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.

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.

Strategies to improve delirium recognition in hospitalized older adults.

As 24-hour caregivers, nurses' detection of delirium is critical to physician diagnosis because of the waxing and waning of delirium-related clinical features. However, nurses fail to accurately interpret delirium-related clinical features more than 30% of the time.

Bundling Interventions to Enhance Pain Care Quality (BITE Pain) in Medical Surgical Patients.

Background: Inadequate pain management and undertreatment remain a serious clinical issue among hospitalized adults, contributing to chronic pain syndromes and opioid dependency. Implementation of individual pain care interventions has been insufficient to improve pain care quality. The purpose of this interprofessional, patient-centered project was to implement a 6-component bundle of evidence-based pain management strategies to improve patients' perception of pain care quality and 24-hour pain experience outcomes. Methods: A quasi-experimental design was used to test the effect of a bundled pain management intervention on 3 medical surgical units. Baseline outcomes using the Pain Care Quality-Interdisciplinary (PainCQ-I©) and Pain Care Quality-Nursing (PainCQ-N©) surveys were measured monthly for 4 months preintervention and 30 months postintervention. Results: A convenience sample of 846 patients was analyzed. The effect of the intervention on pain outcomes could not be tested because unit-based adherence did not meet the goal of 80%. A subsample of 70.2% (594/846) of participants was sufficient to complete a 3-group analysis of preintervention and postintervention participants with confirmed intervention adherence. Participants in the postintervention group who received all 6 components (n=65) had significantly higher odds of higher PainCQ© scores than those in the preintervention group (n=141) (PainCQ-I©: odds ratio [OR] 2.61, 95% confidence interval [CI] 1.54-4.42; PainCQ-N©: OR 3.82, 95% CI 2.06-7.09) or those in the postintervention group receiving ≤5 components (n=388) (PainCQ-I©: OR 2.52, 95% CI 1.57-4.03; PainCQ-N©: OR 3.84, 95% CI 2.17-6.80). Conclusion: Medical surgical patients participating in this study who received the bundled 6-component intervention reported significantly higher levels of perceived pain care quality, suggesting that a bundled approach may be more beneficial than unstandardized strategies.

Clinical Nurse Specialist Roles in Conducting Research: Changes Over 3 Years.

PURPOSE: The aim of this study is to describe clinical nurse specialists' characteristics, interest, confidence, motivators, and barriers in conducting research. DESIGN: This study was a descriptive, multicohort design. METHODS: Clinical nurse specialists were recruited electronically through national and local organizations to complete anonymous surveys 3 times, over 3 years. Comparative analyses included χ and Kruskal-Wallis tests. RESULTS: Of 2052 responders (initial, n = 629; 18 months, n = 465; and 3 years, n = 958), mean (SD) participant age was 50.3 (9.3) years. Overall, 41.7% of participants were involved as principal or coinvestigators in research. Interest in conducting nursing research (on a 0-100 scale) was 61.1 (38.4) and was lowest among the 18-month time point participant group (score, 39.1 [32.2]) and highest at the 3-year time point (68.3, [30.7]; P < .001). Confidence in conducting research, discussion of statistics, and perceptions of motivators and barriers to conducting research did not differ across time period groups. Access to literature and mentors and research knowledge were the most prevalent barriers to conducting research. CONCLUSIONS: Less than 42% of clinical nurse specialists conducted research and the rate did not change between different time groups. Access and knowledge barriers to conducting research were prominent. Workplace leaders need to consider resources and support of academic educational opportunities to increase research conduct by clinical nurse specialists.

Nursing journal clubs and the clinical nurse specialist.

