Current turnover intention among nurse managers, directors, and executives.

BACKGROUND: Nursing leadership turnover can adversely affect nurse retention and thus quality of care. Little research has examined the way nurses at differing levels of leadership experience their workplace and voluntarily decide to leave. PURPOSE: Our study sought to explore and compare intent to leave and turnover experiences of acute care nurse managers, directors, and executives. METHODS: Data were collected via an online survey. Participants included nurse managers, directors, and executives from 47 states (n = 1880) working in acute care settings. FINDINGS: Over 50% of respondents intend to leave their current positions within the next 5 years with reasons for leaving differing by type of nurse leader. Retirement was a factor for slightly over 30% of those nurse leaders overall and almost 50% of nurse executives. DISCUSSION: Nurse managers, directors, and executives experience turnover and intent to leave differently. Most frequently, voluntary factors for leaving a position include job dissatisfaction and a desire for promotion and advancement.

Turnover Intention Among Nurses in Nurse Managers, Directors, and Executives: Developing a Tool for Measuring Environmental Factors.

BACKGROUND AND PURPOSE: Turnover among nurse managers, directors, and executives is associated with staff nurse retention and patient outcomes. The purpose of this article is to describe the development of an instrument to evaluate factors associated with intent to leave among these leaders within acute care facilities. METHODS: The Nurse Leader Environment Support Survey (NLESS) was developed and evaluated using exploratory factor analysis and reliability testing (Cronbach's α). Data was obtained as part of a large nationwide electronic survey (N = 1,903). RESULTS: Factors converged into three major themes (organizational culture, professional vulnerability, and workplace relationships) which were consistent across all three leadership groups. Factor subscales exhibited Cronbach's α > .7. CONCLUSIONS: The NLESS is a useful tool in comparing reasons for turnover among nursing leadership groups. Future refinement may prove useful in identifying and clarifying foundational causes of turnover.

Clinical care and therapeutic trials in PLS.

Primary lateral sclerosis (PLS) is an extremely rare central nervous system degenerative disorder characterized by slowly progressive upper motor neuron loss leading to severe limb and bulbar dysfunction and disability. Although not necessarily life-shortening, PLS disease burden is substantial and improved symptomatic treatments are a major unmet need, especially for the often refractory spasticity that is a core feature of the syndrome. In Section 1, we describe clinical care needs and emphasize a highly personalized approach that can be best attained through multidisciplinary management. In Section 2, we describe progress in clinical trials in PLS that includes advances in symptomatic treatment, disease-modifying therapy, and emerging innovative trials.

Lung cancer screening: Practice guidelines and insurance coverage are not enough.

BACKGROUND AND PURPOSE: Low-dose computed tomography (LDCT) is expected to increase early detection of lung cancer and improve survival. The growth in the number of advanced nurse practitioners (NPs) in primary care settings increases the likelihood that an NP will serve as a patient's provider. This study's purpose was to examine knowledge, attitudes, and practices regarding LDCT among NPs who work in primary care settings. METHODS: An explanatory, sequential, mixed-method design used a 32-item questionnaire, followed by a semi-structured telephone interview. The development of the survey and interview questions were guided by a conceptual framework representing a temporal sequence for behavior change and potential barriers to guideline adherence. CONCLUSIONS: Nurse practitioners believe that shared decision making with their high-risk patients about LDCT is within their scope of their practice. Working in time-constrained primary care settings, NPs have limited abilities to improve the uptake of LDCT. Substantial patient barriers exist that deter follow through on providers' recommendation. Disseminating guidelines and authorizing health insurance reimbursement is insufficient. IMPLICATIONS FOR PRACTICE: Research is needed that investigates the screening process so that barriers can be closely studied. Culture change is needed where early detection has greater value for insurers, providers, and patients.

Decreasing the Time to Insulin Administration for Hospitalized Patients With Cystic Fibrosis-Related Diabetes.

