Improving delirium detection in intensive care units: Multicomponent education and training program.

BACKGROUND: Delirium is a common, devastating, and underrecognized syndrome in the intensive care unit (ICU). The study aimed to describe and evaluate a multicomponent education and training program utilizing a "Train-The-Trainer" (TTT) model, to improve delirium detection across a large health system. METHODS: Fourteen ICUs across nine hospitals participated in a multicomponent delirium program consisting of a 1-day workshop that included: (1) patient testimonials, (2) small group discussions, (3) didactics, and (4) role-playing. Additionally, four ICUs received direct observation/training via telehealth (tele-delirium training). The Kirkpatrick model was used for program evaluation in a pre/post-test design. RESULTS: A 1-day delirium workshop was held at two time points and included 73 ICU nurses. Of the 65 nurses completing the post-workshop satisfaction survey, most (46.2) had >10 years of clinical experience, and no or minimal delirium training (69.2%). All nurses (100%) identified lack of knowledge as a barrier to delirium detection, while time constraints and lack of importance accounted for only 25%. Overall, nurses rated the workshop positively (excellent 66.7%, and very good 23.3%), and likely to change practice (definitely 73.3% and very likely 15.0%). All validated Confusion Assessment Method for the ICU (CAM-ICU) cases demonstrated improvement in number of correct responses. Delirium detection across the health system improved from 9.1% at baseline to 21.2% in ICUs that participated in the workshop and 30.1% in those ICUs that also participated in the tele-delirium training (p = 0.005). CONCLUSION: A multicomponent delirium education and training program using a TTT model was rated positively, improved CAM-ICU knowledge, and increased delirium detection.

The Neonatal Eating Assessment Tool: Development and Content Validation.

PURPOSE: To develop and content validate the Neonatal Eating Assessment Tool (NeoEAT), a parent-report measure of infant feeding. DESIGN: The NeoEAT was developed in three phases. Phase 1: Items were generated from a literature review, available assessment tools, and parents' descriptions of problematic feeding in infants.Phase 2: Professionals rated items for relevance and clarity. Content validity indices were calculated. Phase 3: Parent understanding was explored through cognitive interviews. SAMPLE: Phase 1: Descriptions of infant feeding were obtained from 12 parents of children with diagnosed feeding problems and 29 parents of infants younger than seven months. Phase 2: Nine professionals rated items. Phase 3: Sixteen parents of infants younger than seven months completed the cognitive interview. MAIN OUTCOME VARIABLE: Content validity of the NeoEAT. RESULTS: Three versions were developed: NeoEAT Breastfeeding (72 items), NeoEAT Bottle Feeding (74 items), and NeoEAT Breastfeeding and Bottle Feeding (89 items).

A Recipe for Improved Nonsurgical Cosmetic Outcomes: Know Your Herbs and Spices.

The nonsurgical cosmetic arena continues to grow, with more people consistently seeking minimally invasive procedures for facial rejuvenation. However, although these prospective patients are not seeking surgical correction to obtain their results, there is still the potential for nonsurgical procedures to yield adverse events posttreatment. Patients often do not realize that their dietary regimens may affect their nonsurgical cosmetic outcomes. For example, many patients desiring these types of treatments are often found to be taking prescription medications, herbs, and spices on a daily basis that may have the capacity to potentiate adverse outcomes such as bleeding and/or bruising. For these reasons, it is important for clinicians to be inclusive while taking health histories and to properly educate their patients so that administered treatments have the best chance of yielding the desired results. The focus of this article is to provide health care providers information on many of the herbs and spices that have the potential to negatively impact nonsurgical cosmetic outcomes.

Assessing asthma control: An evidence-based approach to improve skills and outcomes.

The goal of asthma therapy is to achieve and maintain good asthma control. By utilizing evidence-based guidelines recommended by the National Asthma Education Prevention Program Expert Panel-3 Report, nurse practitioners can improve assessment of asthma control, and ultimately improve asthma outcomes.

Self-care management practices for the home health nurse: staying hale and hearty through enhanced self-care and ergonomics--with a case study.

Ergonomics provides a broad framework for home healthcare nurses to improve their individual physical, psychological, cognitive, and spiritual well-being through application of models for self-care planning. As the individual becomes stronger, more resilient and work hardy, the benefits to the individual, along with the work organization and ultimately the clients, grow exponentially. This article seeks to explore the relevant ergonomic domains and assist home healthcare nurses to develop self-care planning practices that lead to healthy lifestyles and improved quality of life.