PURPOSE/OBJECTIVES: The purpose of this article was to describe the clinical nurse specialist's role in developing and implementing a journal club. Tools for critiquing clinical and research articles with an application of each are provided. BACKGROUND: The journal club provides a forum through which nurses maintain their knowledge base about clinically relevant topics and developments in their specific clinical discipline, analyze and synthesize the relevant scientific literature as evidence, and engage in informal discussions about evidence-based and best practices. RATIONALE: The value of journal clubs includes nursing staff education, review of and support for evidence-based practice, promotion of nursing research, and fostering of organization-wide nursing practice changes. DESCRIPTION: The process for establishing a journal club and suggested appraisal tools are discussed. In addition, strategies for overcoming barriers to the implementation of a journal club are outlined. Suggested article review questions and a reporting format for clinical and research articles are provided with examples from 2 articles. Finally, a glossary of terms commonly used by research scientists and manuscript writers are listed and additional resources provided. OUTCOME/CONCLUSION: The clinical nurse specialist's role in developing and implementing a journal club will be facilitated through the use of this article. IMPLICATIONS: Enhanced nursing staff education, evidence-based practice, organization-wide nursing practice changes, and nursing research may be conducted following the implementation of a nursing journal club.

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.

Nurses' recognition of delirium in the hospitalized older adult.

BACKGROUND: Delirium is the most frequent complication associated with hospitalization of older adults, responsible for 17.5 million additional hospital days in the United States each year; yet, nurses fail to recognize it more than 30% of the time. OBJECTIVES: The specific aim of the study was to measure staff nurses' recognition of delirium in hospitalized older adults by comparing nurse and expert diagnostician ratings for delirium using the Confusion Assessment Method (CAM). METHOD: This study investigated the rate of agreement/disagreement between researchers and a convenience sample of 167 nurses caring for 170 medical surgical patients (>65 years) in detecting delirium. Paired (nurse vs researcher) CAM ratings were completed at least every other day until either discharge or delirium was detected by the researcher. RESULTS: The researcher detected delirium in 7% (12/170) of patients. Nurses failed to recognize delirium 75% (9/12) of the time, with poor agreement between nurse/researcher for all observations (κ = 0.34). A generalized estimating equation logistic regression model identified independent predictors of nurses' underrecognition of delirium that included increasing age and length of stay, dementia, and hypoactive delirium. DISCUSSION: Findings provide further support for the significance of nurses' underrecognition of delirium in the hospitalized older adult when using the CAM. Additional research is warranted regarding the clinical decision-making processes that nurses use in assessing acute cognitive changes and in identifying strategies to improve delirium recognition.

Cleaned, ready-to-use, reusable electrocardiographic lead wires as a source of pathogenic microorganisms.

BACKGROUND: Cleaned electrocardiographic lead wires are a potential source of microorganisms capable of causing nosocomial infection. OBJECTIVES: To examine fungal and bacterial growth on cleaned reusable lead wires, determine if microbial growth is associated with hospital site or work environment, determine the prevalence of antibiotic-resistant bacteria, and learn if antibiotic-resistant bacteria are associated with hospital site and work environment. METHODS: Cleaned lead wires (N = 320) from critical care and telemetry units, emergency departments, and operating rooms of 4 hospitals were swabbed and the specimens cultured for microbial growth. Bacterial species were grouped by their risk for human infection: at risk (n = 9), potential risk (n = 5), and no risk (n = 10). Work environments were compared by using pairwise contrasts from a generalized estimating equation model. RESULTS: Fungi were rare (0.6%). Of 226 cultures from 201 wires (62.8%) with bacterial growth, 121 were of at- or potential-risk bacteria (37.8%). Urban hospitals had less growth (P ≤ .001) and fewer bacterial species per wire (P ≤ .001) than did community hospitals. Presence of any bacteria (P = .02) and number of bacterial species per wire (P = .002) were lowest in operating rooms; emergency departments and telemetry units had more growth than did critical care units. Among specimens of staphylococci and enterococci, 6 each were sensitive to antibiotics; of 4 resistant staphylococcal species, 1 was not a human opportunistic pathogen and 3 were potential-risk species. CONCLUSIONS: Bacteria are common on reusable, cleaned lead wires and differ by hospital and clinical area.