Leveraging immersive technology to expand access to opioid overdose reversal training in community settings: Results from a randomized controlled equivalence trial.

BACKGROUND: Immersive video (e.g. virtual reality) poses a promising and engaging alternative to standard in-person trainings and can potentially increase access to evidence-based opioid overdose prevention programs (OOPPs). Therefore, the objective of this equivalence study was to test whether the immersive video OOPP was equivalent to a standard in-person OOPP for changes in opioid overdose knowledge and attitudes. METHODS: A team of nurses and communication researchers developed a 9-minute immersive video OOPP. To test whether this immersive video OOPP (treatment) demonstrated equivalent gains in opioid overdose response knowledge and attitudes as in-person OOPPs (standard of care control), researchers deployed a two-day field experiment in Philadelphia, Pennsylvania, USA. In this equivalence trial, 9 libraries were randomly assigned to offer treatment or control OOPP to community members attending naloxone giveaway events. In this equivalence design, a difference between treatment and control groups pre- to post-training scores within -1.0 to 1.0 supports equivalence between the trainings. RESULTS: Results demonstrate participants (N = 94) exposed to the immersive video OOPP had equivalent improvements on posttest knowledge (ß=-0.18, p = .61) and more favorable attitudes about responding to an opioid overdose (ß=0.26, p = .02) than those exposed to the standard OOPP. However, these minor differences in knowledge and attitudes were within the equivalence interval indicating that the immersive video OOPP remained equivalently effective for community members. CONCLUSIONS: Community partnerships, like those between public health departments and libraries, can provide opportunities for deploying novel immersive video OOPP that, alongside standard offerings, can strengthen community response to the opioid crisis.

A comparative study of video lecture versus video lecture and high fidelity simulation for training nurses on the delivery of targeted temperature management after cardiac arrest.

INTRODUCTION: Targeted temperature management (TTM) is recommended for cardiac arrest patients. Successful implementation of a TTM protocol depends on the nurses' knowledge and skills. The study's aim was to compare the level of knowledge, psychomotor skills, confidence and satisfaction before, immediately after and at 6 weeks after training nurses on the delivery of TTM with video lecture versus video lecture and high fidelity simulation. METHOD: Demographic variables were compared across treatment groups using t-tests and Chi-square tests. Change over 6 weeks after intervention was tested with mixed effects model. RESULTS: Fifty-two registered nurses were enrolled. Knowledge test scores, the primary outcome, did not differ between the groups immediately after the training (beta = 3.80, SE = 3.47, p = .27), but there was a strong trend 6 weeks after the training in favor of simulation (beta = 7.93, SE = 3.88, p = .04). Skills were significantly better immediately after the training in the simulation group, but no different 6 weeks later. No difference in confidence was found at either post-test point. Simulation-trained nurses were more satisfied with their training at both post-testing points. CONCLUSION: In this study of training approaches to TTM after cardiac arrest, nurses trained with video lecture and high fidelity simulation benefitted from this approach by maintaining their TTM knowledge longer.

A pilot study to compare virtual reality to hybrid simulation for opioid-related overdose and naloxone training.

