Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit.

OBJECTIVE: To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS: The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over 6 yr in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (http://www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (http://www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2), and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend …" is used throughout. A weak recommendation, either for or against an intervention, indicated that the trade-off between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest …" is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflict of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Composing a Life that Works with a Life that Counts for Nurses.

The life of a nurse since the Covid-19 pandemic is characterized by high rates of anxiety, depression, and burnout, leading national organizations to declare the nursing shortage a national emergency. Solutions cite work-life balance, but this term has no clear guiding definition. Experts in the organizational psychology and personal development literature suggest other ways to reconsider this dilemma, that of integration. In this paper the concept of integration is proposed to focus on relationships with family and friends, work, and oneself. The American Association of Critical-Care Nurses 'standards for a healthy work environment are used to frame the benefits of an integrated life. Strategies to achieve an integrated life, one with meaning and purpose, are described to create more happiness and joy and to begin to mitigate the nursing shortage.

Success indicators for an accelerated masters entry nursing program: staff RN performance.

The purpose of this exploratory research study was to assess employment performance outcomes of students who completed the prelicensure segment of an accelerated graduate entry program, the Masters Entry Program in Nursing (MEPN) at the University of California, San Francisco. MEPN RNs and their managers at three study sites completed a survey constructed from staff RN performance criteria position descriptions and participated in focus groups. Data were used to evaluate staff RN employment performance and how well the educational program prepared students for the staff RN role. Findings indicate that MEPN RNs' self-assessment and their managers' performance evaluation were rated as very effective in their staff RN roles, regardless of years of nursing experience. Recommendations for further research are discussed, encouraging the use of employment performance criteria as an additional way to evaluate the quality of nursing educational programs.

Evaluating diversity in nursing education: a mixed method study.

This article presents the findings of a methodical examination of how well one school of nursing was meeting its goal of addressing diversity through its pedagogy. The underlying assumption was that a school's curriculum both shapes and reflects a climate of valuing diversity. This mixed-method evaluation study was conducted in four steps, including a content analysis of all syllabi in the School of Nursing's (SON) curriculum, comparison of the content analysis to students' evaluation of diversity in their education, a survey of the 2006 graduates, and an analysis of faculty responses to the findings. The findings are being used to guide the SON in the development of training and to bring about forums for formal dialogue. These will assist faculty to effectively integrate diversity in their teaching and interaction with students and to move toward the long-term goal of preparing culturally humble and sensitive clinicians, educators, and researchers.

Shared faculty governance: a decision-making framework for evaluating the DNP.

The concept of shared governance was used to frame the dialogue and decision-making process around the Doctor of Nursing Practice (DNP) at a leading School of Nursing. This article reports the process used to support dialogue around the DNP so that an informed decision could be made. The shared governance process promoted reflective conversation within the entire faculty and, in the end, supported the decision-making related to the DNP.

Implementing healthy work environment standards in an academic workplace: An update.

In 2005 the American Association of Critical Care Nurses defined six Healthy Work Environment (HWE) standards for the clinical setting (AACN, 2005), which were reaffirmed and expanded in 2016 (AACN, 2016). These clinical standards were adapted for use in the academic setting by Fontaine, Koh, and Carroll in 2012. The intention of this article is threefold: to present a revised version of the academic workplace standards which are appropriate for all School of Nursing (SON) employees, staff as well as faculty; to proposes the addition of a seventh standard, self-care, which provides the foundation for all standards; and to describe the continuing implementation of these seven standards at the University of Virginia School of Nursing (UVA SON).

The accelerated doctoral program in nursing: a university-foundation partnership.

A recent increase in nursing faculty vacancies presents an important impediment to solving the nursing shortage. Today, many schools of nursing are unable to accept qualified nursing students because they do not have sufficient faculty to teach them. Retirements projected during the next decade raise the issue to crisis proportions. One foundation, the Gordon and Betty Moore Foundation, has partnered with the School of Nursing at the University of California, San Francisco, to solve this crisis by supporting the development of an accelerated doctoral program for post-master's degree students in which students earn a PhD in 3 years. Students receive a generous stipend that allows them to devote themselves to study, but they must commit to teaching for 3 years in a nursing program on graduation. This partnership is an innovative solution to the current nursing crisis.

Healthier hospitals?

