Pain, comorbidities, and clinical decision-making: conceptualization, development, and pilot testing of the Pain in Aging, Educational Assessment of Need instrument.

Introduction: Pain is highly prevalent in older adults and often contextualized by multiple clinical conditions (pain comorbidities). Pain comorbidities increase with age and this makes clinical decisions more complex. To address gaps in clinical training and geriatric pain management, we established the Pain in Aging-Educational Assessment of Need (PAEAN) project to appraise the impacts of medical and mental health conditions on clinical decision-making regarding older adults with pain. We here report development and pilot testing of the PAEAN survey instrument to assess clinician perspectives. Methods: Mixed-methods approaches were used. Scoping review methodology was applied to appraise both research literature and selected Medicare-based data. A geographically and professionally diverse interprofessional advisory panel of experts in pain research, medical education, and geriatrics was formed to advise development of the list of pain comorbidities potentially impacting healthcare professional clinical decision-making. A survey instrument was developed, and pilot tested by diverse licensed healthcare practitioners from 2 institutions. Respondents were asked to rate agreement regarding clinical decision-making impact using a 5-point Likert scale. Items were scored for percent agreement. Results: Scoping reviews indicated that pain conditions and comorbidities are prevalent in older adults but not universally recognized. We found no research literature directly guiding pain educators in designing pain education modules that mirror older adult clinical complexity. The interprofessional advisory panel identified 26 common clinical conditions for inclusion in the pilot PAEAN instrument. Conditions fell into three main categories: "major medical", i.e., cardio-vascular-pulmonary; metabolic; and neuropsychiatric/age-related. The instrument was pilot tested by surveying clinically active healthcare providers, e.g., physicians, nurse practitioners, who all responded completely. Median survey completion time was less than 3 min. Conclusion: This study, developing and pilot testing our "Pain in Aging-Educational Assessment of Need" (PAEAN) instrument, suggests that 1) many clinical conditions impact pain clinical decision-making, and 2) surveying healthcare practitioners about the impact of pain comorbidities on clinical decision-making for older adults is highly feasible. Given the challenges intrinsic to safe and effective clinical care of older adults with pain, and attendant risks, together with the paucity of existing relevant work, much more education and research are needed.

Nurse Staffing and Veteran Outcomes in the Veterans Health Administration's Community Living Centers.

BACKGROUND: The demand for nursing care is rising in the long-term care setting. Nurse staffing is a crucial measure linked to health care quality measure outcomes. PURPOSE: To assess for associations between nursing hours per patient day (NHPPD) and outcome measures in the Veterans Health Administration Community Living Centers. METHODS: A retrospective data review of NHPPD and quality measures for 134 community living centers was conducted. Linear regression was used to assess for linear associations between average total NHPPD and 6 quality measures. RESULTS: A significant linear association was found between average total NHPPD and falls with major injury ( P = .02) and help with activities of daily living ( P = .01). No associations were found between nurse staffing and 4 other quality measures. CONCLUSIONS: This study adds to the body of literature regarding the impact of nurse staffing on quality measures.

Veterans Affairs Health Care Provider Perceptions of Virtual Reality: Brief Exploratory Survey.

BACKGROUND: Virtual reality (VR), a simulated experience that can be similar to or completely different from the real world, has become increasingly useful within the psychiatric and medical fields. This VR technology has been applied in medical school trainings, exposure therapy for individuals with posttraumatic stress disorder (PTSD), and reminiscence therapy associated with mood disorders for older adults. Perceptions of VR through the lens of the health care provider require further exploration. VR has grown in popularity; however, this modality continues to be underused in most Veterans Affairs (VA) hospitals. OBJECTIVE: A web-based survey was used to explore health care provider perceptions of immersive VR availability and use for older adults and identify potential barriers for immersive VR use in older adults with cognitive impairment. METHODS: An 8-item web-based survey was developed to obtain health care provider feedback. This survey was disseminated throughout a single Veterans Integrated Services Network (VISN). The VR survey was developed via the Survey Monkey platform and distributed through the secure VA email network. Providers were asked to voluntarily participate in the brief, anonymous survey and offer their perceptions of immersive VR use within their patient population. Survey data were reviewed and interpreted using descriptive statistics. RESULTS: A total of 49 respondents completed the survey over a 15-day period. Of them, 36 respondents (73%) had heard of a VR device, though the majority (n=44, 90%) had never used or prescribed a VR device. Respondents identified several potential barriers to immersive VR use in older adults with cognitive impairment (eg, hearing difficulties, perceptions of technology, cognitive concerns, access to resources, and visual impairment). Despite the barriers identified, providers (n=48, 98%) still reported that they would feel comfortable prescribing immersive VR as an intervention for their patient population. CONCLUSIONS: Survey findings revealed that health care providers within this VISN for VAs have heard of VR, although they may not have actively engaged in its use. Most of the providers reported that they would prescribe the use of an immersive VR intervention for their older adult patients. This key point highlights the desire to implement VR strategies for patient use by their providers. If underlying barriers can be addressed and relatively resolved, this technological intervention has the potential to create substantial breakthroughs in clinical care.

