COVID-19 and the Impact on Delirium Care of Hospitalized Older Adults: A Qualitative Study.

BACKGROUND: Older adult patients with COVID-19 and delirium experience higher rates of adverse outcomes. Early recognition of at-risk patients and implementation of management strategies improve outcomes, though understanding barriers to acute care nurses implementing these strategies is limited. PURPOSE: This study's purpose was to understand the experiences of acute care nurses providing care to older adults with COVID-19 and delirium. Experiences explored included assessment, nursing management interventions, and barriers to care. METHODS: Purposive sampling to recruit nurses for semistructured focus groups was performed, and thematic analysis was generated by 4 members of the research team. RESULTS: Twenty-one nurses participated in focus groups. Thematic analysis revealed themes of increased patient social isolation, barriers to delirium assessment and prevention, increased staff demands, and stressful work environments. CONCLUSION: Rich findings reveal the profound impact of the pandemic on assessment for delirium and implementation of strategies for prevention and management in older adult patients.

National Association of Clinical Nurse Specialists Affiliate Support for Professional Growth of Clinical Nurse Specialist Students.

PURPOSE/OBJECTIVES: The purpose of this article was to describe how a National Association of Clinical Nurse Specialists affiliate partnered with a local university to engage clinical nurse specialist (CNS) students, enhance its mission and activities, and create succession planning opportunities, while providing mentorship and professional growth opportunities. DESCRIPTION OF THE PROJECT: Academic preparation of CNS students endeavors to instill professionalism. A 3-pronged partnership incorporating the inclusion of a student liaison on the board, presentation of student clinical work at the affiliate's annual conference, and development of a student scholarship was implemented. OUTCOMES: Membership in professional nursing organizations for a CNS student provides exposure and access to professional development resources, socialization to the role, rewarding networking opportunities with peers and colleagues, and leadership development. Anecdotal feedback demonstrated a better understanding of the CNS role, increased confidence, and enhanced knowledge on topics such as legislative advocacy as well as experiences of sharing clinical challenges with CNS colleagues. CONCLUSION: Partnership with the local university allowed the affiliate to maintain the influx of new CNSs, which sustains membership, nurtures the growth of new CNSs, and ensures the influx of new ideas. Furthermore, membership in professional nursing organizations is imperative to address the opportunities that exist in healthcare.

Innovative Strategies to Facilitate Newly Licensed Nurse Transition to Practice During the COVID-19 Pandemic: A Quality Improvement Project.

As healthcare facilities transition from initial phases of the COVID-19 pandemic, it is imperative to consider innovative strategies to overcome instructional challenges presented to nursing schools in order to maintain a competent workforce amidst nursing shortages and increasing patient volumes and complexity. Nursing professional development practitioners will play a pivotal role in revitalizing transition-to-practice programs to meet the demands of the new workforce. This article details an academia-practice initiative for newly licensed nurses who enter practice during the pandemic.

Clinical Nurse Specialists Using Evidence-Based Practice to Prevent Falls.

PURPOSE/OBJECTIVES: The purpose of this quality improvement project was to reduce inpatient falls and falls with injury by implementing the Hester Davis Fall Program, a comprehensive, evidence-based prevention program, with the leadership of clinical nurse specialists. DESCRIPTION OF THE PROJECT/PROGRAM: The Plan-Do-Study-Act model was utilized to implement the program at 2 adult acute care facilities. Clinical nurse specialists collaborated with nurse managers to guide planning, implementation, and evaluation of patient outcomes. Routine meetings with Hester Davis sustainability coaches and access to data analytic dashboards provided visibility of audit data, allowing for the intentional selection of targeted strategies to improve risk assessment scoring and implementation of appropriate interventions. OUTCOME: Although both facilities demonstrated overall favorable trends in fall rates, one facility demonstrated rates less than the National Database of Nursing Quality Indicators mean. In the 9 months following implementation, total falls for both facilities decreased from 744 to 692 for the same period in the previous year, resulting in estimated cost-savings of $202 176 to $491 400. CONCLUSION: Clinical nurse specialists play a key role in the successful implementation of evidence-based programs. As organizations look to improve quality measures, it is vital that senior nurse leaders ensure the availability of appropriate resources including the identification of individuals with the appropriate skill set to lead quality improvement.