The validity of neuropathy and neuropathic pain measures in patients with cancer receiving taxanes and platinums.

PURPOSE/OBJECTIVES: To assess the validity of neuropathy and neuropathic pain-measurement approaches. DESIGN: Cross-sectional measurement study. SETTING: Two comprehensive cancer centers in the northeastern United States. SAMPLE: 117 patients with cancer in an outpatient setting. METHODS: Participants were assessed using the five-component Total Neuropathy Score-reduced (TNSr), the TNSr short form (TNSr-SF), individual TNSr items, the Neuropathic Pain Scale for chemotherapy-induced neuropathy (NPS-CIN), and the National Cancer Institute's Common Toxicity Criteria™, version 3.0 (NCI-CTC). MAIN RESEARCH VARIABLES: Neuropathy and pain measure scores, cumulative and per M2 chemotherapy dosage, comorbid risk factors, drug class, and the number of neurotoxic drugs received. FINDINGS: TNSr, TNSr-SF, and tendon reflex scores were greater in patients receiving higher cumulative (z range = -2.2 to -3.6; p range = 0.01 to < 0.001) and per M2 (z range = -1.8 to -2.4; p range = 0.04 to < 0.001) chemotherapy doses. Scores from most neuropathy and pain measures were higher in patients with comorbid illnesses (z range = -1.79 to -3.51; p range = 0.03 to < 0.001). Sensory NCI-CTC scores were higher in patients receiving higher cumulative chemotherapy dosage (z = -2.1; p = 0.02). Only the sensory NCI-CTC correlated with other measures (r range = 0.22-0.63; p range = 0.05 to < 0.001). CONCLUSIONS: Findings support the validity of the TNSr, TNSr-SF, tendon reflex item, NPS-CIN, and NCI-CTC sensory grading scale when measuring taxane and platinum-induced neuropathy. However, additional validity testing is warranted. IMPLICATIONS FOR NURSING: Comprehensive neuropathy and pain measures mainly used by researchers and neurologists were simplified to more clinically useful tools for use by nurses when monitoring chemotherapy-induced peripheral neuropathy.

The development of research tools used in the STORK Study (the Scottish Trial of Refer or Keep) to explore midwives' intrapartum decision making.

OBJECTIVES: to develop appropriate tools to assess midwives' attitudes and behaviour in relation to decision making involving risk. DESIGN: a questionnaire and series of vignettes were developed and testes to explore midwives' intrapartum decision making in relation to their attitudes towards risk. An innovative online computer package was developed specifically for use in the STORK Study which enabled the programme to be very tightly controlled with limited functions accessible to participants. TESTING: a pilot study was conducted with over 50 midwives and nurses to ensure face and content validity of the vignettes and questionnaire. Initially designed to be a paper-based study, rigorous piloting highlighted the many difficulties in presenting it in that particular format. The solution to this problem was to develop the study as a secure online package. FINDINGS: online data collection provided the researchers with a greater degree of control of the data collection process, not achievable using traditional paper survey methods. Another example of this control is the immediate entry of data from participants' responses to a background database which automatically stores and backs up data this means that no additional time is required for data entry. The cost of employing an information technology professional was easily offset by the financial savings made through the limited use of stationery and postage. KEY CONCLUSIONS: although the development and testing of the research tools for the STORK Study was labour and time intensive, ultimately a questionnaire and vignette package was produced that had been rigorously tested by over 50 midwives and nurses. The researchers are confident in the reliability of the questionnaire and vignettes, as well as the validity of the data collected. The use of an online survey is clearly indicated when the population has readily available internet access, and where controlling the process of data collection is required, as such control cannot be achieved in traditional survey and questionnaire implementation.

Measuring the quality of documented care given by Swedish midwives during birth.

OBJECTIVES: To measure the extent to which documented Swedish midwifery care for low-risk labour and birth followed the World Health Organization's (WHO) recommendations for care in normal birth, and to compare midwifery care given to women who's labours were classified as low and high risk. STUDY DESIGN: A retrospective examination of midwifery and medical records, 144 from women with low-risk births and 54 from women with high-risk births, for aspects of pregnancy, labour and birth using a validated instrument based on WHO's recommendations. SETTING: Southern Sweden. OUTCOME MEASUREMENTS: Care given in accordance with WHO's four categories of practice and changes in risk group during the birth process. FINDINGS: Care interventions not recommended by WHO, such as routine establishment of an intravenous route, routine amniotomy during the first stage, continuous electronic fetal monitoring and pharmacological methods of pain relief, were widespread in the records. Documented care differed little between the labours of women at low risk and high risk. The midwives at the unit under study did not routinely carry out risk assessment. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: The mode of care was one of readiness for medical intervention. The act of carrying out risk assessments at the time of the woman's admission may affect awareness of the level of care offered to birthing women, and thus help to reduce the number and variety of practices not recommended by WHO.