Evaluating the staffing methodology model in the veterans health administration's community living centers.

PURPOSE: Program evaluation to describe nursing hours per patient day (NHPPD) within the Veterans Health Administration (VHA) and to evaluate Staffing Methodology in the VHA Community Living Centers (CLCs). METHODS: Targeted and actual NHPPD were compiled retrospectively for each VHA CLC unit over a one-year timeframe for calendar year 2019. For descriptive analyses, actual NHPPD were averaged across months for each CLC unit. RESULTS: The mean for actual hours as a percent of target was 121.6% (95% CI, 118.5 to 124.7%) indicating the units' average hours across 2019 were 21.6% significantly higher than target. The actual NHPPD significantly differed across months (p<0.001) with the 2019 months of January and October having the highest NHPPD. CONCLUSIONS: Veteran safety is a VHA priority and appropriate nurse staffing is key to providing care that improves Veteran outcomes. Further exploration is needed on the impact of nurse staffing on Veteran outcomes, safety, and satisfaction.

Rapid conversion of Tai Chi classes from face-to-face to virtual during the COVID-19 pandemic: A quality improvement project.

PURPOSE: The purpose of this quality improvement project was to examine the feasibility of rapidly converting a Tai Chi program for older Veterans from face-to-face to virtual classes. METHODS: Eighteen Veterans attending our face-to-face Tai Chi course were invited to transition to virtual classes. Feasibility was defined as the ability of program staff and participants to successfully connect and complete the initial and subsequent classes by VA Video Connect (VVC) with little to no technical difficulties, participant ability to participate in the course without safety concerns, and favorable feedback from participants and program staff. RESULTS: Nine of 18 Veterans agreed to transition to the virtual program and attended a median (interquartile range) of 11 (4-15) classes; they were younger (62.7 + 11.5 vs. 70.5 + 7.0 years, p < .05) and more likely to have the knowledge and equipment needed to participate (78% vs. 0%, p < .01) than nonparticipants. Tai Chi instructors and participating Veterans reported being able to connect to and complete the classes virtually with only minimal technical problems. No adverse events were reported. Feedback from the instructors and Veterans was positive and included comments on ease of use and enjoyability. CONCLUSION: Results suggest that virtual Tai Chi classes via VVC are feasible for some older Veterans.

Opioid Use Disorder: Treatment Outcomes in U.S. Veterans.

BACKGROUND: Substance use disorders are a leading cause of morbidity and mortality in the United States, with opioid use disorder representing a growing public health concern and economic burden. Veterans within the Veterans Health Administration are impacted by opioid use disorder. SIGNIFICANCE: A common medication-assisted treatment is sublingual Suboxone (buprenorphine/naloxone) used in combination with behavior modification therapy. Missed Suboxone doses may lead to withdrawal and potential drug diversion. Sublocade (buprenorphine extended-release) is an alternative once-monthly subcutaneous injection administered by a healthcare provider. The purpose of this quality improvement project was to examine the effects of Sublocade on cravings in veterans with opioid use disorder. METHODS: Veterans were considered for Sublocade monthly injections if they were enrolled in the Suboxone program, not taking Suboxone as prescribed, and disenrolled from the Suboxone program more than 2 times. Cravings were measured before and after Sublocade program enrollment. RESULTS: Fifteen veterans were enrolled in the Sublocade program over a 12-month timeframe. Most were male (93%) with a median (range) age of 42 (33-62) years. The following were the primary opioids used before enrollment in the substance use disorder program: hydrocodone (47%), oxycodone (20%), and heroin (20%). Sublocade significantly reduced cravings (p = .001). In this small group, cravings were fully eliminated. DISCUSSION: Recent studies have shown Sublocade effectively blocks the effects of other opioids and minimizes the risk of medication diversion that occurs with Suboxone. For these reasons, Sublocade is an alternative medication-assisted treatment for veterans with opioid use disorder.