A Statewide Survey to Understand Barriers to Utilization of the Medical Orders for Scope of Treatment Form among Emergency Medical Service Providers.

Background: Advance care planning allows communication of end-of-life goals. The Kentucky medical orders for scope of treatment (MOST) form became a legal medical order in 2015. The Kentucky MOST Coalition formed in 2017 to implement MOST. Objectives: In 2019, Kentucky MOST Coalition members developed a survey to determine emergency medical services (EMS) providers' understanding and barriers to utilization of MOST. Design: The Kentucky Board of EMS e-mailed the survey to its members. The survey was voluntarily completed by EMS providers. The data were analyzed by Kentucky MOST Coalition. Results: A majority of participants had never (72%) encountered a MOST form. In addition, 69% said they had never received MOST training. However, 60% knew that "the MOST form is a physician order and shall be followed in all settings." Conclusions: The majority of the EMS providers knew basic information about MOST. However, accessibility and education were barriers to utilization of MOST. EMS providers need continuing education. Education surrounding MOST can help to ensure a person-centered approach.

Faculty perceptions of the impact of the COVID-19 pandemic on new graduate nurses' transition to practice: A qualitative study.

BACKGROUND: The COVID-19 pandemic disrupted nursing education worldwide. Most studies have focused on how the pandemic affected students. With an alarming workforce shortage, a better understanding of the pandemic's impact on new nurses is vital to proactively develop strategies to promote success of the profession's newest members. PURPOSE: This study explored faculty perceptions of the pandemic's impact on new nurses' practice preparedness and recommendations for promoting effective transition to practice. METHODS: Using an exploratory-descriptive qualitative approach and convenience sampling, 116 nurse faculty from across North Carolina, United States responded to open-ended questions within an electronic survey. Data were analyzed with thematic analysis. RESULTS: Four themes emerged: 1) Less Hands-On, 2) Transition-to-Practice Opportunities, 3) Key Role of Preceptors, and 4) Provide Additional Support. CONCLUSIONS: Findings provide strategies clinical nurses and leaders can implement to meet the needs of new nurses entering professional practice during the ongoing pandemic. Due to less hands-on learning, pandemic graduates may benefit from extended time with a trained preceptor and opportunities to focus on clinical reasoning, managing multiple patients, effective communication, and safe skill performance. Upon entering the clinical environment, pandemic graduates' inexperience may increase the likelihood of transition shock, requiring multi-faceted approaches for providing support.

CLABSI Rounding Team: A Collaborative Approach to Prevention.

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are an ongoing concern in health care, resulting in increased mortality, morbidity, length of stay, and additional costs to hospitals. LOCAL PROBLEM: Despite intermittent improvements in CLABSI rates within our facility, long-term sustainment has been challenging. METHODS: This was a quality improvement project including a collaborative rounding approach supported by specialty nursing roles. INTERVENTIONS: In addition to implementing a variety of evidence-based interventions, the rounding team performed audits to assess performance and created focused education tools to address the identified opportunities within each individual unit. RESULTS: High levels of engagement as evidenced by increased audit completion resulted in CLABSI reductions. However, 2 peaks in CLABSI rates were associated with higher volumes of coronavirus disease (COVID-19) hospitalizations and decreased audits. CONCLUSIONS: Despite challenges correlated with COVID-19, a collaborative rounding team promotes and enhances awareness of prevention methods and a culture of safety.

Improving Self-Efficacy of Patients With a New Ostomy With Written Education Materials: A Quality Improvement Project.

PURPOSE: The purpose of this quality improvement project was to determine if supplementing the current education process for new ostomates with standardized, health literate written education materials which are initiated preoperatively improves patient self-efficacy for management of their new ostomy. DESIGN: A convenience sample of 25 patients undergoing new ostomy placement were selected to receive the written education materials. The project occurred in two outpatient clinics and an 874-bed hospital. METHODS: Preoperative education by wound, ostomy, continence (WOC) nurses in the outpatient clinic was supplemented by the new health literate written education materials, and this education continued during the postoperative period before hospital discharge. Stoma self-efficacy was measured at three timepoints: pre- and posteducation in the outpatient clinic and before discharge from the hospital following surgery. FINDINGS: Mean total self-efficacy scores significantly increased from 27.32 (SD = 12.15, confidence intereval [CI] = 22.30, 32.34) pre-education in the clinic to 39.56 (SD = 9.26, CI = 35.74, 43.38) posteducation in the clinic (P = .000), and further increased to 47.20 (SD = 7.38, CI = 44.14, 50.25) at discharge from the hospital postsurgery (P = .0004). CONCLUSIONS: Initiating education preoperatively and supplementing it with standardized, health literate written education materials improved patients' stoma self-efficacy. By improving self-efficacy, patients may be more effective in self-management of their ostomy and better prepared to care for themselves upon discharge from the hospital to prevent complications and improve outcomes.