OBJECTIVES: Children with cystic fibrosis-related diabetes (CFRD) represent a commonly hospitalized pediatric population whose members require insulin for blood glucose (BG) control. The aim of this quality improvement initiative was to increase the proportion of hospitalized patients with CFRD receiving insulin within 30 minutes of a BG check while decreasing severe hypo- and hyperglycemia episodes. METHODS: Quality improvement methodology (gathering a team of stakeholders, identifying metrics, implementing iterative plan-do-study-act cycles and analysis of data over time) was applied in the setting of a cystic fibrosis unit in a tertiary care children's hospital. The percentage of patients with CFRD who received rapid-acting insulin within 30 minutes of a BG check and the rates of hypoglycemia (BG <70 mg/dL) and hyperglycemia (BG >200 mg/dL) were measured. Improvement interventions were focused on efficient communication among patients, nurses and providers; refining carbohydrate calculation; and sharing expectations with patients and caregivers. RESULTS: The proportion of rapid-acting insulin doses given within 30 minutes increased from a baseline mean 40% to a sustained mean of 78%. During active improvement interventions, success rates of 100% were achieved. Hyperglycemic events (BG >200 mg/dL) decreased from 125 events to 85 events per 100 rapid-acting insulin days. Hypoglycemic events (BG <70 mg/dL) remained low at <5 events per 100 rapid-acting insulin days. CONCLUSIONS: Systematic implementation of low-cost interventions successfully resulted in measurable improvement in timely rapid-acting insulin administration for hospitalized patients with CFRD and lower rates of severe hypo- and hyperglycemia on the unit. Future efforts will be directed to increase the reliability of interventions to maintain optimal performance and outcomes.

The Role of the Nurse Executive in Rural Hospital Closure.

Between 2010 and June 2016, 75 rural hospitals closed, and more than 250 more are at risk of closure. Nurse executives need to be prepared for this eventuality. There is a need for formal direction on how to close a highly regulated healthcare facility.

Neuropsychological test performance in soldiers with blast-related mild TBI.

This exploratory study was conducted to increase understanding of neuropsychological test performance in those with blast-related mild traumatic brain injury (mTBI). The two variables of interest for their impact on test performance were presence of mTBI symptoms and history of posttraumatic stress disorder (PTSD). Forty-five soldiers postblast mTBI, 27 with enduring mTBI symptoms and 18 without, completed a series of neuropsychological tests. Seventeen of the 45 met criteria for PTSD. The Paced Auditory Serial Addition Test (Frencham, Fox, & Mayberry, 2005; Spreen & Strauss, 1998) was the primary outcome measure. Two-sided, 2-sample t tests were used to compare scores between groups of interest. Presence of mTBI symptoms did not impact test performance. In addition, no significant differences between soldiers with and without PTSD were identified. Standard neuropsychological assessment may not increase understanding about impairment associated with mTBI symptoms. Further research in this area is indicated.

Traumatic brain injury, posttraumatic stress disorder, and postconcussive symptom reporting among troops returning from iraq.

OBJECTIVES: Analyze the contribution of mild traumatic brain injury (mTBI) and/or posttraumatic stress disorder (PTSD) to the endorsement of postconcussive (PC) symptoms during Post Deployment Health Assessment. Determine whether a combination of mTBI and PTSD was more strongly associated with symptoms than either condition alone. METHODS: Cross-sectional study design where both the exposure, mTBI and/or PTSD, and the outcomes of interest, PC symptoms, were ascertained after return from deployment. Subjects were injured soldiers (n = 1247) from one Fort Carson Brigade Combat Team (n = 3973). MAIN OUTCOME MEASURES: Positive history of PC symptoms. RESULTS: PTSD and mTBI together were more strongly associated with having PC symptoms (adjusted prevalence ratio 6.27; 95% CI: 4.13-9.43) than either mTBI alone (adjusted prevalence ratio = 4.03; 95% CI: 2.67-6.07) or PTSD alone (adjusted prevalence ratio = 2.74; 95% CI: 1.58-4.74) after adjusting for age, gender, education, rank, and Military Occupational Specialty. CONCLUSIONS: In soldiers with histories of physical injury, mTBI and PTSD were independently associated with PC symptom reporting. Those with both conditions were at greater risk for PC symptoms than those with either PTSD, mTBI, or neither. Findings support the importance of continued screening for both conditions with the aim of early identification and intervention.

Head injury as a PTSD predictor among Oklahoma City bombing survivors.