Review AACN's healthy work environments initiative and learn how the standards can be used to build cultures of safety.

Prioritizing Clinician Wellbeing: The University of Virginia's Compassionate Care Initiative.

BACKGROUND: Working in healthcare is increasingly challenging for nurses, physicians, and other health professionals. Ongoing high stress takes a toll on clinicians and interferes with the quality of their patient care. Fostering clinician wellbeing needs to be a priority; if not, the human and financial consequences are significant. OBJECTIVE: To describe the University of Virginia (UVA) School of Nursing's Compassionate Care Initiative (CCI) as an example of an organizational case study that is engaged in multipronged efforts to cultivate a resilient healthcare workforce committed to high-quality, compassionate, relationship-based care. METHODS: This case report describes the development, implementation, and evaluation of the CCI at UVA. Various elements of the program are reviewed, which include harnessing talents and interests of the larger institution in the establishment of Compassionate Care Ambassadors, outreach to the community, innovative student-specific educational activities, and a national media program. CONCLUSION: The UVA CCI is a successful model of an organizational effort to promote clinician wellbeing and resilience. Aspects from this program can be adapted to other organizations that are committed to addressing this critical issue in US healthcare today.

Family presence during cardiopulmonary resuscitation and invasive procedures: practices of critical care and emergency nurses.

BACKGROUND: Increasingly, patients' families are remaining with them during cardiopulmonary resuscitation and invasive procedures, but this practice remains controversial and little is known about the practices of critical care and emergency nurses related to family presence. OBJECTIVE: To identify the policies, preferences, and practices of critical care and emergency nurses for having patients' families present during resuscitation and invasive procedures. METHODS: A 30-item survey was mailed to a random sample of 1500 members of the American Association of Critical-Care Nurses and 1500 members of the Emergency Nurses Association. RESULTS: Among the 984 respondents, 5% worked on units with written policies allowing family presence during both resuscitation and invasive procedures and 45% and 51%, respectively, worked on units that allowed it without written policies during resuscitation or during invasive procedures. Some respondents preferred written policies allowing family presence (37% for resuscitation, 35% for invasive procedures), whereas others preferred unwritten policies allowing it (39% for resuscitation, 41% for invasive procedures), Many respondents had taken family members to the bedside (36% for resuscitation, 44% for invasive procedure) or would do so in the future (21% for resuscitation, 18% for invasive procedures), and family members often asked to be present (31% for resuscitation, 61% for invasive procedures). CONCLUSIONS: Nearly all respondents have no written policies for family presence yet most have done (or would do) it, prefer it be allowed, and are confronted with requests from family members to be present. Written policies or guidelines for family presence during resuscitation and invasive procedures are recommended.

Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the Intensive Care Unit: executive summary.

OBJECTIVE: To revise the "Clinical Practice Guidelines for the Sustained Use of Sedatives and Analgesics in the Critically Ill Adult" published in Critical Care Medicine in 2002. METHODS: The American College of Critical Care Medicine assembled a 20-person, multidisciplinary, multi-institutional task force with expertise in guideline development, pain, agitation and sedation, delirium management, and associated outcomes in adult critically ill patients. The task force, divided into four subcommittees, collaborated over six years in person, via teleconferences, and via electronic communication. Subcommittees were responsible for developing relevant clinical questions, using the Grading of Recommendations Assessment, Development and Evaluation method (www.gradeworkinggroup.org) to review, evaluate, and summarize the literature, and to develop clinical statements (descriptive) and recommendations (actionable). With the help of a professional librarian and Refworks database software, they developed a Web-based electronic database of over 19,000 references extracted from eight clinical search engines, related to pain and analgesia, agitation and sedation, delirium, and related clinical outcomes in adult ICU patients. The group also used psychometric analyses to evaluate and compare pain, agitation/sedation, and delirium assessment tools. All task force members were allowed to review the literature supporting each statement and recommendation and provided feedback to the subcommittees. Group consensus was achieved for all statements and recommendations using the nominal group technique and the modified Delphi method, with anonymous voting by all task force members using E-Survey (www.esurvey.com). All voting was completed in December 2010. Relevant studies published after this date and prior to publication of these guidelines were referenced in the text. The quality of evidence for each statement and recommendation was ranked as high (A), moderate (B), or low/very low (C). The strength of recommendations was ranked as strong (1) or weak (2) and either in favor of (+) or against (-) an intervention. A strong recommendation (either for or against) indicated that the intervention's desirable effects either clearly outweighed its undesirable effects (risks, burdens, and costs) or it did not. For all strong recommendations, the phrase "We recommend..." is used throughout. A weak recommendation, either for or against an intervention, indicated that the tradeoff between desirable and undesirable effects was less clear. For all weak recommendations, the phrase "We suggest..." is used throughout. In the absence of sufficient evidence, or when group consensus could not be achieved, no recommendation (0) was made. Consensus based on expert opinion was not used as a substitute for a lack of evidence. A consistent method for addressing potential conflicts of interest was followed if task force members were coauthors of related research. The development of this guideline was independent of any industry funding. CONCLUSION: These guidelines provide a roadmap for developing integrated, evidence-based, and patient-centered protocols for preventing and treating pain, agitation, and delirium in critically ill patients.