Utility of routine nurse assessment of the risk of chemotherapy-induced febrile neutropenia.

Evidence-based guidelines recommend that patients at high risk (> or = 20%) for febrile neutropenia (FN) should receive prophylactic colony-stimulating factors (Aapro et al., 2006; Kouroukis et al., 2008; National Comprehensive Cancer Network [NCCN], 2008; Smith et al., 2006). We studied the utility of having nurses routinely assess FN risk in new patients before the initiation of chemotherapy. Fifteen nurses used a standardized tool to evaluate FN risk in 150 patients. In 94% of patients studied, nurses detected risk factors that prompted interventions to reduce the incidence of FN. On final evaluation, 67% of nurses said the use of a standardized tool helped them to identify patients at risk for FN, and 73% planned to assess FN risk routinely. Thus, it is feasible and valuable for nurses to assess FN risk using a standardized checklist prior to the initiation of chemotherapy.

Effect of introducing a care pathway to standardize treatment and nursing of schizophrenia.

Care pathways can help to implement evidence-based clinical practice. The introduction of care pathways is difficult for psychiatric disorders. This study examined whether the organization and the effectiveness of care provided to schizophrenic patients can be improved by care pathways. Outcomes from 19 patients receiving treatment using evidence-based care pathways were compared with 17 patients receiving a traditional approach to care over a 3 months period. Results showed significant improvements in the quality of the care for the patients included in the care pathway group. The authors concluded the positive outcomes for patients treated with care pathways were related to the assistance provided to clinicians in identifying and implementing evidence-based standards.

Psychometric testing of the Caregiver Quality of Life Index-Cancer on a Taiwanese family caregiver sample.

Family caregivers' quality of life (QOL) is an important indicator for end-of-life care, but appropriate assessment tools are unavailable in Taiwan. This correlational study therefore tested the psychometric properties of the Caregiver Quality of Life Index-Cancer Mandarin version (CQOLC-M) in 359 dyads of cancer patients with terminal illness and their family caregivers from 5 teaching hospitals throughout Taiwan. Caregivers' QOL, spiritual well-being, social support, pain intensity, and economic situation were assessed using the CQOLC-M and 4 established scales. The CQOLC-M had internal consistency reliability of .87. Construct validity was supported by factor analysis, hypothesis testing, and known-group comparison. Exploratory factor analysis showed 7 underlying factors explaining 48.15% of the variance. Caregiver Quality of Life Index-Cancer Mandarin version scores correlated moderately with caregivers' social support (P < .01) and spiritual well-being (P < .01). Caregivers' QOL was inversely related to both patients' (F = 4.90; P = .008) and caregivers' average pain (t = -4.22; P < .001) in the past 24 hours. We suggest removing 4 items with factor loading of less than 0.4. Since caregivers' QOL depends on patients' and caregivers' physical dimensions, we recommend adding physical-related items to the CQOLC-M. Clinicians can improve caregivers' QOL not only by maintaining their health, social support, and spirituality but also by better managing the pain of patients with terminal illness.

Cancer-related fatigue: role of oncology nurses in translating National Comprehensive Cancer Network assessment guidelines into practice.

This article reviews the National Comprehensive Cancer Network's (NCCN's) guidelines for cancer-related fatigue (CRF) assessment and discusses many of the common barriers that hinder the translation of the CRF guidelines into practice settings. Current assessment and measurement scales validated in patients with cancer are highlighted, and case studies reflect the vital roles that oncology nurses can play in managing patients with CRF. Oncology nurses must remember to assess the "gang of 7" (i.e., anemia, pain, sleep difficulties, nutrition issues, deconditioning or changes in activity patterns, emotional distress [depression or anxiety], and presence of comorbidities) that may affect workup, treatment, and supportive care referrals. Teaching patients about the importance of viewing CRF as the "sixth vital sign" can emphasize this symptom's importance and significance. Oncology nurses also can recognize the many patient-, provider- and system-related barriers that exist and work with others in a systematic and collaborative fashion within the system to decrease these barriers and begin to incorporate a simple intensity scale for CRF assessment and screening, documentation, and ongoing monitoring. By using available resources, oncology nurses can play significant roles in the translation of the NCCN's evidence-based practice guidelines for CRF in their practice settings.

