Exploring attitudinal barriers to participation in inpatient fall risk assessment using the Theoretical Domains Framework: A survey of providers.

Background and Aims: Lack of provider (physicians and advanced practice providers) participation in fall risk assessment was theorized to be contributing to rising rates of falls with injury at our institution. This project sought to identify if attitudinal barriers to inpatient provider participation in fall risk assessment were similar to those identified in other clinical settings. Methods: Barriers to provider participation in fall risk assessment were identified in the literature. These were mapped to the Theoretical Domains Framework (TDF) domains to assist with interpretation of the data. A 10-item survey using a 5-point Likert scale (strongly agree to strongly disagree) with two open-ended questions was developed using these barriers. The survey was distributed via email to all providers on the Medical Staff in July 2021. Results: The response rate was 9.1% (188/2062). 72.6% (95% confidence interval [CI]: 65.6, 78.5) of providers at our institution did agree that fall risk assessment was within their role and 72% (95% CI: 66.1, 78.5) agreed that assessment can prevent falls. Nearly half felt that they lacked formal training in fall risk assessment (48.1% [95% CI: 41.1, 55.1]) and 52.2% (95% CI: 44.6, 58.6) agreed that other aspects of patient care took priority over falls assessment. These barriers correlated best with the TDF domains of Beliefs about Capabilities and Beliefs about Consequences. Conclusions: Survey results indicate that interventions focused on increasing provider motivation and capability regarding fall risk assessment and helping providers prioritize fall risk assessment are potential targets for future quality improvement projects.

The role of clinical nurse specialists in the implementation and sustainability of a practice change.

AIM: This project's purpose was to promote and sustain a practice change focusing on delirium utilising the clinical nurse specialist (CNS) in a leadership role. BACKGROUND: Delirium is an altered state of consciousness accompanied by an acute change in cognition that tends to have a fluctuating course. Delirium is strongly associated with negative outcomes and is often unrecognised. METHOD: A policy was implemented stating that the RNs will screen patients for delirium with the confusion assessment method (CAM). Interdisciplinary delirium education was offered prior to the practice change and repeated at 3, 6 and 12 months after implementation. The documentation, completion and CAM accuracy screening were determined by the CNS. RESULTS: The CAM documentation and completion audit goal was met and sustained by week 21, and screenings were accurate 83% of the time. CONCLUSIONS: The CNS has an opportunity to take a leadership role when instituting an innovative practice change. Successful implementation of a new practice requires that patient care units are divided into cohorts with systematic roll-out of the initiative. IMPLICATIONS FOR NURSING MANAGEMENT: In addition to leadership, CNS availability on the patient care units is imperative to staff acceptance and sustainability of a practice change.

Disparities in hospice care among older women dying with ovarian cancer.

BACKGROUND: Timely hospice referral is an essential component of quality end-of-life care, although a growing body of research suggests that for patients with various types of cancer, hospice referrals often occur very late in the course of care, and are marked by sociodemographic disparities. However, little is known about the ovarian cancer patient population specifically. We examined the extent and timing of hospice referrals in ovarian cancer patients over age 65, and the factors associated with these outcomes. METHODS: We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 8211 women aged 66+ with ovarian cancer who were diagnosed between 2001 and 2005 and died by December 31, 2007. We excluded women who were not eligible for Medicare A continuously during the 6 months prior to death. Outcomes studied included overall hospice use in the last 6 months of life and late hospice enrollment, defined as within 3 days of death. We examined variations in these two measures based on year of diagnosis and sociodemographic characteristics (age, race, marital status, rural residence, income, education) and type of Medicare received (fee-for-service vs. managed care). RESULTS: Among 8211 women in the cohort who died from ovarian cancer, 39.7% never received hospice care (3257/8211). Overall hospice care increased over the period of observation, from 49.7% in 2001 to 63.6% [corrected] in 2005, but the proportion of women receiving hospice care within 3 days of death did not improve. Among those who received hospice care, 11.2% (556/4954) and 26.2% (1299/4954) received such care within 3 and 7 days of death, respectively. A higher proportion of black women (46.5% vs. 38.4% among whites), women in the lowest income group (42.8% vs. 37.0% in the highest income group), and those receiving fee-for-service Medicare (41.3% vs.33.5% for women in managed care) never received hospice care. In multivariable models, factors associated with lack of hospice care included age younger than 80 years (OR 1.27, 95% CI 1.15-1.40), non-white race (OR 1.44, 95% CI 1.26-1.65), low income (OR 1.17, 95% CI 1.04-1.32) and enrollment in fee-for-service Medicare compared with managed care (OR 1.39, 95% CI 1.24-1.56). CONCLUSION: More older women with ovarian cancer are receiving hospice care over time, however, a substantial proportion receive such care very near death, and sociodemographic disparities in hospice care exist. Our data also support the need to target lower-income and minority women in efforts to increase optimally timed hospice referrals in this population. Our finding that ovarian cancer patients enrolled in managed care plans were more likely to receive hospice care suggests the importance of health care system factors in the utilization of hospice services.