Exploring the Relationship Between Health-Illness Transition Experiences and Distress Among Patients With Pancreatic Cancer.

OBJECTIVES: To explore the correlation between health-illness transition (HIT) experiences and distress among patients with pancreatic cancer. SAMPLE & SETTING: 55 patients with a diagnosis of pancreatic cancer receiving chemotherapy at a tertiary cancer center in New York. METHODS & VARIABLES: A prospective correlational study was performed to explore the frequency, extent, and management of HITs. HITs were evaluated using the Measurement of Transitions in Cancer Scale, and distress was measured with the National Comprehensive Cancer Network Distress Thermometer. RESULTS: All patients experienced at least one HIT. The extent of HITs decreased over time. Patients reported that they managed HITs moderately well. There was a significant correlation between unmanaged HITs and distress. As distress increased, the extent of the physical and emotional HITs increased and management worsened. IMPLICATIONS FOR NURSING: HITs are ubiquitous among patients diagnosed with pancreatic cancer. Associated distress inhibits management. Nurses are well suited to assess for potential HITs and to support self-management of HITs.

Development and palliative care staff reactions to a sleep regulation educational intervention.

BACKGROUND: In palliative care, sleep and circadian rhythm problems are common symptoms. Nonpharmacological interventions are available; however, health care providers are not aware of these or lack the knowledge to effectively implement in practice. This study reports the content and design development of the PRIME™ (Program for Improving & Managing Environments for Sleep) sleep online educational intervention as well as the evaluation of the intervention by practicing nurses with a focus on perceived acceptability and satisfaction. METHODS: Development of the education employed a multi-step process that assesses the current state of the science in this area (literature reviews), the needs of regional target recipients (hospice/palliative care staff), expert recommendations and views of a national pool of hospice/palliative workers. A cross-sectional, descriptive study with key staff informants evaluated the acceptability and usability of the modules using both scale-response items to rate the content and design of the modules and overall satisfaction and five open-response questions to suggest changes to the educational intervention. RESULTS: Among 31 palliative care professionals, most rated the content and design favorably. A total of 20 participants provided suggestions to improve the educational intervention. Their comments were categorized into six themes: Integration into Practice; Content, Exercises and Material Provided by Modules; User Interface and Design; and Adapt and Expand Modules for Public, Family and Caregivers. CONCLUSIONS: The data suggest that the PRIME™ educational intervention can be an effective tool to train direct-care palliative care professionals on interventions for use in their daily practice. We also demonstrated that the educational intervention is feasible to deliver online and that the online modules appealed to respondents, suggesting that future delivery of the educational intervention can use the same or similar modes of presentation.

Perceptions of Older Adult Care Among Ambulatory Oncology Nurses.

BACKGROUND: Most cancer treatment is provided in the ambulatory setting; thus, it is important to know what issues ambulatory oncology nurses identify in their practice with older cancer patients as well as resources that are helpful or are needed. OBJECTIVE: The aim of this study was to capture ambulatory oncology nurses' perceptions of the unique aspects of caring for older patients and to present the development process, content validity testing, and psychometric evaluation of a survey designed to denote nurse perceptions of older adult care. METHODS: An expert panel and 2 focus groups informed the development of a 34-item survey scored on a 5-point Likert-type agreement scale and 2 open-ended questions. Psychometric testing and descriptive statistics summarized the quantitative responses. Using thematic analysis, we identified the themes from the open-ended responses. RESULTS: The survey demonstrated good psychometric qualities. A total of 401 participants, mostly staff from large, academic cancer centers, reported an average total score of 3.76, indicating generally positive perceptions of older adult care. The 269 (67%) open-ended responses were categorized into 4 main themes: concerns over medical issues, the need for specialized services, adequate support systems, and appropriate communication. CONCLUSIONS: Although most perceived their geriatric practice environment favorably, nurses recognized the complexity of caring for older adults with cancer. They identified gaps in care, such as the need for geriatric specialists and better community resources, paid by insurance. IMPLICATIONS FOR PRACTICE: Nurses need more time in the clinic to address complex advanced care planning, symptom burden and home services of older adults with cancer. Each institution should seek feedback from nurses to guide resource allocation.

Palliative Care Nurse Perceptions of Nonpharmacological Sleep-Promoting Interventions.

