Healthcare Awareness Profile Interview: Development of a new evidence-based brief clinical tool to assess awareness in people with dementia.

People with dementia vary in awareness of difficulties. Evaluating awareness could facilitate personalized care. However, current research measures are unsuitable for practical clinical application. We aimed to develop a brief multidimensional awareness interview for clinical use. Informed by available evidence about awareness of dementia, items suitable for both in-person and remote administration were modified from validated measures or developed for clinical application. The interview was administered via telephone or videoconference to 31 community-dwelling people with mild-to-moderate dementia. An informant completed a corresponding questionnaire. A multidimensional profile of awareness was created using self-report of symptoms, and discrepancies between self-rating and either informant rating or objective memory task performance. Feedback from participants and informants and discussions with clinical advisory and patient and public involvement groups helped finalize the interview. Remote administration was straightforward taking on average under 11 min. Awareness profiles showed a spectrum of awareness across domains. Feedback indicated that the items were acceptable and understandable. Certain aspects could be mildly upsetting where current difficulties were highlighted. Subject to further validation, the Healthcare Awareness Profile Interview (HAPI) shows potential as an evidence-based brief clinical tool for assessing awareness in people with mild-to-moderate dementia.

Dyadic influences on awareness of condition in people with dementia: findings from the IDEAL cohort.

Introduction: The discrepancy between caregiver-ratings and self-ratings of abilities is commonly used to assess awareness in people with dementia. We investigated the contribution of caregiver and dyadic characteristics to the difference in perspective between caregiver-informants and people with dementia about difficulties experienced, when considering awareness of condition. Methods: We conducted exploratory cross-sectional analyses using data from the IDEAL cohort. Participants were 1,038 community-dwelling people with mild-to-moderate dementia, and coresident spouse/partner caregivers. The Representations and Adjustment to Dementia Index (RADIX) checklist reporting difficulties commonly experienced in dementia was completed by 960 caregiver-informants and 989 people with dementia. Difference in scores was calculated for 916 dyads. Demographic information, cognition, informant-rated functional ability and neuropsychiatric symptoms were recorded for the person with dementia. Self-reported data were collected on mood, comorbidity, religion, importance of religion, relationship quality, and caregiver stress. Results: For most dyads, caregivers reported more RADIX difficulties than people with dementia. Caregiver RADIX ratings were more closely associated with informant-rated functional ability and neuropsychiatric symptoms than with cognition. More RADIX difficulties and higher stress were reported by female caregivers. Greater RADIX difference was associated with more caregiver stress, and older age but less depression in people with dementia. Conclusion: Few dyadic characteristics were important, but caregiver stress was higher where caregivers reported more RADIX difficulties and/or the difference in perspective was greater, whereas partners with dementia reported better mood. In addition to offering information about awareness of condition, the caregiver rating and difference in perspectives could indicate where more support is needed.

Original Research: Exploring Frontline Nurses' Self-Perceived Levels of QI Engagement and QI Competence.

BACKGROUND AND PURPOSE: Nurse engagement in quality improvement (QI) is critical in the delivery of safe high-quality care, yet few studies have evaluated frontline nurses in this area. The purpose of this study was to identify and compare levels of self-reported QI engagement and QI competence among frontline nurses and nurse leaders. METHODS: This study used a cross-sectional descriptive design. A convenience sample of frontline nurses (bedside RNs and advanced practice nurses) and nurse leaders from acute and ambulatory care sites completed the Nursing Quality Improvement in Practice (NQuIP) tool, which measures engagement and competence (knowledge, skills, and attitudes) in QI. RESULTS: Data from 6,351 surveys completed by frontline nurses and nurse leaders representing 66 sites nationwide were analyzed. Only 52.5% of all respondents reported participating in QI. Knowledge scores were relatively high, while skills scores-especially those related to using QI tools-were low. Overall attitudes toward QI were positive. Nurse leaders scored significantly higher in engagement and competence than the frontline nurses they supervise. CONCLUSIONS: The study findings indicate that nurse engagement in QI is limited. Although nurses' knowledge levels appear to be high, their limited competency in QI-related skills may contribute to low QI engagement. Leaders must make efforts to increase nurse engagement in order to attain high-quality outcomes. Using the NQuIP tool will allow leaders to evaluate nurses' self-perceived QI competence and engagement, which will aid in identifying target areas and developing effective strategies for improvement.