BACKGROUND: In the midst of the international opioid-related overdose (OOD) crisis, appropriate naloxone training is needed by both healthcare professionals and community members to better leverage its life-saving potential. OBJECTIVE: Pilot the use of a virtual reality simulation for training student nurses to identify signs and symptoms of an OOD, properly administer intranasal naloxone, and provide immediate recovery care after revival. DESIGN: This quasi-experimental pretest-posttest study evaluated knowledge and attitudes towards intervening during an opioid-related overdose among student nurses before and after participating in a traditional hybrid simulation or virtual reality simulation. SETTING: A medium sized urban university's school of nursing in the Northeastern United States. PARTICIPANTS: Fifty (N = 50) senior Bachelor of Nursing Science (BSN) students. METHODS: Knowledge and attitudes were assessed using the Opioid Overdose Knowledge Scale (OOKS) and Opioid Overdose Attitudes Scale (OOAS). Students completed measures 3 weeks prior to training and 3 weeks after. Appropriate t-tests evaluated changes in OOAS and OOKS scores both within and between training groups (e.g. hybrid simulation compared to virtual reality). RESULTS: Sample characteristics were well balanced in both the hybrid simulation group (n = 31) and virtual reality group (n = 19). There were no statistically significant differences in average OOKS and OOAS scores at baseline or at follow up between those receiving hybrid simulation or the virtual reality training. All participants' attitudes scores decreased from baseline to follow up by <2 points. However, there was no difference in the change in knowledge scores between the training groups. CONCLUSIONS: Individuals participating in the virtual reality simulation had similar knowledge retention and attitudes towards responding during an opioid-related overdose and administering intranasal naloxone when compared to individuals participating in hybrid simulation. The lack of significant findings between training groups indicates that the mobile virtual reality training is comparable to the in-person hybrid simulation for training nursing students to appropriately administer naloxone to reverse OOD and provide immediate recovery care after revival.

Trends in the treatment of chronic kidney disease-associated anaemia in a cohort of haemodialysis patients: the Irish experience.

BACKGROUND: Anaemia among haemodialysis patients is treated with iron and erythropoietin-stimulating agents (ESAs). ESAs reduce requirements for blood transfusions but are also expensive and overzealous use may be associated with adverse outcomes. Recent international trends have been characterised by reduced ESA doses and a greater reliance on intravenous (IV) iron. We determined trends in prescribing patterns of ESAs and IV iron for the treatment of anaemia in two representative Irish dialysis centres and correlated with current guidelines and international trends. METHODS: Patient data was accessed from the Kidney Disease Clinical Patient Management System (KDCPMS) for the period 2012 to 2014. We generated reports on ESA and iron doses, lab data (haemoglobin (Hb), transferrin saturation (TSAT) and ferritin) and patient population characteristics. We mapped the trends in ESA, iron dosing and lab parameters achieved. A linear mixed model determined the significance of these trends over time. RESULTS: ESA dosing became lower in the second, third and fourth quarters of 2014. Dosing of iron increased throughout but a large increase was seen in the third and fourth quarters of 2014. Ferritin levels decreased and TSAT and haemoglobin levels increased. Changes in iron dosing were significant with p value of < 0.05. CONCLUSIONS: Our findings are consistent with recent global trends toward increasing iron use. Such trends may have economic implications given the high cost of ESAs and the relative affordability of iron. In addition, the potential harm of excessive iron dosing may need to be considered.

Standardized Parenteral Nutrition for the Transition Phase in Preterm Infants: A Bag That Fits.

The optimal composition of standardized parenteral nutrition (SPN) is not yet known, contributing to nutrient deficit accrual and growth failure, with the period of parenteral nutrition weaning, i.e., transition (TN) phase, being identified as particularly vulnerable. We created a comprehensive nutrition database, representative of the nutritional course of a diverse range of preterm infants (n = 59, birth weight ≤ 1500 g, gestation < 34 weeks) by collecting hourly macronutrient intake data as part of a prospective, observational study over 19 months. Using a nutrient modeling technique for the TN phase, various amino acid (AA) concentrations of SPN were tested within the database, whilst acknowledging the nutritional contribution from enteral feeds until target AA intakes were consistently achieved. From the modeling, the AA composition of SPN was determined at 3.5 g/100 mL, which was the maximum to avoid exceeding target intakes at any point in the TN phase. However, in order to consistently achieve target AA intakes, additional nutritional strategies were required, which included increasing the exclusion of enteral feeds in fluid and nutrient calculations from <20 mL/kg/day to <40 mL/kg/day, and earlier fortification of breastmilk at 80 mL/kg/day. This data-driven nutrient modeling process supported the development of an improved SPN regimen for our preterm population in the TN phase.

Transition Phase Nutrition Recommendations: A Missing Link in the Nutrition Management of Preterm Infants.