Poor quality of sleep is common among those with advanced serious illness. Several interventions have been demonstrated to improve sleep; however, the extent to which these are used is unknown. This study describes nurses' perceptions of 36 nonpharmacological sleep-promoting interventions as well as facilitators and barriers to implementing nonpharmacological interventions. A descriptive survey design was used to collect data via an online, anonymous survey from nurses throughout the United States that included demographic items and open-ended questions (barriers and facilitators). The 108 respondents were nurses working in either a hospital (33.3%) or home care/outpatient (54.6%) setting. Among 36 interventions presented, a mean (SD) total score of feasible interventions per respondent was 27.1 (6.5). There were no significant differences in the mean total feasibility score due to practice site, nurse type, or years of experience. Most thought individual belief in the efficacy of the nonpharmacological intervention was an important facilitator whereas perceived lack of value and institutional support were the major barriers. There was an overall appreciation and positive perception of nonpharmacological, sleep-promoting interventions by palliative care nurses. Increasing use will depend on overcoming barriers by identification of specific patient/caregiver and institutional factors in each setting or patient population.

Self-Management Interventions for Psychological Distress in Adult Cancer Patients: A Systematic Review.

Psychological distress is prevalent among cancer patients, who may be vulnerable to distress at times of transition, such as a change in symptom experience, employment, or goal of treatment. Independently, both psychological distress and transitions impair patients' quality of life, and together their adverse impact may be intensified. Self-management allows patients to engage in tasks that influence the disease experience and can include strategies to help mitigate distress associated with transitions. The purpose of this systematic review was to examine research on the relationship between self-management interventions and distress in adult cancer patients receiving active tumor-directed therapy. From a search of seven electronic databases, 5,156 articles were identified; however, nine studies met inclusion criteria. Our review suggested that self-management interventions may help address psychological distress in patients receiving cancer treatment but that the current evidence is not robust enough to support a definitive conclusion.

Non-pharmacological solutions to sleep and circadian rhythm disruption: voiced bedside experiences of hospice and end-of-life staff caregivers.

BACKGROUND: Sleep disturbance is a significant issue, particularly for patients with advanced terminal illness. Currently, there are no practice-based recommended approaches for managing sleep and circadian disruptions in this population. To address this gap, a cross-sectional focus group study was performed engaging 32 staff members at four hospices/end-of-life programs in three demographically diverse counties in New York State. METHODS: Participants responded to structured open-ended questions. Responses were transcribed and subjected to qualitative content analysis. The themes and recommendations for improved practice that emerged were tabulated using Atlas TI qualitative software. RESULTS: This report details the experiences of hospice and end-of-life care staff in managing sleep and circadian disruptions affecting patients and analyzes their recommendations for improving care. Caregivers involved in the study described potential interventions that would improve sleep and reduce circadian disruptions. They particularly highlighted a need for improved evaluation and monitoring systems, as well as sleep education programs for both formal and informal caregivers. CONCLUSIONS: The voiced experiences of frontline hospice and end-of-life caregivers confirmed that disruption in sleep and circadian rhythms is a common issue for their patients and is not effectively addressed in current research and practice. The caregivers' recommendations focused on management strategies and underscored the need for well-tested interventions to promote sleep in patients receiving end-of-life care. Additional research is needed to examine the effectiveness of systematic programs that can be easily integrated into the end-of-life care process to attenuate sleep disturbances.

Development of a Community-Based Palliative Care Screening Tool for Underserved Older Adults With Chronic Illnesses.

Although they experience high rates of chronic illness, low-income minority communities have traditionally underutilized palliative care services compared to whites and those with higher incomes. One reason for this trend is lack of screening by community providers. We utilized a community-based participatory research approach to develop and implement an innovative multidomain palliative care screening tool in aging service agencies. Participants were aging service providers and clients in the East and Central Harlem neighborhoods of New York City, which are characterized by high poverty, largely African American and Latino populations, disproportionally high rates of chronic conditions, and limited health-care access. Screening tool development included reviewing existing measures and obtaining feedback from an expert panel, aging service providers, and older adults. We developed a 22-item tool covering 3 domains of palliative care need (physical symptoms, emotional concerns, and goals of care), which can be administered in 10 to 15 minutes. Sixteen providers at 2 aging service agencies were trained to use the tool over a 3-month pilot period. The tool showed evidence of feasibility of implementation, with 44 older adult clients screened. Providers reported high acceptability, 36% of clients screened positive, and the majority accepted referrals to outpatient palliative care clinics. The screening tool has the potential to increase palliative care utilization among underserved community-dwelling older adults and may improve their quality of life, potentially in communities worldwide. Future work should examine the psychometric proprieties of the tool, examine predictors of positive screens, explore its impact on clinical outcomes, and expand its reach.