Predictors of Awareness of Functional Ability in People with Dementia: The Contribution of Personality, Cognition, and Neuropsychiatric Symptoms - Findings from the IDEAL Program.

INTRODUCTION: Discrepancy scores reflecting the difference between parallel ratings made by people living with dementia (PwD) in the mild-to-moderate stages and by their informants provide a way to investigate awareness of functional ability in relation to activities of daily living (ADL). METHODS: Two measures of ADL (Functional Activities Questionnaire; Dependence Scale) were completed by 1,227 PwD and their informants in the IDEAL cohort study baseline assessment. Self-rated and informant-rated scores were used to calculate discrepancies, which were used as an indicator of awareness of functional ability. Smaller discrepancy scores were considered to reflect greater awareness on the part of PwD. PwD completed questionnaires on depression, personality, comorbidities, neuropsychiatric symptoms, and completed a measure of cognition. Informants provided ratings of stress. Univariable and multiple regressions were used to investigate factors related to ADL discrepancy. RESULTS: A similar pattern of associations were found for both ADL discrepancy scores. Smaller discrepancy scores were associated with higher levels of depression, higher neuroticism, fewer neuropsychiatric symptoms, higher comorbidity, lower carer stress, and receipt of less than 1 hour of care per day from the informant. DISCUSSION/CONCLUSION: There was a clear pattern of factors that were associated with greater awareness for both measures of functional ability. These factors associated with smaller discrepancy scores could be used to identify PwD who might benefit from targeted interventions to support their independence.

Changes in awareness of condition in people with mild-to-moderate dementia: Longitudinal findings from the IDEAL cohort.

OBJECTIVES: Awareness of difficulties shown by people with dementia is known to vary, but few studies have explored changes in awareness over time. Investigating this could further the understanding of surrounding concepts and reasons for impaired awareness. Recognising emerging or diminishing awareness could facilitate discussions about diagnosis and appropriate post-diagnostic support. METHODS: Using longitudinal data from the Improving the experience of Dementia and Enhancing Active Life (IDEAL) cohort, awareness in community-dwelling people with mild-to-moderate dementia was assessed at three timepoints over 2 years. A validated checklist was used to evaluate awareness of difficulties associated with dementia. We examined changes in awareness for people with low awareness at baseline, and used case-matching to describe differences in characteristics between people who gained awareness, and those who continued with low awareness. RESULTS: At baseline, 83 people from a sample of 917 showed low awareness. The majority of those remaining in the study at later timepoints had gained awareness, some as late as four or more years after diagnosis. Case-matched comparisons revealed few distinguishing characteristics: cases with stable low awareness had similar or better cognitive and functional ability than those who gained and retained awareness at 12 and 24 months, but may have had more co-morbidities. CONCLUSIONS: Self-reported awareness of difficulties can change and may increase over time in people with mild-to-moderate dementia. There may be individual reasons for ongoing low awareness, not explained by cognitive or functional ability. This challenges the view that a single record of low awareness represents a fixed disease-related symptom, and highlights the complex, individual and dynamic nature of awareness.

Quality improvement engagement: Barriers and facilitators.

A comparison of frontline nurses, advanced practice nurses, and nurse leaders.

An Integrative Review of the Barriers and Facilitators to Nurse Engagement in Quality Improvement in the Clinical Practice Setting.