BACKGROUND: The aim of the Oklahoma City (OKC) bombing retrospective review was to investigate the relationship between physical injury, environmental contributors, and psychiatric disorders such as posttraumatic stress disorder (PTSD) in an event-based, matched design study focused on injury. METHODS: The 182 selected participants were a random subset of the 1,092 direct survivors from the OKC bombing. Only 124 of these 182 cases had a full complement of medical/clinical data in the OKC database. These 124 cases were assessed to explore relationships among PTSD diagnoses, levels of blast exposure, and physical injuries. Associations among variables were statistically tested using contingency analysis and logistic regression. RESULTS: Comparison of the PTSD cases to symptoms/diagnoses reported in the medical records reveals a statistically significant association between PTSD and head/brain injuries associated with head acceleration. PTSD was not highly correlated with other injuries. Although blast pressure and impulse were highly correlated with head injuries, the correlation with PTSD was not statistically significant. Thus, a correlation between blast pressure and PTSD may exist, but higher fidelity pressure calculations are required to elucidate this potential relationship. CONCLUSIONS: This study provides clear evidence that head injury is associated with subsequent PTSD, giving caregivers' information on what physical injuries may suggest the development of psychologic disorders to aid them in developing a profile for the identification of future survivors of terrorist attacks and Warfighters with brain injuries and potential PTSD.

Case report of a soldier with primary blast brain injury.

Primary blast injury of the central nervous system is described in a service-member exposed to a large ordinance explosion. Neuroimaging abnormalities are described together with normalization of the fractional anisotrophy on diffusion tensor imaging after follow-up imaging studies.

Traumatic brain injury screening: preliminary findings in a US Army Brigade Combat Team.

OBJECTIVES: The objective of this article is to report the proportion of soldiers in a Brigade Combat Team (BCT) with at least 1 clinician-confirmed deployment-acquired traumatic brain injury (TBI) and to describe the nature of sequelae associated with such injuries. PARTICIPANTS: Members of an Army unit (n = 3973) that served in Iraq were screened for history of TBI. Those reporting an injury (n = 1292) were further evaluated regarding sequelae. Of the injuries suffered, 907 were TBIs and 385 were other types of injury. The majority of TBIs sustained were mild. METHODS: Postdeployment, responses to the Warrior Administered Retrospective Casualty Assessment Tool (WARCAT) facilitated clinical interviews regarding injury history and associated somatic (ie, headache, dizziness, balance) and neuropsychiatric symptoms (ie, irritability, memory). Traumatic brain injury diagnosis was based on the American Congress of Rehabilitation Medicine mild TBI criteria, which requires an injury event followed by an alteration in consciousness. RESULTS: A total of 22.8% of soldiers in a BCT returning from Iraq had clinician-confirmed TBI. Those with TBI were significantly more likely to recall somatic and/or neuropsychiatric symptoms immediately postinjury and endorse symptoms at follow-up than were soldiers without a history of deployment-related TBI. A total of 33.4% of soldiers with TBI reported 3 or more symptoms immediately postinjury compared with 7.5% at postdeployment. For soldiers injured without TBI, rates of 3 or more symptoms postinjury and postdeployment were 2.9% and 2.3%, respectively. In those with TBI, headache and dizziness were most frequently reported postinjury, with irritability and memory problems persisting and presenting over time. CONCLUSION: Following deployment to Iraq, a clinician-confirmed TBI history was identified in 22.8% of soldiers from a BCT. Those with TBI were significantly more likely to report postinjury and postdeployment somatic and/or neuropsychiatric symptoms than those without this injury history. Overall, symptom endorsement decreased over time.

Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

OBJECTIVES: To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. DESIGN: Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. SETTING: Four Veterans Administration acute inpatient TBI rehabilitation programs. PARTICIPANTS: Adult veterans or active duty military service members (N=360) with moderate to severe TBI. INTERVENTIONS: One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. MAIN OUTCOME MEASURES: The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. RESULTS: The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. CONCLUSIONS: Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.

Reference data from the automated Neuropsychological Assessment Metrics for use in traumatic brain injury in an active duty military sample.