Expanding palliative care's reach in the community via the elder service agency network.

Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the U.S., highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care "champions" in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.

Identification of Seniors at Risk (ISAR) in the emergency room: A prospective study.

INTRODUCTION: The Identification of Seniors at Risk (ISAR) is one of the most frequently utilized risk screening tools in emergency departments (ED). The goal of this study was to evaluate the predictive validity of the ISAR screening tool for adverse outcomes in an ED. METHODS: This was a prospective single-center observational study in a Portuguese urban university hospital ED, and included 402 older adults (OA). After triage, baseline sociodemographic and clinic data were collected by the researcher and the ISAR was administered. Baseline ISAR, adverse outcomes (ED revisits and hospital admission) at 30 (early) and 180 (late) days were evaluated. RESULTS: ISAR screening showed that 308 (76.62%) OAs were at risk (cutoff≥2). High-risk patients were more like to be older, take more medication, have urgent or very urgent ED visits and have longer ED lengths of stay. The high-risk group were more likely to demonstrate both early (OR=2.43, 95% CI 1.35-4.35, p<0.01) and late returns to the ED (AO=1.70, 95% CI 1.04-2.79, p<0.05). The ISAR did not predict any significant variable for hospital admission in 30 or 180days. DISCUSSION: The ISAR predicted returns to EDs at 30 and 180days for OAs at risk, but was unable to predict early or late hospital readmission.

Nurse perception of care of hospitalized older adults - a comparative study between northern and central regions of Portugal / Percepção dos enfermeiros sobre o cuidado a idosos hospitalizados - estudo comparativo entre as regiões Norte e Central de Portugal / Percepción del cuidado de los adultos mayores hospitalizados -un estudio comparativo entre las regiones del Norte y Centro de Portugal

Resume Objective: to analyze the relationship between the perceptions of nurses about geriatric care (GC) environment and geriatric nurses' knowledge and attitudes according to unit type considering the northern and central regions of Portugal. Method: a cross-sectional study was developed among 1068 Portuguese's nurses in five hospitals. The instrument was Geriatric Institutional Assessment Profile - Portuguese version. The independent samples t-test was when the assumption of normality was verified, otherwise, the Mann-Whitney U test was used. The level of significance was 5%. Results: the profile of perceptions of GC showed a relatively homogeneous pattern (no statistically significant results were found). For the geriatric care environment scale, only the CC/ED units presented significant differences in all considered subscales (resource availability; aging-sensitive care; institutional values; and continuity of care), with more positive perceptions among nurses in the northern region. In Professional Issues scales, only the scale perception of burden related with upsetting behaviors revealed significant differences between regions in all specialties. Conclusion: the findings suggest the need for increased investment by hospital leaders to promote a geriatric nursing practice environment that supports the specialized needs of hospitalized older adults.

Resumo Objetivo: analisar a relação entre as percepções dos enfermeiros sobre o ambiente de cuidado geriátrico (CG) e os conhecimentos e atitudes destes de acordo com o tipo de unidade, considerando as regiões Norte e Central de Portugal. Método: estudo transversal, desenvolvido com 1068 enfermeiros portugueses em cinco hospitais. O instrumento foi o Geriatric Institutional Assessment Profile - versão em Português. Foi utilizado o teste t para amostras independentes quando a suposição de normalidade foi verificada; caso contrário, utilizou-se o teste de Mann-Whitney. O nível de significância foi de 5%. Resultados: o perfil de percepções de cuidado geriátrico mostrou um padrão relativamente homogêneo (não foram encontrados resultados estatisticamente significantes). Para a escala de ambiente de cuidado geriátrico, apenas as unidades de cuidados intensivos e serviço de urgência apresentaram diferenças significativas em todas as subescalas consideradas (disponibilidade de recursos, cuidado sensível à idade, valores institucionais; e continuidade do cuidado), com percepções mais positivas entre os enfermeiros da região Norte. Nas escalas de Questões Profissionais, somente a escala percepção da sobrecarga relacionada aos comportamentos perturbadores revelou diferenças significativas entre as regiões em todas as especialidades. Conclusão: os resultados sugerem a necessidade de maior investimento pelos gerentes hospitalares para promover um ambiente de prática de enfermagem geriátrica e que vá ao encontro das necessidades e especificidades das pessoas idosas hospitalizadas.