BACKGROUND: Nurse engagement in quality improvement (QI) improves health care quality and outcomes but is typically low in clinical settings. PURPOSE: An integrative review was conducted to identify facilitators and barriers of nurse engagement in QI. METHODS: This integrative review was conducted using an electronic search of databases with search terms specific to nursing engagement in QI. The Johns Hopkins Nursing Evidence-Based Practice Evidence Level and Quality Guide was used to rate quality and level of evidence. RESULTS: Nine articles met the criteria for review. Top barriers were leadership, education and training, resource constraints, data, culture, and time. Top facilitators were leadership, education and training, culture, mentors, and champions. CONCLUSION: High-quality literature exploring barriers and facilitators of nurse engagement in QI is lacking. Research is needed to examine the degree to which these barriers and facilitators impact engagement and how they can be addressed to increase it.

A qualitative study on barriers and facilitators of quality improvement engagement by frontline nurses and leaders.

AIM: This study aimed to understand the facilitators and barriers of quality improvement (QI) from the perspective of nurses and leaders at the frontline. BACKGROUND: Nurse engagement in QI has been associated with quality care and improved patient outcomes, yet nurse reported participation is low. METHODS: A descriptive qualitative design and purposive sampling was used to examine barriers and facilitators of nurse engagement. RESULTS: Facilitators (1) A leader's influence on a QI culture. Subthemes: creating buy-in, support of a just culture and working in partnership with nurses. Barriers (1) Barriers in organizational culture for nurses to lead QI. Subthemes: organizational hierarchy, absence of a just culture, nurses' role not valued, lack of accountability for QI in nursing role and resistance to change. (2) Barriers in organisational structure for nurses to lead QI. Subthemes: manager disengagement, time pressures, lack of access to timely data, lack of QI knowledge, siloed departments and lack of QI experts. CONCLUSION: Barriers to QI engagement prevent nurses from fully engaging in QI. Creating a just culture and building the infrastructure to support nurse engagement is critical for success. IMPLICATIONS FOR NURSING MANAGEMENT: Specific facilitators and barriers were identified that nurse leaders can assess in their practice setting and use relevant strategies to support engagement in QI.

Does awareness of condition help people with mild-to-moderate dementia to live well? Findings from the IDEAL programme.

BACKGROUND: People living with dementia vary in awareness of their abilities. We explored awareness of the condition and diagnosis in people with mild-to-moderate dementia, and how this relates to quality of life, well-being, life satisfaction, and caregiver stress. METHODS: This study was a cross-sectional exploratory analysis of data from the IDEAL cohort, which recruited people with dementia living at home and available caregivers from 29 research sites in Great Britain. Our study included 917 people with mild-to-moderate dementia and 755 carers. Low and high awareness groups were derived from self-reported responses to a dementia representation measure. Logistic regression was used to explore predictors of awareness of condition and diagnosis using demographic, cognitive, functional and psychological measures, and the relationship with quality of life, well-being and life satisfaction ('living well'), and caregiver stress. RESULTS: There were 83 people with low awareness of their condition. The remaining 834 people showed some awareness and 103 of these had high awareness of their condition and diagnosis. Psychosocial factors were stronger predictors of awareness than cognitive and functional ability. Those with higher awareness reported lower mood, and lower scores on indices of living well as well as lower optimism, self-efficacy and self-esteem. Low awareness was more likely in those aged 80y and above, and living in more socially deprived areas. No relationship was seen between caregiver stress and awareness. CONCLUSIONS: Awareness of the condition and diagnosis varies in people with mild-to-moderate dementia and is relevant to the capability to live well. Awareness should be considered in person-centered clinical care.

Filling the Knowledge Gap for Nurse Leaders: Next Steps Following COVID-19.

The purpose of this article is to share gaps in knowledge and research related to pandemic management identified by nurse leaders during the COVID-19 pandemic. As part of a larger Delphi study, nurse leaders responded to an open-ended question about gaps in research they saw as important following the pandemic. Responses were analyzed using directed content analysis. Results are presented as 4 supercategories: Organizational leadership preparedness, adaptive leadership in crisis, innovations in care delivery, and health, well-being, and resilience.

