paper.

Pressure ulcer prevention and management in spinal cord-injured adults: analysis of educational needs.

OBJECTIVE: The authors assessed the educational needs of adults with spinal cord injury (SCI) in the prevention and early detection of pressure ulcers (PrUs). Specific recommendations are provided for the top needs identified, along with key issues to consider in implementing solutions. DESIGN: The authors used a needs assessment methodology using a purposeful, maximum variation sampling strategy that was based on age, injury level and completeness, time since injury, and PrU history to select cases that would identify the diverse influences on PrU education. PARTICIPANTS: The authors interviewed 16 adults with SCI concerning perception of PrU risk, education, environmental considerations, and access to care. Also interviewed were 8 SCI professionals, including a physician specializing in rehabilitation medicine, physical and occupational therapists, a nurse case manager, and a wound care nurse practitioner. MAIN OUTCOME: The outcome of this research is the identification of educational needs for adults with SCI in PrU prevention and early detection. RESULTS: The needs identified are rank-ordered, and possible educational objectives are considered for each. Education needs identified include the following: *Awareness of lifelong risk for developing PrUs, including the ability to assess own risk factors and how risk changes over time. *Ability to take charge of own skin care regimen and to partner with health care providers. *Perform prevention strategies consistently that fit level of functioning and activity, and update practices as risk changes. *Ability to coordinate social supports. CONCLUSION: The need for effective education among adults with SCI in the prevention and early detection of PrUs is critical.

Assessing risk and preventing pressure ulcers in patients with cancer.

OBJECTIVE: To identify risk factors for pressure ulcers that may place the patient with cancer at higher risk. The role of nursing to provide pressure ulcer preventive measures will be discussed. DATA SOURCES: Current research and published literature CONCLUSION: Research suggests that comprehensive prevention programs are effective in reducing pressure ulcer incidence rates and can be cost-effective. Comprehensive pressure ulcer prevention guidelines include risk assessment, skin care, offloading, and nutrition. Immobility places patients with cancer at greater risk. IMPLICATIONS FOR NURSING PRACTICE: Nurses are at the forefront of predicting patients at risk for pressure ulcers and working with the multidisciplinary team to implement a pressure ulcer preventive program. There remains a dearth of research related to pressure ulcers and cancer. Research in this area is strongly suggested.

Pressure ulcer prevention and care: preventing and managing pressure ulcers in long-term care: an overview of the revised federal regulation.

Although the Centers for Medicare and Medicaid Service's Federal Regulation as it relates to pressure ulcer prevention and care in long-term care facilities has not changed, the Guidance to Surveyors (F-314) has been expanded significantly. In addition to more clearly defining commonly used terms, the new guidance document emphasizes the use of pressure ulcer risk assessment and prevention strategies, pain assessment and treatment, and monitoring the care outcomes. The Centers for Medicare and Medicaid Service has clearly raised the bar on pressure ulcer care. Based on currently available evidence, the guidance document is clear in its intent to encourage all long-term care facilities to adopt evidence-based pressure ulcer protocols of care. This transition, and the development and implementation of this guidance document, may present considerable challenges to some long-term care facilities. However, the lack of ambiguity in the F-314 document and its consistency with currently available evidence may be helpful to staff and improve outcomes of care.

Pressure ulcer prevention and care: implementing the revised guidance to surveyors for long-term care facilities.

The revised guidelines for long-term care surveyors by the Centers for Medicare and Medicaid Services link the existing pressure ulcer prevention and treatment evidence base with federal guidelines. The guidance document is detailed and attempts to ensure that residents receive optimal care to help prevent and manage these wounds. Implementation of the guidance document recommendations requires a complete review, and possibly revision, of existing policies and procedures. Understanding the background, rationale, and methods to implement these recommendations will help administrators and clinicians develop protocols of care that are effective, cost efficient, and comply with the new guidelines.

Protocol for the successful treatment of pressure ulcers.

Bed-bound patients with pressure ulcers are almost twice as likely to die as are those without pressure ulcers. If pressure ulcers are treated with a comprehensive regimen upon early recognition, nearly all stage IV ulcers can be avoided. Furthermore, such a regimen can significantly reduce the comorbidities, mortalities, and costs of treatments resulting from stage IV ulcers. The costs of treatments for comorbidities after the ulcer progresses to stage IV far outweigh the costs for early treatment of the ulcer before it progresses beyond the early stages. We describe herein the 4 stages of pressure ulcers, as well as the pathogeneses, costs, and complications associated with these wounds. A comprehensive 12-step detailed protocol for treatment of pressure ulcers is described; this includes recognizing that every patient with limited mobility is at risk for developing a sacral, ischial, trochanteric, or heel ulcer; daily assessment of the skin; objective measurement of every wound; immediate initiation of a treatment protocol; mechanical debridement of all nonviable tissue; establishment of a moist wound-healing environment; nutritional supplementation for malnourished patients; pressure relief for the wound; elimination of drainage and cellulitus; biological therapy for patients whose wounds fail to respond to more traditional therapies; physical therapy; and palliative care. Availability of the described treatment modalities, in combination with early recognition and regular monitoring, ensures rapid healing and minimizes morbidity, mortality, and costs.

Quality improvement for pressure ulcer care in the nursing home setting: the Northeast Pressure Ulcer Project.