Resume Objetivo: analizar la relación entre la percepción de los enfermeros sobre el entorno de la atención geriátrica y el su conocimiento y actitudes según el tipo de unidad tomando en cuenta las regiones del Norte y Centro de Portugal. Método: estudio transversal desarrollado con 1068 enfermeros portugueses en cinco hospitales. El instrumento fue Geriatric Institutional Assessment Profile - versión en portugués. Se utilizo la prueba t para muestra independientes cuando fue verificada la supuesta normalidad; de lo contrario, se utilizó la prueba de Mann-Whitney. El nivel de significancia fue del 5 %. Resultados: el perfil de las percepciones de atención geriátrica mostró un patrón relativamente homogénea (no se encontraron resultados estadísticamente significativos). Para la escala de entorno atención geriátrica, solo las unidades de cuidados intensivos y servicios de urgencias presentaron diferencias significativas en todas las subescalas estudiadas (disponibilidad de recursos; cuidado sensible a edad; valores institucionales y continuidad del cuidado), con una percepción más positiva entre los enfermeros en la región Norte. En las escalas de las cuestiones de carácter profesional, solo la escala percepción de la sobrecarga relacionada con comportamientos desconcertantes reveló diferencias significativas entre las regiones en todas las especialidades. Conclusión: los hallazgos sugieren la necesidad de una mayor inversión por parte de los gerentes del los hospitales para promover un entorno de la práctica de enfermería geriátrica que sea compatible con las necesidades específicas de los adultos mayores hospitalizados.

Distress and Coping Self-Efficacy in Inpatient Oncology Nurses.

PURPOSE/OBJECTIVES: To examine distress and coping self-efficacy in inpatient oncology nurses. 
. DESIGN: Cross-sectional survey design.
. SETTING: Oncology Nursing Society (ONS) chapter meetings and Hunter-Bellevue School of Nursing, both in New York, New York, as well as social media.
. SAMPLE: 163 oncology nurses who work with an inpatient adult population.
. METHODS: Participants were recruited through the ONS New York, New York, area chapter meetings, Hunter College, and ONS Facebook pages. An adapted Nurse Distress Thermometer (NDT) measured distress levels. The Occupational Coping Self-Efficacy Questionnaire for Nurses (OCSE-N) used a Likert-type scale to measure coping self-efficacy. Open-ended questions elicited additional perceptions of nurse respondents. 
. MAIN RESEARCH VARIABLES: Descriptive statistics summarized sample demographics. A Pearson correlation between distress levels and coping self-efficacy scores was calculated. Low, normal, and high coping scores were compared to mean distress levels. 
. FINDINGS: Survey participants showed high levels of distress, with a mean NDT score of 8.06. Those with higher coping self-efficacy scores reported less distress. A moderate, negative correlation was shown, with a statistically significant Pearson coefficient of -0.371. Responses to the open-ended questions revealed common stressors and pointed to solutions that institutions might implement to support nurses.
. CONCLUSIONS: Because coping self-efficacy related to lower distress levels in inpatient oncology nurses, institutional-level support for oncology nurses should be provided. 
. IMPLICATIONS FOR NURSING: Interventions aimed at coping self-efficacy may prepare oncology nurses to cope better with their professional demands. Future research should explore how nurse distress affects patients.

Community-based participatory research: understanding a promising approach to addressing knowledge gaps in palliative care.

Concern over the need for effective and accessible healthcare for individuals with advanced chronic illness has drawn attention to the significant gaps in our knowledge of palliative medicine. To advance our understanding of this field, community-based participatory research (CBPR) is proposed as a tool for future research initiatives. This paper offers a rationale for how CBPR may be employed to address specific gaps in palliative care research. Several examples where this approach has been used previously are described, and potential obstacles to implementing this research method are delineated. Despite challenges to incorporating CBPR to palliative care research, this approach holds substantial potential to advance our current understanding of the field and promote sensitivity for future programs, practices and policies.

Impact of Inpatient Palliative Care on Treatment Intensity for Patients with Serious Illness.