Setting the Research Agenda for Nursing Administration and Leadership Science: A Delphi Study.

OBJECTIVE: The aim of this study was to identify and prioritize research topics for nursing administration and leadership science. BACKGROUND: Nursing administration and leadership research priorities should provide a framework for building the science needed to inform practice. METHODS: The Association for Leadership Science in Nursing (ALSN) and American Organization for Nursing Leadership (AONL) Foundation (AONL-F) for Nursing Leadership and Education collaborated on a Delphi study. Initial input on research priority items were received from ALSN and AONL members. National experts participated in a 3-round Delphi study. RESULTS: Top-ranked priorities included: 1) nurses' health, well-being, resiliency, and safety in the workplace; 2) developing and managing a nursing workforce to meet current and future healthcare needs; 3) healthy work/practice environments for direct care nurses; 4) healthy work/ practice environments for nurse leaders; 5) quantification of nursing's value across the healthcare delivery system; and 6) nurse leader development and essential competencies. CONCLUSIONS: Researchers and funders should use these priorities to guide future studies.

Peripheral intravenous catheter management in childbirth (PICMIC): A multi-centre, prospective cohort study.

BACKGROUND: Childbirth is a normal, physiological process, yet intervention is common. Arguably the most common intervention is the insertion of a peripheral intravenous catheter; however, there are few studies guiding best practice. This study aimed to describe current intravenous catheter insertion practice, explore clinician decision-making during insertion and perceptions of women. METHODS: This prospective, observational cohort study recruited 101 women and clinicians from two Australian regional hospitals. Data collection incorporated non-participant observation, brief interview and chart review. Variables measured included pain score, insertion attempts, catheter gauge and dwell time. RESULTS: Childbearing women were, on average, aged 31 with body mass index (BMI) above 28. Women reported a mean pain score of 3.3/10 at 24 h for catheter insertion and 12% reported bruising. An 18-gauge catheter was considered more painful than a 16-gauge, and multiple attempts did not increase perceived average pain score. Association between failed first attempts and higher BMI was not established. Participant clinicians were predominantly midwives, who selected and placed 18-gauge catheters mostly in hand or wrist (66%). Decision-making about site, catheter gauge, dressing and attempts varied. Thirty-four per cent attempted two to three times, despite regular practise. Confidence to reliably insert determined catheter gauge and almost half clinician participants cited hospital policy and preferred non-dominant arm as key reasons for the location of PIVC. CONCLUSIONS: Regular use of a large-gauge catheter is counter intuitive when placed in the small veins of the hand with extension tubing. More research is needed to promote best practice around gauge selection, site and women's experience.

Quality improvement engagement and competence: A comparison between frontline nurses and nurse leaders.

BACKGROUND: Nurses play a pivotal role in improving patient care. To maximize nurses' impact on quality, nurses must have quality improvement (QI) competence and engage fully in QI initiatives. PURPOSE: To describe QI competence (knowledge, skills, and attitudes) among frontline nurses and leaders; and compare variations in competence among nursing roles, experience, and specialty areas. METHODS: A total of 681 nurses at one heath system fully completed the Nursing Quality Improvement Practice tool electronically. FINDINGS: Half of the respondents reported QI engagement (53.6%). Mean knowledge scores were 5.08 (SD 1.16, 7 items). Skill proficiency was low (M = 2.82, SD = 1.03; range 1-6) although QI attitudes were favorable (M = 3.76, SD = 0.63; range 1-5). Significant differences in skills and attitudes were identified by role. QI competence among nurses employed in various specialty areas were similar. DISCUSSION: Strategies for increasing QI competence and engagement of nurses must be created and deployed in order to improve quality and safety.

Building a Reliable Health Care System: A Lean Six Sigma Quality Improvement Initiative on Patient Handoff.