The Relationship between Insulin Resistance and Spatial QRS-T Angle in American Adults.

BACKGROUND: Insulin resistance can impair the electrical conductivity of the heart. Spatial QRS-T axis reflects ventricular depolarization and repolarization. The relationship between insulin resistance and spatial QRS-T angle has not been examined in the general population. OBJECTIVE: We examined the relationship between insulin resistance and spatial QRS-T angle in an American population-based sample. METHODS: We used data collected from the National Health and Nutrition Examination Survey III (NHANES III), and a directed acyclic graph to select confounders. We fitted logistic regression models and adjusted for the effect of the confounders. We stratified all analyses by gender. RESULTS: The odds ratios (OR) of the abnormal QRS-T angle and their 95% confidence intervals (CI) for females and males were 1.08 (1.03-1.16) and 1.03 (0.96-1.11), respectively. A 5-unit increase in insulin resistance in females increased the odds of an abnormal QRS-T angle by 47% (OR = 1.47, 95% CI, 1.10-2.10); in males, a 5-unit increase in insulin resistance increased the OR by 17% (OR = 1.17, 95% CI, 0.82-1.70). CONCLUSIONS: Spatial QRS-T angle may be associated with insulin resistance, especially in women. The individuals with a higher insulin resistance value had higher odds for major adverse cardiovascular events. Nevertheless, the results of this study should be verified in prospective studies.

From the Other Side of the Bed: Lived Experiences of Registered Nurses as Family Caregivers.

BACKGROUND: To provide patient- and family-centered care, health care providers must understand the caregiver experience. Evidence suggests that registered nurses functioning as family caregivers (RNFCs) may have unique experiences and challenges. PURPOSE: The purpose of this study was to explore the lived experiences of RNFCs during an adult family member's episode of care in the southern United States. METHODS: A descriptive phenomenological approach was used to describe the essence of the RNFC experience throughout an episode of care. Twenty-five participants were recruited for semistructured, audio-recorded interviews. Data were analyzed using descriptive data analysis and constant comparison techniques. RESULTS: Participants were predominantly female (88%). The essence of the phenomenon was dual roles. Five themes emerged: (1) blurring the boundaries, (2) revealing my identity, (3) having insider knowledge, (4) managing expectations, and (5) learning from my experience. CONCLUSIONS: While caregiver experiences may be similar, RNFCs struggle with dual roles of registered nurse and caregiver, occasionally blurring boundaries of care.

An outpatient Tai Chi program: Effects on veterans' functional outcomes.

PURPOSE: To evaluate the effectiveness of an evidence-based 12-week Tai Chi course designed to improve balance and physical function in a population of older veterans. METHODS: Community dwelling veterans of all ages with gait and balance problems were invited to participate in the Tai Chi program. Participants completed the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, and the Falls Efficacy Scale-International (FES-I) at baseline and again at the end of the program. Descriptive statistics were used to summarize study participants' characteristics. The change from baseline to the end of the 12-week program was calculated for each of the three primary outcome variables (BBS, TUG, FES-I). RESULTS: Twenty-two veterans, aged 58 years and above, with perceived gait and/or balance issues were enrolled in the program with completion by 11 veterans. Veterans who completed their final assessments showed the BBS, improved significantly (p = 0.004) from baseline to the 12-week assessment. The TUG scores improved by a median of 1.3 s (p = 0.022). There was not a significant change in the FES-I. CONCLUSIONS: Preliminary findings provide evidence of the effectiveness of a 12-week Tai Chi program to improve functional outcomes for older veterans with mild to moderate gait and balance problems.