BACKGROUND: Palliative care is associated with decreased treatment intensity and improved quality for individual patients at the end of life, but little is known about how hospital-wide outcomes are affected by the diffusion of palliative care principles. OBJECTIVE: We examined the relationship between presence of palliative care programs and hospitals' average treatment intensity, as indicated by mean intensive care unit (ICU) length of stay (LOS) and days under Medicare hospice coverage, in the last six months of life among Medicare beneficiaries aged 67 and over with serious chronic illness. METHODS: We linked hospital-level data from the American Hospital Association Annual Survey, National Palliative Care Registry, and Dartmouth Atlas of Health Care to examine hospital-level treatment intensity for chronically ill Medicare beneficiaries who died in 2010. We used propensity score-adjusted linear regression to estimate the relationship between palliative care programs and hospitals' mean ICU LOS and hospice length of enrollment. RESULTS: Among 974 hospitals meeting inclusion criteria, we compared 295 hospitals with palliative care programs to 679 hospitals without. Hospitals with palliative care programs were higher volume, more likely to be teaching hospitals, and have oncology services and less likely to be located in rural areas. In propensity score weighted analyses, the mean ICU LOS in hospitals with palliative care was shorter by 0.23 days (standard error [SE] = 0.26), but this was not statistically significant (p = 0.76). In addition, the mean length of hospice enrollment among beneficiaries served by hospitals with palliative care was longer by 0.22 days (SE = 0.61), but also was not statistically significant (p = 0.76). CONCLUSIONS: Hospital-based palliative care programs alone may not be sufficient to impact ICU LOS or hospice length of enrollment for all chronically ill older adults admitted to hospitals. Future work should measure hospital-wide palliative care outcomes and effects of core palliative knowledge and skills provided by nonpalliative care specialists.

Nurses' perspectives: hospitalized older patients and end-of-life decision-making.

AIMS: To explore pressing issues identified by nurses caring for older patients in US NICHE (Nurses Improving Care for the Healthsystem Elders) hospitals, regarding palliative care and end-of-life (EOL) decision-making. Objectives are to (1) identify the most pressing palliative care and EOL decision-making issues and strategies to address them and (2) identify the association of nursing demographics (age, gender, race, education and experience), institutional/unit characteristics and these issues. BACKGROUND: Critical care nurses have an integral role in supporting older patients and families faced with palliative care and EOL decision-making issues. Despite national imperatives to improve the quality of palliative care, patients continue to experience uncontrolled pain, inadequate communication, disregard of their wishes and life prolonging interventions. These contribute to increased hospitalizations and costs. Understanding the prevalent issues is needed to address patient needs at the end-of-life. DESIGN: It is a mixed method study. METHODS: A secondary analysis of the NICHE Geriatric Institutional Assessment Profile (GIAP) database (collected 1/08-9/13) was conducted using the sample of Critical Care RNs who provided comments regarding palliative care and EOL decision-making. Qualitative data were analyzed using Dedoose software. Data clusters and patterns of co-occurring codes were explored through an iterative analysis process. Themes were examined across nurse demographics, institutional and unit characteristics. RESULTS: Comments specifically addressing issues regarding EOL decision-making were provided by 393 critical care nurses from 156 hospitals (x‾ age = 42·3 years, 51% BSN degree). Overarching theme was discordance in goals of care (prolonging life versus quality of life), ineffective physician-patient-family communication, lack of time and unrealistic expectations. CONCLUSIONS: Nurses' descriptions highlight the need for increased communication, staff education and availability of palliative care services. RELEVANCE TO PRACTICE: Palliative care and EOL decision-making will remain a nursing priority as people age and require increased care.

Validation of geriatric care environment scale in portuguese nurses.

The number of hospitalized older adults in Portugal necessitates a better understanding of the acute care environment for older adults. This study translated and examined the psychometric qualities of the Geriatric Care Environment Scale (GCES) among 1,068 Portuguese registered nurses (RNs). Four factors emerged from the exploratory factor analyses: resource availability, aging-sensitive care delivery, institutional values regarding older adults and staff, and continuity of care. The internal consistency of the GCES was α = .919. The GCES was significantly associated with the variables of region, hospital type, unit type, and RNs perception of hospital educational, staff knowledge, difficulty, rewarding, and burdensome in caring for older adults. Nurses who worked in hospitals centers in the northern region and medical and surgery units had more positive perceptions of the geriatric care environment. More positive perception was also found among RNs that reported more educational support, had more knowledge, and felt more rewarding and less difficulty and burden in caring older adults. This process resulted in a valid and reliable measurement of the geriatric care environment Portuguese version which provides hospital leadership with an instrument to evaluate organizational support for geriatric nursing practice and target specific areas that support or hinder care delivery.