BACKGROUND: Despite the availability of international nutrition recommendations, preterm infants remain vulnerable to suboptimal nutrition. The standard approach of assessing nutrient intakes chronologically may make it difficult to identify the origin of nutrient deficits and/or excesses. OBJECTIVE: To develop a "nutrition phase" approach to evaluating nutrition support, enabling analysis of nutrient intakes during the period of weaning from parenteral nutrition (PN) to enteral nutrition (EN), called the transition (TN) phase, and compare the data with those analyzed using the standard "chronological age" approach to assess whether the identification of nutrient deficits and/or excesses can be improved. METHODS: Analysis of a comprehensive nutrition database developed using actual nutrient intake data collected on an hourly basis in 59 preterm infants (birth weight ≤1500 g, gestation <34 weeks) over the period of PN delivery (range, 2-21 days). RESULTS: The nutrition phase analysis approach revealed substantial macronutrient and energy deficits during the TN phase. In particular, deficits were identified as maximal during the EN-dominant TN phase (enteral feeds ≥80 mL/kg/d) of the infant's nutrition course. In contrast, the chronological age analysis approach did not reveal a corresponding pattern of deficit occurrence but rather intakes that approximated or exceeded recommendations. CONCLUSION: Actual intakes of nutrients, analyzed using a nutrition phase approach to evaluating nutrition support, enabled a more infant-driven rather than age-driven application of nutrition recommendations. This approach unmasked nutrient deficits occurring during the transition phase. Overcoming nutrient deficits in this nutrition phase should be prioritized to improve the nutrition management of preterm infants.

Optimising preterm nutrition: present and future.

The goal of preterm nutrition in achieving growth and body composition approximating that of the fetus of the same postmenstrual age is difficult to achieve. Current nutrition recommendations depend largely on expert opinion, due to lack of evidence, and are primarily birth weight based, with no consideration given to gestational age and/or need for catch-up growth. Assessment of growth is based predominately on anthropometry, which gives insufficient attention to the quality of growth. The present paper provides a review of the current literature on the nutritional management and assessment of growth in preterm infants. It explores several approaches that may be required to optimise nutrient intakes in preterm infants, such as personalising nutritional support, collection of nutrient intake data in real-time, and measurement of body composition. In clinical practice, the response to inappropriate nutrient intakes is delayed as the effects of under- or overnutrition are not immediate, and there is limited nutritional feedback at the cot-side. The accurate and non-invasive measurement of infant body composition, assessed by means of air displacement plethysmography, has been shown to be useful in assessing quality of growth. The development and implementation of personalised, responsive nutritional management of preterm infants, utilising real-time nutrient intake data collection, with ongoing nutritional assessments that include measurement of body composition is required to help meet the individual needs of preterm infants.

Structured promotion of breastmilk expression is associated with shortened hospitalisation for very preterm infants.

AIM: This study assessed neonatal outcomes following implementation of a structured, practical approach for promotion of breastmilk expression in mothers of very preterm infants. METHODS: A multidisciplinary team developed a protocol that focussed on the enhancement of expression of human milk by mothers of very preterm infants. A pre- and poststudy intervention was subsequently performed. The group of infants enrolled in this time period was compared to a pre-intervention group from 2010. Outcomes assessed included breastmilk expression, initiation of feeding, re-attainment of birthweight, attainment of full enteral feeding, the incidence of necrotising enterocolitis (NEC), sepsis and duration of hospitalisation. RESULTS: In total, 82 infants (39,43) were included. While there was no statistically significant difference in earlier initiation of enteral feeding with EBM (median = 2 days) nor earlier achievement of fully enteral feeding (median = 12 days), birthweight was regained earlier in the postintervention cohort (mean = 10.42 days; p = 0.038) and there was a reduced length of stay (mean = 50 days; p = 0.021). CONCLUSION: A structured, focussed, multimodal approach to enhance breastmilk production has shown potential for producing positive end outcomes, particularly, a significant reduction in duration of hospitalisation.

Judgment, inquiry, engagement, voice: reenvisioning an undergraduate nursing curriculum using a shared decision-making model.