Is a STAS-based tool valid to triage patients at a specialist palliative care inpatient unit?

Many tools exist to assess the symptoms and needs of palliative care patients, but no tool has been validated to prioritise patients referred for specialist inpatient palliative care. The aim of this study was to produce and validate such a tool. A prospective pilot study produced a Support Team Assessment Schedule- (STAS-) based tool--the Admission Assessment Tool (AAT)--and compared this with the existing system of triage at the Marie Curie Hospice, Edinburgh. Validity of the tool was not confirmed and the tool was modified and re-evaluated. One hundred and twenty-seven consecutive patients referred to the hospice received three AAT scores: from the bed manager; the admitting doctor; and the admitting nurse. The hospice's multidisciplinary team assessed the urgency of each patient's admission. The overall correct classification rate was approximately two thirds, but false positive rates were high and there was poor inter-rate correlation. It is concluded the AAT has not been validated.

National audit of continence care for older people: management of urinary incontinence.

INTRODUCTION: the Department of Health report 'Good practice in continence services' highlights the need for proper assessment and management of urinary incontinence. The National Service Framework for Older People required service providers to establish integrated continence services by April 2004. A national audit was conducted to assess the quality of continence care for older people and whether these requirements have been met. METHOD: the audit studied incontinent individuals of 65 years and over. Each site returned data on organisational structure and the process of 20 patients' care. Data were submitted via the internet, and all were anonymous. RESULTS: the national audit was conducted across England, Wales and Northern Ireland. Data on the care of patients/residents with bladder problems were returned by 141/326 (43%) of primary care trusts (PCT), by 159/196 (81%) of secondary care trusts (involving 198 hospitals) and by 29/309 (9%) of invited care homes. In all 58% of PCT, 48% of hospitals and 74% of care homes reported that integrated continence services existed in their area. Whilst basic provision of care appeared to be in place, the audit identified deficiencies in the organisation of services, and in the assessment and management of urinary incontinence in the elderly. CONCLUSION: the results of this audit indicate that the requirement for integrated continence services has not yet been met. Assessment and care by professionals directly looking after the older person were often lacking. There is an urgent need to re-establish the fundamentals of continence care into the practice of medical and nursing staff and action needs to be taken with regard to the establishment of truly integrated, quality services in this neglected area of practice.

Development and validation of a scale assessing spiritual needs for Korean patients with cancer.

The purpose of this study was to develop a scale assessing the spiritual needs of Korean patients with cancer. For the scale development, qualitative interviews and theoretical analyses were conducted to extract measurable constructs within the Korean culture. As a result, 26 items were developed for the validation of a scale. The scale was administered to 257 cancer patients; the reliability and validity of the scale were examined using Cronbach's alpha and factor analysis, respectively. The reliability was 0.92. The results of factor analysis revealed five subconstructs: love and connection, hope and peace, meaning and purpose, relationship with God, and acceptance of dying. Given these subconstructs, suggestions are provided for future studies. Spirituality has been shown to be important in the lives of patients with chronic disease. Therefore, having a scale which adequately assesses patients' spiritual needs is critical to determining how to address these needs in a clinical setting.

Pulse oximetry knowledge and its effects on clinical practice.

AIM: to explore literature pertaining to registered nurses' and/or doctors' knowledge in relation to the pulse oximetry in clinical practice. BACKGROUND: pulse oximeters provide non-invasive readings of both pulse rate and peripheral oxygen saturation, leading to quick identification of potential/actual problems. Because of this, clinicians, like nurses, may become too dependent on it, neglecting other aspects of the holistic assessment process. METHODS: a literature search was carried out between 1980 and 2006, with much of the data skewed towards 1994-2006. As the central focus was to be on pulse oximetry knowledge of nurses and/or doctors, articles included had to contain a central theme addressing this. Other criteria for inclusion were links between pulse oximetry and knowledge in clinical practice, nurses and/or doctors as participants in studies addressing this, as well as the clinical competency in relation to the device. CONCLUSION: improving knowledge may not necessarily be the answer in improving clinical competency. Future research will need to be carried out to measure the connection between knowledge and competency and to use that as a basis for education and training.