Medication discrepancy and potentially inappropriate medication in older Chinese-American home-care patients after hospital discharge.

BACKGROUND: Studies of potential medication problems among older adults have focused on English-speaking populations in a single health care setting or a single potential medication problem. No previous studies investigated potential inappropriate medications (PIMs) and medication discrepancies (MDs) among older Chinese Americans during care transitions from hospital discharge to home care. OBJECTIVE: The aims of this study were to examine, in older Chinese Americans, the prevalence of both PIMs and MDs; the relationship between PIMs and MDs; and the patient and hospitalization characteristics associated with them during care transitions from hospital discharge to home care. METHODS: This cross-sectional study was conducted with a sample of older Chinese Americans from a large certified nonprofit home-care agency in New York City from June 2010 to July 2011. PIMs were identified by using 2002 diagnosis-independent Beers criteria. MDs were identified by comparing the differences between hospital discharge medication order and home-care admission medication order. Prevalence of PIMs and MDs and their relationship was determined. Logistic regression examined the relationship between hospitalization and patient characteristics with PIMs and MDs. RESULTS: The sample consisted of 82 older Chinese-American home-care patients. Twenty (24.3%) study participants were prescribed at least one PIM at hospital discharge. Fifty-one (67.1%) study participants experienced at least one MD. A positive correlation was found between the occurrence of PIMs and MDs (r = 0.22; P = 0.05). Number of medications was the only significant factor associated with both PIMs and MDs. In addition, older age and more hospitalization days were associated with PIMs. CONCLUSIONS: The evident prevalence of PIMs and MDs supports the practice of evaluating the appropriateness of medications while reconciling inconsistencies in medication regimens. The number of medications was the only factor associated with both PIMs and MDs, underscoring the need to address polypharmacy as a multifaceted threat to patient health.

Prevalence and predictors of adverse events in older surgical patients: impact of the present on admission indicator.

PURPOSE OF THE STUDY: to examine the effects of the present on admission (POA) indicator on the prevalence of and factors associated with postsurgical adverse events in older patients. DESIGN AND METHODS: this is a secondary data analysis of 82,898 surgical patients aged 65 years or older in 252 acute care hospitals in California in 2004. Four adverse events were counted using the Agency for Healthcare Research and Quality's Patient Safety Indicator (PSI) definitions with and without using the POA indicator. We also examined the effects of the POA indicator on the relationships between patient- and hospital-level factors and adverse events, using generalized linear mixed models. RESULTS: the use of the POA indicator resulted in a marked reduction in the estimated rates of all 4 adverse event rates. Adjustment for POA conditions also influenced factors associated with adverse events. Compared with those with newly occurring adverse events only, admissions with only POA conditions were more likely to be admitted through the emergency department, be unplanned, and belong to patients with one or more preceding admissions or those with multiple admissions within the same year. IMPLICATIONS: adverse event rates estimated from discharge abstracts using PSI methodology could be overstated when the POA indicator was not used. The POA indicator could influence predictors of adverse events. Studies on geriatric safety and outcomes using large administrative data sets should consider using the POA indicator. Further studies are needed on how to determine POA conditions.

Reporting near-miss events in nursing homes.

Since the Institute of Medicine report To Err Is Human was published in 1999, improving patient safety has become a major initiative for nurses working in all care settings. Nursing homes are a fertile environment for both a high frequency of adverse events to occur and a high number of institutional barriers to reporting them. This article outlines the barriers to reporting adverse events in nursing homes and provides support for why reporting near-miss events can serve as a means of reducing these barriers. It also provides recommendations and specific strategies for how to implement near-miss reporting systems in nursing homes such as policy changes, supportive leadership, and educating nurses about near-miss events. Further nursing research in this evolving area of patient safety is warranted.

Staff perceptions concerning barriers and facilitators to end-of-life care in the nursing home.

Although many nursing home residents have chronic, life-limiting conditions, most die without the benefit of palliative care or with palliation delayed until the last days of life. The goal of this study was to determine whether the presence of a comprehensive palliative care program in nursing homes would affect the knowledge and attitudes of the staff. The intervention group was able to identify more problems in delivering palliative care than the control group, but this only reached statistical significance on 2 items. Nevertheless, the current study suggests that the presence of a palliative care program within a nursing home does increase general knowledge of the problems faced in caring for the dying.