Nursing Morbidity and Mortality: The Clinical Nurse Specialist Role in Improving Patient Outcomes.

PURPOSE: The purpose of this article is to discuss the development and implementation of a nursing morbidity and mortality (M&M) monthly conference at an academic medical center. Nursing M&M was developed as a peer review process in which cases where clinical errors or misjudgments that have occurred are reviewed in a nonpunitive setting. The cases are selected based on the National Database for Nursing Quality Indicators and the implications they have for the quality of nursing practice. BACKGROUND/RATIONALE: Morbidity and mortality conferences are well documented in the physician arena as an avenue to review and discuss adverse events. There is little published in the literature related to nursing using this peer review format and what impact this forum can have on clinical outcomes. Clinical nurse specialists and clinical nurse educators are oftentimes positioned to help implement this type of forum and evaluate the impact that it has for the staff and patients that they work with. DESCRIPTION: The clinical nurse specialists/clinical nurse educators at this fourth-time designated Magnet® academic medical center facilitate the monthly M&M and select 4 to 5 cases to present. At the end of each brief presentation, the outcome is determined to be either preventable or unpreventable. Action items for educational needs are also identified. OUTCOMES: Nursing M&M has been well attended over the past year. Since its inception, multiple practice changes have been implemented. Based on the positive feedback from the evaluations, this monthly conference has become standing practice in the institution.

The effects of music on pain and anxiety during screening mammography.

One in four women who are diagnosed with breast cancer die annually, and the single most important way to prevent this is early detection; therefore, women older than 40 years should have an annual screening mammography. Many barriers have been reported that prevent compliance with this recommendation, including lack of insurance, fear, anxiety, pain, worry, and mistrust of the medical community. Nurses are in a position to use creative interventions, such as music therapy, to help minimize barriers. Although this study did not show that music therapy during screening mammograms decreased the amount of pain that the participants experienced, it did suggest that music therapy has the potential to decrease the amount of anxiety. Assisting patients in decreasing anxiety reduces barriers for screening mammography. The literature does suggest that music is a distraction for many populations of patients; however, when patients are faced with the possible diagnosis of breast cancer, it may be difficult to find an intervention to distract a woman's mind, which was supported by the findings of this study.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures.

BACKGROUND: Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved. OBJECTIVES: To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures. SEARCH METHODS: We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies. SELECTION CRITERIA: Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided. DATA COLLECTION AND ANALYSIS: Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data. MAIN RESULTS: We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results.  AUTHORS' CONCLUSIONS: Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.