Increasing the availability of Tai Chi to veterans through a training of trainers course.

PURPOSE: The purpose of this nurse-led project was to increase the number of interprofessional Tai Chi instructors for veterans through a 5-week (32 hours) training of trainers (ToT) course led by a Tai Chi master trainer. METHODS: This project was designed to evaluate the effectiveness of using the ToT model to increase the availability of Tai Chi to veterans. To understand how well the ToT course met learners' needs, a two-phase course evaluation was conducted. RESULTS: Fifteen interprofessional employees enrolled in and completed the course. Most learners were white (67%) females (67%) with a median age of 50 years. All agreed that the training provided the skills, materials, and confidence to lead Tai Chi classes. Most (93%) indicated experiencing positive health benefits from the training and none experienced any negative effects. The 3-month follow-up evaluation indicated that 10 (67%) were teaching veterans in individual or group classes with two others assisting. Twelve instructors taught more than 150 veterans. CONCLUSIONS: Overall, learners evaluated this ToT course positively and indicated their needs were met and felt prepared to teach Tai Chi despite being inexperienced. The course was a success with 80% of new instructors teaching or coteaching Tai Chi to veterans.

Psychometric Properties of the Authentic Leadership Inventory in the Nursing Profession.

BACKGROUND AND PURPOSE: A valid and reliable Authentic Leadership (AL) measurement instrument is paramount as nursing leadership research grows. The purpose of this study was to analyze the reliability and construct validity of the Authentic Leadership Inventory (ALI) among nurses. METHODS: This study was a cross-sectional, prospective design that explored the relationship between registered nurses' (RNs) perceptions of AL qualities in nurse managers in a random sample of RNs working in an acute care setting. RESULTS: A Cronbach α 0.96 confirmed reliability. Exploratory factor analysis determined a one-factor structure. Confirmatory factor analysis utilized the one-factor structure for a final best-fit model (χ2 = 107.3, df = 70, p = .003; TLI = 0.95, CFI = 0.96, RMSEA = 0.08). CONCLUSIONS: This study gives support to using the ALI with the nursing profession.

Implementation of an Interdisciplinary Communication Workgroup on an Acute Psychiatric Unit.

Communication among Interdisciplinary Healthcare Teams is an essential component of providing optimal patient care. Staff members at one U. S. Department of Veterans Affairs on an Acute Psychiatric Unit identified fragmented communication on the unit and expressed interest in forming an interdisciplinary communication workgroup. This quality improvement (QI) project was designed to enhance communication among the Interdisciplinary Healthcare Team on the Acute Psychiatric Unit. A workgroup was formed and met four times at 1-hour intervals. A pre/post-test was used to determine the initial effectiveness of the intervention. The results of the intervention suggested increased communication among the Interdisciplinary Healthcare Team as an upward trend of the mean scores was noted.

Nurse manager perspective of staff participation in unit level shared governance.

AIM: To examine the nurse manager perspective surrounding implementation of unit level shared governance in one Veterans Health Administration facility. BACKGROUND: Nursing shared governance is a formal model allowing nursing staff decision-making input into clinical practice, quality improvement, evidence-based practice and staff professional development. Unit level shared governance is a management process where decision authority is delegated to nursing staff at the unit level. METHODS: Convenience sampling was used to recruit ten nurse managers who participated in face-to-face semi-structured interviews. Data were analysed using content analysis and constant comparison techniques. Demographic data were described using descriptive statistics. RESULTS: The participants included seven female and three male nurse managers with seven Caucasian and three African American. Participant quotes were clustered to identify sub-themes that were then grouped into four global themes to describe unit level shared governance. The global themes were: (1) motivation, (2) demotivation, (3) recommendations for success, and (4) outcomes. CONCLUSION: These research findings resonate with previous studies that shared governance may be associated with increased nurse empowerment, self-management, engagement, and satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: These findings reflect the need for nurse managers to promote and recognize staff participation in unit level shared governance.

Tobacco myths: the older adult perspective.

