Professional judgments about advance care planning with community-dwelling consumers.

CONTEXT: There is limited research on how community-based long-term care (CBLTC) providers' personal characteristics and attitudes affect their decisions to initiate advance care planning (ACP) conversations with consumers. OBJECTIVES: To examine judgments by CBLTC providers as to whether a consumer was in need of ACP and to compare the relative influence of situational features of the consumer with the influence of personal characteristics of the CBLTC provider. METHODS: Factorial surveys with vignettes with randomly assigned situational features of a hypothetical consumer were obtained from 182 CBLTC providers at three Area Agencies on Aging located in the Midwestern U.S. Measures included the consumer's situational features, such as demographics, diagnosis, pain level, level of functioning, and caregiver involvement. Personal characteristics of the CBLTC provider included demographics, discipline, past experience with ACP, and attitudes toward ACP. RESULTS: Hierarchical linear models indicated that most variability in ACP decisions was the result of differences among CBLTC providers (64%) rather than consumers' situational features. Positive decisions to discuss ACP were associated with consumers who needed assistance with legal issues and had a cancer diagnosis; these variables explained 8% of the vignette level variance. Significant personal characteristics of the CBLTC provider included a nursing background, less direct contact with consumers, past experience with ACP, and positive attitudes toward ACP; these variables explained 41% of the person-level variance. CONCLUSION: This study shows the lack of normative consensus about ACP and highlights the need for consistent educational programs regarding the role of the CBLTC provider in the ACP process.

Indicators of acute deterioration in adult patients nursed in acute wards: a factorial survey.

OBJECTIVES: The primary objective of the study was to determine which professional, situational and patient characteristics predict nurses' judgements of patient acuity and likelihood of referral for further review. A secondary aim was to test the feasibility of the factorial survey method in an acute area. BACKGROUND: There is increasing recognition that indicators of deterioration in acutely unwell adults are being missed and referrals delayed. The reasons for this are unclear and require exploration. Assessing nurses' clinical decision-making or judgements in a 'real-world' situation is problematic. DESIGN: The study used a factorial survey design where participants completed randomly generated paper-based vignettes on one occasion. METHODS: The dependent variables were assessment of patient acuity and likelihood of referral. Independent variables consisted of a number of patient characteristics, i.e. heart rate, blood pressure, nurse characteristics, i.e. clinical experience, and situational characteristics i.e. staffing. SETTING AND PARTICIPANTS: Participants were registered nurses working in acute areas excluding intensive care and theatre. Ninety-nine participants responded resulting in 1940 completed vignettes. RESULTS: An early warning score was the single most significant predictor of referral behaviour accounting for 9.6% of the variance. When this was not included in the vignette, nurses used physiological characteristics e.g. respiratory rate, urine output, neurological status. These explained 12% of the variance in the model predicting assessment of patient acuity and 9.4% or the variance predicting likelihood of referral. CONCLUSIONS: When given a series of vignettes, nurses appear to use appropriate physiological parameters to make decisions about patient acuity and need for referral. Our results support the use of early warning scoring systems. Education and professional development should focus more on developing and maximising clinical experience and expertise rather than knowledge acquisition alone. A factorial survey method is feasible to explore decision-making in this area. RELEVANCE TO PRACTICE: This study has several implications for practice. The emergence of an early warning scoring system as a significant individual predictor supports the use of such systems. However, the small amount of explained variance suggests that there are other influences on nurses' assessment of patient acuity and referral decisions that were not measured by the factorial survey approach. Educational provision might focus not just on knowledge acquisition but include educational delivery methods that incorporate or mimic real-ward settings.

Effect of situational and clinical variables on the likelihood of physicians ordering physical restraints.

OBJECTIVES: To model clinical and situational variables that may affect likelihood of physicians to order physical restraints. DESIGN: Cross-sectional, factorial survey. SETTING: One academic medical center. PARTICIPANTS: One hundred eighty-nine physicians: interns in all specialty practices and resident and attending physicians in departments of surgery, general internal medicine, family practice, emergency medicine, and psychiatry. MEASUREMENTS: Vignettes were randomly generated using different values of six situational and eight clinical variables. Each physician received five unique vignettes for which they indicated their likelihood to order restraint on a 10-point scale. RESULTS: Nine hundred six distinct vignettes were completed. The mean likelihood that physicians would order restraint was 3.9 + or - 3.0 (range 0 (not at all) to 9 (absolutely)). Exploratory regression analysis on physician's likelihood to restrain with independent variables of secondary diagnosis, patient age, sex, time of day, familiarity and trust with requesting nurse, patient behavior, vital signs, oxygen saturation, and dehydration explained 12.5% of variance (F=5.43, P<.001). Independent factors of unsafe patient behavior (P=.001) and secondary diagnosis of dementia (P=.06) resulted in greater likelihood of ordering restraint, whereas lack of trust in the judgment of the reporting nurse (P=.008) resulted in lower likelihood of ordering restraints. CONCLUSION: Patients' clinical status had less influence on physicians' likelihood of ordering physical restraints than the working relationship with the requesting nurse or the patient's behavior. Interdisciplinary team approaches with active physician input for nonrestraint strategies in the management of patient behavior is emphasized to minimize restraint use.

Likelihood of ordering physical restraints: influence of physician characteristics.

