A Pilot Randomized Controlled Trial of the Feasibility of a Multicomponent Delirium Prevention Intervention Versus Usual Care in Acute Stroke.

BACKGROUND: Delirium after acute stroke is a serious complication. Numerous studies support a benefit of multicomponent interventions in minimizing delirium-related complications in at-risk patients, but this has not been reported in acute stroke patients. The purpose of this study was to explore the feasibility of conducting a randomized (delirium care) versus usual standardized stroke care (usual care) in reducing delirium in acute stroke. OBJECTIVE: This pilot study assessed the feasibility of (1) enrollment within the 48-hour window when delirium risk is greatest, (2) measuring cognitive function using the Montreal Cognitive Assessment, (3) delivering interventions 7 days per week, and (4) determining delirium incidence in stroke-related cognitive dysfunction. METHODS: A 2-group randomized controlled trial was conducted. Patients admitted with ischemic and hemorrhagic strokes and 50 years or older, English speaking, and without delirium on admit were recruited, consented, and randomized to usual care or delirium care groups. RESULTS: Data from 125 subjects (delirium care, n = 59; usual care, n = 66) were analyzed. All Montreal Cognitive Assessment subscales were completed by 86% of subjects (delirium care, mean [SD], 18.14 [6.03]; usual care, mean [SD], 17.61 [6.29]). Subjects in the delirium care group received a mean of 6.10 therapeutic activities (range, 2-23) and daily medication review by a clinical pharmacist using anticholinergic drug calculations. Delirium incidence was 8% (10/125), 3 in the delirium care group and 7 in the usual care group. CONCLUSION: Findings support the feasibility of delivering a multicomponent delirium prevention intervention in acute stroke and warrants testing intervention effects on delirium outcomes and anticholinergic medication administration.

Educating nurses to provide culturally competent care during disasters.

Health disparities are exacerbated during times of disasters. To decrease health disparities, it is essential that health care providers understand the specific needs, culture, and norms of individuals, groups, and populations in a disaster. Survivors respond and recover from disaster events within the context of their culture and beliefs; therefore, implementing cultural competent interventions for disaster victims is central to providing services and care. This article describes the development, implementation, and evaluation of a continuing education program and academic courses for nurses and nursing students.

Mixed-methods approach to understanding nurses' clinical reasoning in recognizing delirium in hospitalized older adults.

A mixed-methods study was conducted to enhance understanding of nurses' clinical reasoning in recognizing delirium in the hospitalized older adult. Paired nurse and researcher ratings of the confusion assessment method in 103 medical-surgical patients were analyzed to determine the rate of agreement in detecting delirium and to identify a purposive sample of nurses to be interviewed about the patients with delirium who were under their care. Nurses' clinical reasoning in recognizing and underrecognizing delirium was investigated using semistructured interviews. The incidence of delirium was 13%, with poor agreement (95% CI [0.05, 0.64], p < 0.05) between the researchers and the nurses in detecting delirium. Sixteen nurses were interviewed and transcripts were analyzed with grounded theory. Confusion was the primary causal factor for recognizing symptoms of delirium. The findings explicated a framework that forms the basis for generating testable assumptions to improve nurses' recognition of delirium.

Providing culturally competent care during disasters: strategies for nurses.

Planning for and responding to disasters involves more than traditional emergency management; members of vulnerable populations should be included in the disaster response cycle. Nurses are key to employing culturally competent strategies with vulnerable populations during disasters, enhancing the access of these populations to care and reducing their health disparities.

Disrupted by disaster: shared experiences of student registered nurse anesthetists affected by hurricane Katrina.

The purpose of this focused ethnography was to describe the shared experiences of student registered nurse anesthetists (SRNAs) whose senior year of education and training was disrupted by Hurricane Katrina, as well as to determine the storm's psychosocial impact on them. A convenience sample of 10 former SRNAs participated in focus groups that were audiorecorded, transcribed, and qualitatively analyzed. Three major themes emerged from the study: Seriousness of Urgency, Managing Uncertainty, and Stability Equaled Relief. The themes represented how the SRNAs appraised and coped with the stressful events surrounding Hurricane Katrina. The psychosocial impact of Hurricane Katrina on the SRNAs resulted mainly in temporary increased alcohol consumption and short-term anxiety. One person started smoking. The results of this study should serve as a guide to formulate policies regarding the education of SRNAs during and immediately after a disaster and to provide a framework for future disaster studies regarding SRNAs.

Reduction of aggressive and violent behavior toward behavioral health unit staff and other patients: a best practice implementation project.