BACKGROUND: There is limited evidence available identifying best practices to promote and sustain optimal outpatient-to-inpatient handoff processes to ensure safe and reliable continuity of care. LOCAL PROBLEM: A sentinel event occurred during the transition of care from the outpatient-to-inpatient setting. A root cause analysis revealed that the facility's standard operating procedure for patient handoffs was not consistently followed. METHODS: A Lean Six Sigma approach was used to improve patient transfer with the implementation of a Situation-Background-Assessment-Recommendation handoff policy. Inferential and statistical process control methods were used to assess performance outcomes pre- and postdissemination. RESULTS: Over 36 months there was a slow, steady decrease in patient transfer time including reduced variability. The most significant improvement effect occurred in the third year with a 50% reduction in transfer time. CONCLUSIONS: Longitudinal monitoring provides the opportunity to accurately identify beneficial outcomes, which develop downstream from initial quality improvement efforts.

Measuring Awareness in People With Dementia: Results of a Systematic Scoping Review.

BACKGROUND: Awareness of the diagnosis or related changes in functioning varies in people with dementia (PwD), with implications for the well-being of PwD and their carers. Measuring awareness in a clinical setting could facilitate tailored support and optimize involvement in personal health and care decisions. This scoping review aimed to identify validated methods of assessing awareness in dementia and appraise their clinical utility. METHOD: A systematic search was conducted of English-language publications that measured awareness in PwD, in 6 electronic databases. Search terms included dement*, Alzheimer*, Pick disease, and awareness, unawareness, anosognosia, insight, denial, metacognit*, or discrepanc*. RESULTS: We screened 30,634 articles, finding 345 articles that met our inclusion criteria. We identified 76 measures, most commonly using a discrepancy questionnaire comparing evaluations of function by PwD and an informant. There were 30 awareness measures developed and validated for use in dementia populations but few designed for general clinical use. CONCLUSIONS: Although we found a range of clinical indications for measuring awareness, there were few studies investigating clinical applications and few tools designed for clinical purposes. Further investigation and development of a person-centered tool could facilitate health and care choices in mild-to-moderate dementia.

Australian midwives and clinical investigation: Exploration of the personal and professional impact.

BACKGROUND: The purpose of regulation of health professionals is public protection. Concerns regarding professional conduct or midwifery care can lead to clinical investigation. Midwifery literature reveals midwives feel ill-equipped and unprepared for clinical investigation and experience stress and abreaction. AIM: To explore the lived experience of clinical investigation and identify the personal and professional impact on Australian midwives. METHOD: Semi-structured interviews of a purposive sample of Australian midwives. Data analysis was informed by a phenomenological conceptual framework derived from Husserl, Heidegger and Merleau-Ponty. FINDINGS: Twelve midwives were interviewed, with seven under current investigation. Discussion involved personal and professional experiences of three or more investigations each, over a period of three to five years. Most investigations were instigated by hospitals with two complaints from women. Seven participants were alleged negligent following adverse neonatal outcomes and five had misconduct allegations. Midwives were employed or in private practice and half provided homebirth services. Themes included being safe, being connected, time and being, perception and well-being. DISCUSSION: The investigative process involves different health services, state and national bodies using varying powers and processes over protracted time periods. Participants discussed aspects such as disrespect, inequity, powerlessness, silence and ostracization. Midwives who successfully navigated clinical investigation developed resilience through reflection on clinical practice in a culture of safety. CONCLUSION: The process of regulating midwives, designed to protect the Australian public, may be harming investigated midwives. Understanding the personal and professional impact of clinical investigation needs to underpin midwifery education, clinical practice, inform policy and regulatory reform.

Development of the Nursing Quality Improvement in Practice Tool: Advancing Frontline Nursing Practice.