Twenty adults ages 50 and older who had ceased using tobacco for 1 year or longer were interviewed. Participants provided personal insights into three myths found in the literature surrounding tobacco use and cessation in older adults and were asked to describe any perceived benefits of tobacco use. The findings indicate older adult tobacco users may need additional education on tobacco risks and cessation benefits provided by health care providers during routine office visits.

The feasibility of a regional cardiac arrest receiving system.

BACKGROUND: Patients suffering out-of-hospital cardiac arrest (OOHCA) are generally transported to the closest ED, presumably to expedite a hospital level of care and improve the chances of return for spontaneous circulation (ROSC) or provide post-resuscitative care for patients with prehospital ROSC. As hospital-based therapies for survivors of OOHCA are identified, such as hypothermia and emergency primary coronary interventions (PCI), certain hospitals may be designated as cardiac arrest receiving facilities. The safety of bypassing non-designated facilities with such a regional system is not known. OBJECTIVES: To explore the potential ED contribution in OOHCA victims without prehospital ROSC and document the relationship between transport time and outcome in patients with prehospital ROSC. METHODS: This was a prospective, observational study conducted in a large, urban EMS system over an 18-month period. Data were collected using the Utstein template for OOHCA. The incidence of prehospital ROSC was calculated for patients who were declared dead on scene, transported but died in the ED, died in the hospital, and survived to hospital discharge. The relationship between transport time and survival was also explored for patients with prehospital ROSC. RESULTS: A total of 1141 cardiac arrest patients were enrolled over the 18-month period. A strong association between prehospital ROSC and final disposition was observed (chi-square test for trend p<0.001). Only two patients who survived to hospital discharge did not have prehospital ROSC. Mean transport times were not significantly different for patients with prehospital ROSC who were declared dead in the ED (8.3min), died following hospital admission (7.8min), and survived to hospital discharge (8.5min). Outcomes in patients with prehospital ROSC who had shorter (7min or less) versus longer transport times were similar, and receiver-operator curve analysis indicated no predictive ability of transport time with regard to survival to hospital admission (area under the curve=0.52). CONCLUSIONS: In this primarily urban EMS system, the vast majority of survivors from OOHCA are resuscitated in the field. A relationship between transport time and survival to hospital admission or discharge was not observed. This supports the feasibility of developing a regional cardiac arrest system with designated receiving facilities.

The three-phase model of cardiac arrest as applied to ventricular fibrillation in a large, urban emergency medical services system.

BACKGROUND: Cardiac arrest is responsible for significant morbidity and mortality, with consistently poor outcomes despite the rapid availability of prehospital personnel for defibrillation attempts in patients with ventricular fibrillation (VF). Recent evidence suggests a period of cardiopulmonary resuscitation (CPR) prior to defibrillation attempts may improve outcomes in patients with moderate time since collapse (4-10 min). OBJECTIVES: To determine cardiac arrest outcomes in our community and explore the relationship between time since collapse, performance of bystander CPR, and survival. METHODS: Non-traumatic cardiac arrest data were collected prospectively over an 18-month period. Patients were excluded for: age <18 years, a "Do Not Attempt Resuscitation" (DNAR) directive, determination of a non-cardiac etiology for arrest, and an initially recorded rhythm other than VF. Patients were stratified by time since collapse (<4, 4-10, > 10 min, and unknown) and compared with regard to survival and neurological outcome. In addition, patients with and without bystander CPR were compared with regard to survival. RESULTS: : A total of 1141 adult non-traumatic cardiac arrest victims were identified over the 18-month study period. This included 272 patients with VF as the initially recorded rhythm. Of these, 185 had a suspected cardiac etiology for the arrest; survival to hospital discharge was 15% in this group, with 82% of these having a good outcome or only moderate disability. Survival was highest among patients with time since collapse of less than 4 min and decreased with increasing time since collapse. There were no survivors among patients with time since collapse greater than 10 min. Among patients with time since collapse of 4 min or longer, survival was significantly higher with the performance of bystander CPR; there was no survival advantage to bystander CPR among patients with time since collapse less than 4 min. CONCLUSIONS: The performance of bystander CPR prior to defibrillation by EMS personnel is associated with improved survival among patients with time since collapse longer than 4 min but not less than 4 min. These data are consistent with the three-phase model of cardiac arrest.