Promoting a healthy workplace for nursing faculty and staff.

Promoting a healthy workplace in academic nursing settings is vital to recruit new faculty and enhance the work life of all faculty and staff for retention and happiness. When a healthy work environment is fostered, incivility becomes unacceptable, and individuals embrace a culture where all can flourish. This article addresses the imperative of a healthy workplace, with practical suggestions for making the academic setting in schools of nursing one of optimism and confidence where future generations of nurse leaders are developed.

Achieving transformational change: using appreciative inquiry for strategic planning in a school of nursing.

To achieve transformational change, a transformational approach is needed. The Appreciative Inquiry (AI) summit is a method that has been used to achieve transformational change in business for at least 20 years, but this innovative alternative approach is unknown to nursing. At the University of Virginia School of Nursing, an AI Summit was designed to bring all staff, faculty, student representatives, and members of the community together to rewrite the school's strategic plan. New connections within the school, the university, and the community were made when 135 participants engaged in the appreciative, 4-step AI process of discovering, dreaming, designing, and creating the school's future. During the summit, 7 strategic teams formed to move the school toward the best possible future while building on the existing positive core. This article describes 10 steps needed to design an AI summit and implications for using this method at other schools of nursing.

Psychological symptoms of family members of high-risk intensive care unit patients.

BACKGROUND: Family members of patients in intensive care are at increased risk for psychological symptoms. OBJECTIVES: To compare levels of posttraumatic stress disorder, anxiety, and depression during and 3 months after the intensive care experience in family members of patients at high risk for dying and to determine if differences were related to the patient's final disposition. METHODS: Longitudinal descriptive study of 41 family members in 3 tertiary care intensive care units. RESULTS: By repeated-measures analysis of variance, family members' levels of posttraumatic stress disorder were significantly lower (P = .01) at 3 months after (mean score, 1.27; SD, 0.86) than during (mean, 1.61; SD, 0.81) the experience. Mean anxiety and depression scores were significantly lower (P < .001) after (anxiety: 7.35; SD, 3.91; depression: 5.63; SD, 4.58) than during (anxiety: 11.5; SD, 4.88; depression: 9.51; SD, 4.31) the experience. Scores for posttraumatic stress disorder, anxiety, and depression did not differ significantly between family members of patients who died and family members of patients who survived. Yet, all 13 family members of deceased patients and 42% of the total sample of 41 had traumatic stress scores of 1.5 or greater. Among the total sample, 44% had significant anxiety, and 27% were depressed. CONCLUSION: Family members' symptoms of posttraumatic stress disorder, anxiety, and depression significantly decreased 3 months after the intensive care experience and did not differ according to the patients' final disposition. However, many family members still had significant risk for posttraumatic stress disorder and borderline anxiety and depression at 3 months.

Meeting the nursing faculty shortage challenge: an accelerated doctoral program in nursing.

In 2003, the Gordon and Betty Moore Foundation partnered with a major west coast school of nursing to create an accelerated doctoral program in nursing. The program's chief aim was to address the nursing shortage by increasing the number of nurse faculty by funding 42 doctoral students in five cohorts. Students accepted into the accelerated program receive a generous stipend and commit to earn their doctorate in 3 years and teach for 3 years after graduation at 1 of 17 area nursing programs. Two cohorts have graduated from the accelerated program and are currently in faculty positions. This article describes the accelerated doctoral program and the academic progression and postgraduation employment of the first two cohorts.