OBJECTIVES: The current project aimed to implement evidence-based recommendations for the management of inpatient aggressive and violent behaviors in four behavioral health units (BHUs) in a mental healthcare area within an academic medical center. INTRODUCTION: Patient violence against healthcare workers is a global concern, particularly in mental health care. All employees who work in inpatient psychiatric environments are at higher risk for targeted violence than are other healthcare workers. For healthcare organizations and staff, violent episodes involving patients can bring about medical expenses, potential legal expenditure, sick leave and a high turnover rate. The hospital at which this project was implemented had been experiencing a steady increase in violence and aggressive behavior. METHODS: The project used the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice audit tool for promoting practice change in four BHUs. A baseline retrospective audit of 10 electronic health records from four BHUs assessed compliance with best practice regarding violent episodes. The Getting Research into Practice tool was used to identify barriers and develop an evidence-based educational strategy for 70 BHU staff aimed to improve compliance with best practice for managing aggression and violence. Staff education compliance was assessed via hospital education department records. A pre and postimplementation staff satisfaction survey assessed perceptions about education, confidence and unit safety. RESULTS: The baseline audit indicated that one of the three criteria had 0% compliance. Following implementation of an educational strategy using mock codes for BHU staff, there was 96% improvement in compliance for the BHU staff education audit criterion. Staff de-escalated patients in 83% of the episodes postimplementation. There was a slight decrease (9.1%) in the rate of violence across all four inpatient BHUs. Staff satisfaction survey findings did not show a statistically significant difference. CONCLUSION: Enhanced evidence-based education and mock codes resulted in BHU staff competence and confidence in managing aggressive and/or violent patients. Early signs of a decrease in the violence rate and improvement in the efficient use of de-escalation will be sustained with on-going yearly education, quarterly mock codes and future audits. This project was limited by its small size and short timeframe (21 weeks), making results not generalizable.

Spiritual development of nursing students: developing competence to provide spiritual care to patients at the end of life.

Nurses spend more time with their patients than do other health care workers. Therefore, the spiritual needs of patients must be recognized as a domain of nursing care. Holism cannot exist without consideration of the spiritual aspects that create individuality and give meaning to people's lives. The purpose of this article is to provide nursing faculty with tools that may be used to develop spiritually knowledgeable nursing students who can overcome barriers to providing spiritual care to end-of-life patients. Our students were required to complete care maps to ensure they are prepared for patient care at the end of life. In this article, we present tools that faculty and students may use to complete the spiritual concept in care mapping. The literature on spirituality is reviewed, use of care mapping in nursing curricula is described, and our teaching approach to develop nursing students who are skilled at providing spiritual care is explained. Three case studies and care maps created by former students are also presented to demonstrate examples of spiritual competence.

Using second life to facilitate peer storytelling for grieving oncology nurses.

BACKGROUND: Oncology nurses often experience intense emotional reactions to patient deaths but may be forced to ignore or hide their feelings because of work-related responsibilities. The complexity of nurses' work and personal lives creates obstacles for participating in traditional support groups where grieving nurses can bond and share. We hypothesized that using a web-based, three-dimensional (3-D) virtual world technology (Second Life) may provide a venue to facilitate peer storytelling to support nurses dealing with grief. METHODS: We used a mixed-methods approach involving focus groups and surveys to explore the use of peer storytelling for grieving oncology nurses. Nine acute and ambulatory oncology nurses in groups of 3 participated using avatars in 5 group moderator-guided sessions lasting 1 hour each in a private 3-D outdoor virtual meeting space within Second Life. Baseline information was collected using a 12-item demographic and professional loss survey. At the end of the study, a 20-item survey was administered to measure professional losses during the study, exchange of support during sessions, and meaning-making and to evaluate peer storytelling using Second Life. RESULTS: Overall, nurses reported peer storytelling sessions in Second Life were helpful in making sense of and in identifying a benefit of their grief experience. They felt supported by both the group moderator and group members and were able to personally support group members during storytelling. Although nurses reported Second Life was helpful in facilitating storytelling sessions and expressed overall satisfaction with using Second Life, open-ended comments registered difficulties encountered, mostly with technology. Three central themes emerged in sessions, representing a dynamic relationship between mental, spiritual, and emotional-behavioral responses to grief: cognitive readiness to learn about death, death really takes death experience, and emotional resilience. CONCLUSION: This study suggests a potential benefit in using peer storytelling sessions in Second Life to facilitate oncology nurses' grief resolution. In particular, Second Life provides a nonthreatening venue for participating nurses to share their innermost feelings and accrue their own inventory of stories. Through these stories, each nurse's relational experience in expressing and coping with grief is realized.