Nurse faculty perceptions of readiness for practice among new nurses graduating during the pandemic.

BACKGROUND: The COVID-19 pandemic caused major changes in nursing education, namely a shift to remote learning and significant reduction of clinical practice experience. It is not known how these changes will affect new graduate nurses transitioning to practice. PURPOSE: To provide guidance to transition-to-practice programs, this study quantitatively described and compared nurse faculty perceptions of readiness for practice among students who graduated pre-pandemic and those who will graduate during the pandemic. METHODS: A convenience sample of 116 nurse faculty across North Carolina completed surveys online. Surveys collected information on demographics, professional experience, and teaching changes experienced during the pandemic. The Nursing Practice Readiness Tool was used to measure perceptions of readiness for practice. RESULTS: Nurse faculty reported a wide range of changes due to the pandemic, with limitations in clinical learning prevalent. There was a statistically significant decrease in practice readiness scores for the total scale, six subscales, and all tool items at p < 0.001 for all paired comparisons. CONCLUSIONS: While there was an overall significant decrease in scores for all competency areas, further analysis of the tool subscales and items can provide guidance for clinical nurses working with new graduates and nurse faculty working with continuing students.

COVID-19 Pandemic: Clinical Nurse Specialist Practice Supporting Preparedness in the Spheres of Impact.

PURPOSE/OBJECTIVES: The goal of this article is to describe how a high-functioning clinical nurse specialist (CNS) team rapidly responded to the needs of the patients, nursing staff, and organization as a whole to address the coronavirus disease 2019 (COVID-19) crisis. DESCRIPTION OF THE PROJECT: Using the advanced practice knowledge and skills, each CNS moved effortlessly between the 3 spheres of influence, patient, nursing, and organization, to address the unique needs of the COVID-positive patient, as well as the routinely ill who still needed care during a pandemic. In addition to observing and addressing opportunities at the bedside, the CNS team was essential in the development of plans of care, crisis care standards, and a structure for critical care cross-training. OUTCOMES: Five themes essential to success were identified: a common motivation and goal, collaboration, the importance of communication in utilizing established groups to create rapid change, power of influence, and the availability of a vast number of resources including professional nursing roles. CONCLUSION: Using the expertise of a specially trained team of CNSs, an effective plan was established to ensure safe, optimal care during the COVID-19 pandemic and effectively support frontline nurses.

A Multifaceted Approach to the Prevention of Clostridioides (Clostridium) Difficile.

PURPOSE/OBJECTIVES: The purpose of this project was to design and implement a sustainable program to reduce hospital-acquired cases of Clostridioides difficile. DESCRIPTION OF THE PROJECT: Experiencing higher rates in a large, academic medical center, hospital leaders were assembled. The overall facility rate was 6.9% in 2014 with a first quarter rate of 8.4% in 2015. Individual unit rates were as high as 19.8%. A team of key stakeholders was assembled to plan, execute, and reevaluate targeted solutions. Strategies implemented were an innovative, automated screening tool, an evidence-based prevention bundle; and staff education. OUTCOMES: A facility-wide C difficile prevention program was implemented with a sustained decrease in rates observed from 8.4% in the first quarter of 2015 to 6.0% in the fourth quarter of 2017. The standardized infection ratio ranged from 0.541 to 0.889, consistently below the national mean. CONCLUSION: Clostridioides difficile is a leading cause of hospital-associated diarrhea and a tremendous burden on healthcare systems increasing morbidity, mortality, and financial strain. A multidisciplinary, multifaceted approach was critical to ensure early detection, reduce risk of transmission, and decrease overall rates.