OBJECTIVES: The objectives of this study were to evaluate the impact of a collaborative model of quality improvement in nursing homes on processes of care for the prevention and treatment of pressure ulcers. STUDY DESIGN: The study design was experimental. SETTING: We studied 29 nursing homes in New Jersey, Pennsylvania, and Rhode Island. PARTICIPANTS: Participants consisted of pressure ulcer quality improvement teams in 29 nursing homes. INTERVENTION: Quality improvement teams attended a series of workshops to review clinical guidelines and quality improvement principles and to share best practices, and worked one-on-one with mentors to implement quality improvement techniques and to collect data independently. MEASUREMENTS: We calculated process measures based on the Agency for Healthcare Research and Quality (AHRQ) guidelines. Process measures addressed each facility's processes of care for the prevention and treatment of pressure ulcers at baseline and after 12 months of intervention. Prevention measures focused on recent admissions and high-risk residents; treatment measures focused on patients newly diagnosed with pressure ulcers and all patients with pressure ulcers. RESULTS: Overall, 6 of 8 prevention process measures improved significantly, with percent difference between baseline and follow up ranging from 11.6% to 24.5%. Three of 4 treatment process measures improved significantly, with 5.0%, 8.9%, and 25.9% difference between baseline and follow up. For each process measure, between 5 and 12 facilities demonstrated significant improvement between baseline and follow up, and only 2 or fewer declined for each process measure. CONCLUSION: Improvement in processes of care after the use of a structured collaborative quality improvement approach is possible in the nursing home setting.

Pressure ulcer prevention and management.

This chapter reviews 218 published and unpublished research reports of pressure ulcer prevention and management by nurse researchers and researchers from other disciplines. The electronic databases MEDLINE (1966-July 2001), CINAHL (1982-June 2001), AMED (1985-July 2001), and EI Compedex Plus (1980-June 2001) were selected for the searches because of their focus on health and applied research. Moreover, evaluations of previous review articles and seminal studies that were published before 1966 are also included. Research conducted worldwide and published in English between 1930 and 2001 was included for review. Studies using descriptive, correlational, longitudinal, and randomized control trials were included. This review found that numerous gaps remain in our understanding of effective pressure ulcer prevention and management. Moreover, the majority of pressure ulcer care is derived from expert opinion rather than empirical evidence. Thus, additional research is needed to investigate pressure ulcer risk factors of ethnic minorities. Further studies are needed that examine the impact of specific preventive interventions (e.g., turning intervals based on risk stratification) and the cost-effectiveness of comprehensive prevention programs to prevent pressure ulcers. Finally, an evaluation is needed of various aspects of pressure ulcer management (e.g., use of support surfaces, use of adjunctive therapies) and healing of pressure ulcers.

A comprehensive program to prevent pressure ulcers in long-term care: exploring costs and outcomes.

With scrutiny from survey agencies (Centers for Medicare and Medicaid Services and state agencies) and potential litigation increasing, long-term care facilities must implement aggressive pressure ulcer prevention programs. However, cost-effective pressure ulcer prevention continues to be a challenge for most long-term care facilities, in part because limited research is available to guide their efforts. Two long-term care facilities (Facility A with 150 beds and Facility B with 110 beds) participated in a quasi-experimental study using retrospective and prospective study data to evaluate the effect of implementing a protocol of care to address the incidence of pressure ulcers. Retrospective study results showed a combined, cumulative, 5-month pressure ulcer incidence of 43% in Facilities A and B. Implementation of the comprehensive prevention program resulted in an 87% decrease in pressure ulcer incidence in Facility A (from 13.2% to 1.7% per month, P = 0.02) and a 76% decrease in Facility B (from 15% to 3.5% per month, P = 0.02). The average monthly cost of prevention for a high-risk resident was $519.73 (plus a one time cost of $277 for mattress and chair overlays). More than half ($277.15) of the monthly costs relates to labor; the most expensive item cost is for support surfaces. This study demonstrated that this comprehensive program resulted in a significant decrease in the incidence of pressure ulcers in two long-term care facilities. Because labor and support surface costs remain high, long-term care facilities are encouraged to use prevention intervention strategies based on risk stratification.

Cost effectiveness of wound management in long-term care.

Today's healthcare environment -- and the economic environment in general -- necessitate efforts to lower healthcare costs, both for patients and for providers. This need is especially relevant to long-term care facilities, where residents' healthcare problems are a daily and expensive certainty. Both pressure ulcers and venous ulcers are common in long-term facilities, and the aging of our citizens means managing these facilities will be an increasingly significant concern for providers.

Do high frequency ultrasound images support clinical skin assessment?

High frequency ultrasound imaging has been reported as a potential method of identifying the suspected tissue damage in patients "at risk" of pressure ulceration. The aim of this study was to explore whether ultrasound images supported the clinical skin assessment in an inpatient population through identification of subcutaneous tissue damage. Skin on the heels and/or sacral coccygeal area of fifty vascular surgery inpatients was assessed clinically by tissue viability nurses and with ultrasound pre operatively and at least every other day until discharge. Images were compared to routine clinical skin assessment outcomes. Qualitative classification of ultrasound images did not match outcomes yielded through the clinical skin assessment. Images corresponding to 16 participants were classified as subgroup 3 damage at the heels (equivalent to grade 2 pressure ulceration); clinical skin assessment rated no heels as greater than grade 1a (blanching erythema). Conversely, all images captured of the sacral coccygeal area were classified as normal; the clinical skin assessment rated two participants as grade 1b (non-blanching erythema). Ultrasound imaging is a potentially useful adjunct to the clinical skin assessment in providing information about the underlying tissue. However, further longitudinal clinical assessment is required to characterise images against actual and "staged" pressure ulceration.