OBJECTIVES: To determine physician knowledge regarding restraint regulations and effectiveness and effect of physician characteristics on likelihood of ordering restraints. DESIGN: Cross-sectional, factorial research survey. SETTING: Academic medical center. PARTICIPANTS: Interns in all specialties; residents in internal medicine, family practice, emergency medicine, psychiatry, and surgery; and attending faculty at an academic medical center. MEASUREMENTS: Survey of demographic, professional, and restraint knowledge items and for each of five distinct vignettes; physician ratings of probability of patient harm and likelihood of ordering restraints. For each, physicians rated probability of patient harm and likelihood of ordering restraint. RESULTS: One hundred eighty-nine of 246 (77%) surveys were returned. More than half (58%) were men; the median age was 30 (range 25-63), median years experience was 2 (range 0-33), and 60% were U.S. medical school graduates. Mean knowledge score was 68.4% (range 27-100%). Mean likelihood of ordering restraints ranged from 0.6 (not likely) to 9 (absolutely) (overall mean 3.9 +/- 2.2). Exploratory hierarchical regression on mean likelihood of ordering restraint (outcome) with independent variables of physician age and sex (Step 1), years experience and physician level (Step 2), specialization (Step 3), restraint knowledge (Step 4), and judgment of harm (Step 5) explained 31.9% of the variance (F=7.19, degrees of freedom 13,159, P<.001). Higher appraisal of harm (P<.001), less knowledge regarding restraint (P=.03), and male sex (P=.005) were unique indicators for the likelihood of ordering restraints. Psychiatry (P=.03) or internal medicine physicians (P=.05) were less likely to order restraints. CONCLUSION: Physician characteristics and lack of restraint knowledge are associated with likelihood of ordering restraints. Results will guide medical education initiatives to reduce restraint rates.

Undergraduate drinking and academic performance: a prospective investigation with objective measures.

OBJECTIVE: Findings from previous prospective research suggest the association between alcohol use and undergraduate academic performance is negligible. This study was designed to address weaknesses of the past research by relying on objective measures of both drinking and academic performance. METHOD: A prospective study was conducted with repeated measures of exposure to alcohol linked to institutional academic records. Alcohol data were collected in residence halls at a nonselective, midwestern, public university in the United States. A total of 659 first- and second-year undergraduate students were tracked over the course of 15-week semesters. RESULTS: A statistically significant negative association with semester academic performance was found for different alcohol indicators: frequency of breath alcohol concentration (BrAC) above .08, mean BrAC, standard deviation, and maximum BrAC recorded. These associations remained statistically significant when controlled for sociodemographic variables and individual level confounders, but the effect sizes were relatively small with a contribution to explained variance of less than 1%. When additionally adjusted for residence hall building, all alcohol indicators no longer reached statistical significance (p > or = .05). CONCLUSIONS: Consistent with past prospective research, the magnitude of the association between undergraduate alcohol use and academic performance is small when the effects of high school academic aptitude and performance are accounted for in multivariable analyses. This is the first study to find that living environment may have a robust effect on the academic achievement of undergraduates. Future research should examine more closely the relation between residence and academic performance and the role that alcohol use may play in creating residential environments.

Oncology nurses' responses to patient-initiated humor.

The purpose of this study was to investigate potential predictors (patient variables) that would result in oncology nurses' recognition of and response to patient-initiated humor (PIH). Participants included 47 nurses of an 80-member Oncology Nursing Society chapter (57% response rate), which yielded 232 usable vignettes. Previously collected qualitative data of patient-nurse conversations were used to construct simulated vignettes using a factorial survey design. Five randomly generated vignettes containing 14 independent patient variables with different levels were used to examine nurses' identification of PIH. The unit of analysis in factorial survey is the vignette. Multiple regression and analysis of variance were used to analyze variables in each vignette. Two of 14 variables were significant: "verbal" (actual words the patient spoke) and "intonation" (inflection, pitch, or manner of speech). A 2x2 factorial analysis of variance using verbal and intonation variables revealed that oncology nurses' recognition of and response to PIH were primarily predicted by patients' verbal words. This study distinguishes PIH as a patient-initiated behavior rather than nurse-driven interventions and is a new venue for research in patient-nurse interactions. Results demonstrate the central role of patient-centered communication to inform clinical practice about patient preferences, individualized integration/participation in their care, and a knowledge base of patient-centered behaviors for outcomes of personal importance.

DXA, health beliefs, and osteoporosis prevention behaviors.

OBJECTIVE: This experimental longitudinal study was designed to examine the relationship between having a bone density through dual energy X ray absorptiometry (DXA) and osteoporosis preventing behaviors (OPB) among healthy postmenopausal women. METHODS: Subjects were 203 healthy community-based women 50-65 years of age. Mediating variables were general knowledge of osteoporosis and revised health belief model variables. Treatment group women (n = 101) had a DXA screen and control group women (n = 102) did not. Study questionnaires were completed at three time points; initially and at 6 months and 12 months. RESULTS: Repeated measures ANOVA revealed treatment group women scored significantly higher on perceived susceptibility and calcium intake. Wilks's Lambda F revealed a significant difference in use of osteoporosis preventing medications. DISCUSSION: Personal knowledge gained from DXAs increased perceived susceptibility to osteoporosis, calcium intake, and use of osteoporosis preventing medications and appears to be an effective intervention in promoting OPB in younger postmenopausal women.

An improved methodology for advancing nursing research: factorial surveys.

Clinical judgments and decisions are an integral component of nurse work and nurses are increasingly being challenged to account for their judgments and decisions. Nursing research is needed to help explain judgment and decision making in nursing, but most research in this area is almost exclusively characterized by descriptive studies. This article describes the use of the factorial survey method, which combines the explanatory power of a factorial experiment with the benefits of a sample survey. This hybrid technique is an excellent method for studying judgments and decisions across settings, roles, disciplines, and countries. This article outlines the steps of the method and demonstrates its applicability with an exemplar from a study across nurses from 3 countries.