The Cardiac Rehabilitation Inventory: A New Method of Tailoring Patient Support.

BACKGROUND: Uptake and adherence to cardiac rehabilitation (CR) are low, and a contributing factor to this may be the practical difficulties of providing a tailored CR environment suited to individual preferences and needs. OBJECTIVE: The aim of this study was to develop and test a short questionnaire that CR practitioners can use to understand individual patient need and tailor support accordingly. METHODS: A conceptual framework of engagement in CR was derived from a comprehensive literature review and the content analysis of semistructured interviews with 15 CR patients. The conceptual framework was used to construct the first version of the Cardiac Rehabilitation Inventory (CRI), which comprised 42 items. Responses on the CRI were measured using a 5-point Likert scale. The CRI was administered to 380 phase III and IV CR patients, and factor analysis (FA) was used to identify salient CR engagement factors. RESULTS: The simplest structure found using FA was three 6-item subscales that all had good levels of internal consistency (Cronbach's α) and were labeled (a) outcome anxiety, α = .726; (2) process anxiety, α = .724; and (3) autonomy, α = .653. The 3-factor CRI model was verified using confirmatory FA (CMin/df = 3.2, root-mean-square error of approximation = 0.073). Attenders were found to have higher levels of outcome anxiety than nonattenders (P < .001), and precontemplator nonattenders were found to have lower autonomy compared with attenders (P < .001). Standard multiple regression analysis indicated outcome anxiety was a strong predictor of CR intentions (r = 0.716), followed by autonomy (r = 0.110) and process anxiety (r = 0.031). CONCLUSIONS: The CRI is a reliable method of measuring CR outcome anxiety, process anxiety, and autonomy. These CRI measurements provide rehabilitation practitioners with valuable information that can help provide individual tailored support.

Neurovascular assessment in the critically ill patient.

AIM: To outline the pathophysiological processes involved in neurovascular impairment and compartment syndrome and examine common contributory factors within the development and clinical presentation of neurovascular impairment in critical care patients with musculoskeletal trauma. BACKGROUND: Thorough and systematic assessment of neurovascular status in critically ill patients with musculoskeletal trauma is crucial to detect secondary ischaemic injury and implement appropriate and timely treatment of any neurovascular deficits. METHOD: Current literature relating to neurovascular assessment and associated patient care was reviewed and utilised to outline distinct assessment components, indicators of neurovascular impairment and highlight the important issues for critical care nursing practice. RESULTS: Diminished limb perfusion secondary to vascular impairment and compartment syndrome are well documented. Complications associated with musculoskeletal trauma and surgical intervention can have wide-ranging effects on the patient's functional ability and overall outcome. It is crucial that appropriate neurovascular assessment is undertaken for patients admitted to the critical care unit following musculoskeletal trauma, crush injury, orthopaedic surgery (involving internal or external fixation of fractures) and those who may have experienced prolonged external pressure from casts or tight-fitting bandages. Several elements of neurovascular assessment are, however, more complex to undertake in the context of the unconscious or sedated critically ill patient. CONCLUSIONS: Effective practice requires that the critical care nurse has a comprehensive understanding of the aetiology, pathophysiology, physiological responses and clinical presentation associated with neurovascular impairment, secondary ischaemia and compartment syndrome. RELEVANCE TO CLINICAL PRACTICE: Undertaking an effective neurovascular assessment for patients at risk of neurovascular impairment or acute compartment syndrome (ACS) in the critical care setting can be problematic when patients are unable to communicate with the nurse. The risk of long-term functional impairment or limb loss can be significant in this group of patients, particularly following musculoskeletal trauma. This article reviews the aetiology and pathophysiology of neurovascular impairment in the critical care context and provides guidance for nurses undertaking this important element of nursing assessment with non-verbal, critically unwell patients. Informed practice in neurovascular assessment has the potential to enable early detection and timely management for these patients, which is crucial to optimise patient outcomes.

'Back to the bedside': graduate level education in critical care.

The need for post registration education for nurses practising at specialty level in critical care environments is widely acknowledged in nursing and educational literature. There is also clear consensus that the ultimate aim of educational preparation and practice development is to improve the delivery of nursing care to patients who are critically ill and provide support for their families. Yet the 'right' approach to educational delivery and evaluation is less clear and stimulates considerable debate amongst nursing educators, care providers, learners and regulatory bodies. The need for critical care nurses to apply advanced knowledge and technical skills to complex and dynamic practice situations necessitates the development of critical thinking and a problem-solving approach to clinical practice that can be fostered through education and experience. This paper explores the relationships within teaching, learning and practice development in critical care nursing and questions the popular assumption that 'post graduate (Master's level) education fits all'. Discussion focuses on the successful development and implementation of graduate level education for critical care nurses in the South Island of New Zealand and how this development is challenging existing approaches to the provision and evaluation of formal critical care education in New Zealand.

The meaning of effective education for critical care nursing practice: a thematic analysis.

Continuing education and practice development are integral components of specialist nursing practice in environments such as intensive and critical care. Previous studies have examined the 'effectiveness' of various approaches to teaching and learning in critical care, yet few have considered how effective education affects the relationship between education and practice development. Using thematic analysis, this study explored the phenomenon of effective education (for critical care nursing practice) by asking: What does effective education for critical care nursing practice mean to nurses currently practising in the specialty? Eighty eight critical care nurses from the South Island of New Zealand provided written descriptions of what effective education for critical care nursing practice meant to them. Descriptive statements were analysed to reveal constituents, themes and essences of meaning. Four core themes of personal quality, practice quality, the learning process and learning needs emerged. Appropriateness or relevance for individual learning needs is further identified as an essential theme within the meaning of effective education for critical care nursing practice. Shared experiences of the phenomenon are made explicit and discussed with reference to education and practice development in the specialty. The study results lend support to education that focuses on individual learning needs, and identifies work based learning as a potential strategy for learning and practice development in critical care nursing.