BACKGROUND: Frontline nurse engagement in quality improvement (QI) improves nurse-sensitive outcomes; yet research suggests frontline nurses are not engaging in QI. PURPOSE: The purpose of this study was to develop, refine, and psychometrically evaluate the Nursing Quality Improvement in Practice (N-QuIP) tool to measure nurses' competency, engagement, and barriers/facilitators to QI engagement. METHODS: Item development was guided by an expert panel and literature review. Factor analysis and reliability indices were assessed through 681 surveys completed by nurses at one medical center. RESULTS: Cronbach α coefficients were 0.97 (Skill Scale) and 0.90 (Attitude Scale). Kuder-Richardson Formula 20 (KR-20) for knowledge was 0.36. Exploratory factor analysis identified 4 (Skill) and 3 (Attitude) subscales respectively, aligning well with QI competencies. CONCLUSIONS: Preliminary data suggest that the N-QuIP is a valid and reliable tool for assessing nurse QI competence and engagement. Understanding current knowledge, skills, and attitudes and identified barriers/facilitators can help the development of strategies aimed at increasing QI engagement.

Doctor of Nursing Practice Project Advisement: A Roadmap for Faculty and Student Success.

BACKGROUND: Robust enrollment in Doctor of Nursing Practice (DNP) programs has created a need for faculty teaching in other nursing programs to be project advisers. Faculty may lack the knowledge and skills needed to advise projects that are evidence-based practice (EBP) or quality improvement (QI) initiatives. A project roadmap with tools and resources was needed. METHOD: Practice-based evidence from members of the Quality and Safety Education for Nurses (QSEN) DNP Leadership Taskforce was used to inform the process for DNP project advisement. This evidence was integrated with the American Association of Colleges of Nursing Taskforce 2015 recommendations and literature on DNP project criteria to develop a roadmap. RESULTS: Twenty-two students and six faculty have piloted the DNP Project Roadmap and provided positive feedback. Eight peer-reviewed presentations and three manuscript submissions with one acceptance have resulted from using the roadmap. CONCLUSION: Data support that the project roadmap phases and associated tools and resources facilitate faculty project advisement and offer students clear project guidelines and a foundation for future practice scholarship. [J Nurs Educ. 2019;58(12):728-732.].

Measuring awareness in people with dementia: protocol for a scoping review.

BACKGROUND: People with dementia (PwD) vary in the degree of awareness they show about their situation, both generally concerning the diagnosis and more specifically around certain aspects or objects of awareness such as awareness of memory impairment, altered daily activities or social functioning. The extent of awareness or lack of awareness has consequences for well-being of PwD and carers, impacting on rates of hospital admission, institutionalization, mood, adjustment to diagnosis, outcomes from intervention and carer burden. An accurate estimation of a person's awareness could therefore be useful in a clinical setting to support PwD and their carers in making appropriate choices for health and care decisions, and could facilitate safe management by health care professionals, e.g. in an acute care setting. There is a range of different approaches to measuring awareness reported in the dementia research literature, with varying estimates of the frequency of lack of awareness, reflecting different methodologies and populations. The majority of the methods have been developed for research purposes and may not be suitable for clinical use. There are no recent scoping or systematic reviews of the available methods. METHOD: We will conduct a scoping review of published studies that have assessed awareness in people with dementia of all types, and all degrees of severity. The systematic search will include the electronic databases PubMed, Embase, PsycInfo, CINAHL, Web of Science and Cochrane Library, using search terms for dementia ("dement*" or "Alzheimer*" or "Pick's disease") and "awareness", "unawareness", "anosognosia", "insight", "denial", "metacognit*" or "discrepanc*" identified from pilot searches. Findings will be mapped and described according to the method used, the setting and diagnosis and the object of awareness studied if specified. Validated measures will be identified. DISCUSSION: This scoping review will provide an overview of the methods used to measure awareness in people with dementia, allowing comparison of the methods along with identification of validated measures. The methods or components will be appraised for potential clinical use, and gaps in research will be highlighted.