A microbiological study to investigate the carriage and transmission-potential of Clostridium difficile spores on single-use and reusable sharps containers.

BACKGROUND: A 2015 study matching use of disposable and reusable sharps containers (DSCs, RSCs) with Clostridium difficile infection (CDI) incidence found a decreased incidence with DSCs. We conducted microbiologic samplings and examined the literature and disease-transmission principles to evaluate the scientific feasibility of such an association. METHODS: (i) 197 RSCs were sampled for C. difficile at processing facilities; (ii) RSCs were challenged with high C. difficile densities to evaluate efficacy of automated decontamination; and (iii) 50 RSCs and 50 DSCs were sampled in CDI patient rooms in 7 hospitals. Results were coupled with epidemiologic studies, clinical requirements, and chain-of-infection principles, and tests of evidence of disease transmission were applied. RESULTS: C. difficile spores were found on 9 of 197 (4.6%) RSCs prior to processing. Processing completely removed C. difficile. In CDI patient rooms, 4 of 50 RSCs (8.0%) and 8 of 50 DSCs (16.0%) had sub-infective counts of C. difficile (P = .27). DSCs were in permanent wall cabinets; RSCs were removed and decontaminated frequently. CONCLUSION: With C. difficile bioburden being sub-infective on both DSCs and RSCs, sharps containers being no-touch, and glove removal required after sharps disposal, we found 2 links in the chain of infection to be broken and 5 of 7 tests of evidence to be unmet. We conclude that sharps containers pose no risk of C. difficile transmission.

Antibodies specific for Epstein-Barr virus nuclear antigen-1 cross-react with human heterogeneous nuclear ribonucleoprotein L.

Epstein-Barr virus (EBV) is associated with multiple sclerosis (MS), and antibodies to the EBV nuclear antigen-1 (EBNA-1) are consistently increased in MS patients. The hypothesis of this study is that anti-EBNA-1 antibodies cross-react with a self antigen in MS patients. We affinity purified anti-EBNA-1 antibodies from human plasma, used the anti-EBNA-1 to immunoprecipitate antigens from human brain, and identified bound antigens with mass spectrometry. Anti-EBNA-1 consistently bound heterogeneous nuclear ribonucleoprotein L (HNRNPL). We expressed both the long and short isoforms of this protein, and verified with Western blots and ELISA that the long isoform cross-reacts with EBNA-1. Immunohistochemistry demonstrated that anti-EBNA-1 bound to an antigen in the nucleus of cultured rat central nervous system cells. ELISA demonstrated the presence of antibodies to HNRNPL in the plasma of both healthy controls and MS patients, but anti-HNRNPL was not increased in MS patients. We conclude that HNRNPL is an autoantigen which cross-reacts with EBNA-1. The relevance of this autoantigen to MS and other autoimmune diseases remains to be investigated.

Morphological evaluation of MRC-5 fibroblasts after stimulation with static magnetic field and pulsating electromagnetic field.

The quality of tissue repair and the speed with which that repair can be accomplished are the two major variables in the healing of any injury. Today, magnetic field exposure to traumatized areas has shown to be a promising tool in the healing process. The exact mode of action by which radiating and unchanging magnetic fields still has to be elucidated. The objective of this study was to evaluate the morphology of MRC-5 fibro-blasts after stimulation with static and pulsating magnetic fields. Under sterile environment, a total of 24 wells were loaded with 50,000 MRC-5 cells each and further divided into three groups. Groups 1 and 2 were exposed to magnetic fields, static and pulsating respectively. Group 3 wells were unexposed and served as the control group. The cells were monitored at 0, 24, 48, and 72 hours and representative views were captured using digital analysis techniques. The live cells were screened for cellular mobility, cell distribution, and cellular morphology (size, shape, lysis, and background). After 72 hours, the supernatants and cells of all three groups were collected and MDA analysis was performed to determine possible cellular damage. Group 1 cells continued to grow at a reasonable rate, but there was substantial cell membrane damage (high MDA levels, p < 0.05). Group 2 cells appeared to be very stressed under these conditions especially at the initial phase (24 hours). In conclusion, the use of pulsating magnetic stimulation can be beneficial in the healing process of soft tissues.