The current study examined the performance of active duty soldiers on the Automated Neuropsychological Assessment Metrics (ANAM) traumatic brain injury test battery, to expand the reference data for use in military settings. The effects of age and gender on cognitive performance also were explored. The ANAM traumatic brain injury battery, consisting of six performance tests and two subjective scales, was administered to a sample of healthy active duty soldiers (N = 5,247) as part of a concussion surveillance program. Performance means and SDs, stratified according to age and gender, are reported as reference data. In addition, the impact of age and gender on performance measures was analyzed. Because ANAM is rapidly being adopted for use in many military medical and research applications, the establishment of these reference values is invaluable, particularly for assisting with rapid accurate evaluation and treatment in clinical settings.

Improving identification of traumatic brain injury after nonmilitary bomb blasts.

OBJECTIVE: To improve identification of traumatic brain injury (TBI) in survivors of nonmilitary bomb blasts during the acute care phase. METHODS: The Centers for Disease Control and Prevention convened a meeting of experts in TBI, emergency medicine, and disaster response to review the recent literature and make recommendations. RESULTS: Seven key recommendations were proposed: (1) increase TBI awareness among medical professionals; (2) encourage use of standard definitions and consistent terminology; (3) improve screening methods for TBI in the acute care setting; (4) clarify the distinction between TBI and acute stress disorder; (5) encourage routine screening of hospitalized trauma patients for TBI; (6) improve identification of nonhospitalized TBI patients; and (7) integrate the appropriate level of TBI identification into all-hazards mass casualty preparedness. CONCLUSIONS: By adopting these recommendations, the United States could be better prepared to identify and respond to TBI following future bombing events.

Traumatic brain injuries sustained in the Afghanistan and Iraq wars.

UNLABELLED: Because these injuries can go unrecognized, nurses stateside need to know how to recognize possible cases and how to help. OVERVIEW: When traumatic brain injury (TBI) occurs simultaneously with more obviously life-threatening wounds, it may go unrecognized. Civilians and military personnel working in or near combat zones are at risk for this injury. Blast-related and closed-head injuries, rather than penetrating injuries, constitute the majority of TBIs in this population. The authors describe the experiences of the Defense and Veterans Brain Injury Center team at Walter Reed Army Medical Center in Washington, DC, and present a composite case to illustrate the nurse's role in the assessment and care of the TBI patient.

Traumatic brain injury risk while parachuting: comparison of the personnel armor system for ground troops helmet and the advanced combat helmet.

Military paratroopers are inherently at risk for a variety of injuries when they jump, including traumatic brain injuries (TBIs). U.S. Army paratroopers rely on their ballistic helmets for protection against TBIs when jumping. Currently, two different helmets are available to Army paratroopers, that is, the personnel armor system for ground troops helmet and the advanced combat helmet. This study compared the incidence of self-reported, jump-related TBIs in a small sample of paratroopers (N = 585) using each type of helmet. Data were obtained from surveys of soldiers at Fort Bragg, North Carolina. The overall relative risk of sustaining a TBI while jumping was 2.3 times (95% confidence interval, 1.3-4.3) higher for personnel armor system for ground troops helmet users. Most of the increase in risk was accounted for by the most-minor TBIs (American Academy of Neurology grade 1 or 2 concussion).

Screening for traumatic brain injury in troops returning from deployment in Afghanistan and Iraq: initial investigation of the usefulness of a short screening tool for traumatic brain injury.

OBJECTIVE: Preliminary assessment of a new instrument, the Brief Traumatic Brain Injury Screen (BTBIS). DESIGN: Cross-sectional study of 596 soldiers returning from Iraq and/or Afghanistan, comparing the consistency of their reports of traumatic brain injury (TBI) across instruments with similar TBI questions, and in a brief follow-up interview. SETTING: Military base. MEASURES: Self-reported probable TBI on the BTBIS and on 2 longer questionnaires, and a brief follow-up interview. RESULTS: Self-reports of probable TBI were higher on the BTBIS, than on the longer instruments. Participants who screened positive on the BTBIS generally provided consistent information about probable TBI in the follow-up interview. CONCLUSIONS: In this initial study, the BTBIS demonstrated promise as part of a triage process in mass casualty situations, permitting individuals with probable TBI to self-report injury and continued symptoms. Further study, including full validation and reliability assessment, is warranted and required before these screening tools can be fully evaluated.