In light of recent recommendations from the American Association of Colleges of Nursing's Baccalaureate Essentials, the Institute of Medicine's Future of Nursing, and the Carnegie Foundation's Educating Nurses, many schools of nursing are actively redesigning their undergraduate curriculums. Although the process of curricular change is a complicated one, it is also one that can generate faculty excitement, growth, and engagement. This article describes the process used to bring together the entire faculty and other stakeholders in a unique way to create a new undergraduate nursing curriculum that looks to the future and taps university and faculty strengths. The trajectory of the process and important points within that trajectory are discussed. Key products of the process, which served as articulating steps in building the final product, are also considered and how the framework translates into course work. Faculty engagement at each step resulted in a curriculum owned and endorsed by all constituents, a curriculum that breaks down the "silos" that exist not only among courses and clinical experiences but also between the undergraduate educational experience and the more complicated and contingent one of clinical practice.

New management strategy for fluid resuscitation: quantifying volume in the first 48 hours after burn injury.

This study evaluated a 24-hour resuscitation protocol, established a formula to quantify resuscitation volume for the second 24 hours, described the relationship between the first and second 24 hours, and identified which patients required high volumes. A protocol for patients with burn >15% TBSA was implemented in 2009. Initial fluid was based on the Parkland calculation and adjusted to meet a goal urine output. Protocol compliance was defined as appropriate fluid titration to maintain urine output. Resuscitation ratio in the second 24 hours was tabulated as total fluid /(evaporative loss + maintenance fluid + estimated colloid). Data were collected prospectively from 2009 to 2011. A Wilcoxon rank test compared differences between groups. Regression analyses analyzed volume administered. P < .05 was statistically significant. Forty patients with burn >15% TBSA met criteria for inclusion. Mean age, burn size, and resuscitation volumes in the first and second 24 hours (mean + SD) were 47+ 20.7 years, 29.9 + 14.6% TBSA, 7.4 + 3.7 ml/kg/% TBSA, and a ratio of 1.9 times expected volume (SD, 1.3), respectively. Protocol compliance was 34%. Intubation, older age, and increased narcotic administration correlated with higher resuscitation volumes. A higher resuscitation volume in the first 24 hours significantly correlated with a higher resuscitation volume in the second 24 hours (P < .001). In conclusion, there is a significant relationship between fluid administration in the first and second 24 hours of resuscitation; intubation, older age, and narcotics correlate with higher volumes. A formula for observed/expected volumes in the second 24 hours is total fluid/(evaporative loss + maintenance fluid +estimated colloid).

The paradigm shift.

This article examines current trends in nursing education and proposes undergraduate curriculum changes that are needed to meet the needs and goals of the Institute of Medicine Report: The Future of Nursing, Leading Change, Advancing Health, and The Patient Protection and Affordable Care Act. Curricular changes were developed and implemented during the development of the Affordable Care Act, the Future of Nursing Initiative report, and the Carnegie Report on Undergraduate Nursing Education. The changes will continue to evolve dynamically and are presented here for consideration.

Lesbian, gay, bisexual, transgendered, or intersexed content for nursing curricula.

There has been limited identification of core lesbian, gay, bisexual, transgendered, or intersexed (LGBTI) experience concepts that should be included in the nursing curricula. This article addresses the gap in the literature. To move nursing toward the goals of health equity and cultural humility in practice, education, and research, nursing curricula must integrate core LGBTI concepts, experiences, and needs related to health and illness. This article reviews LGBTI health care literature to address the attitudes, knowledge, and skills needed to address curricular gaps and provide content suggestions for inclusion in nursing curricula. Also considered is the need to expand nursing students' definition of diversity before discussing the interplay between nurses' attitudes and culturally competent care provided to persons who are LGBTI. Knowledge needed includes a life span perspective that addresses developmental needs and their impact on health concerns throughout the life course; health promotion and disease prevention with an articulation of unique health issues for this population; mental health concerns; specific health needs of transgender and intersex individuals; barriers to health care; interventions and resources including Internet sites; and legal and policy issues. Particular assessment and communication skills for LGBTI patients are identified. Finally, there is a discussion of didactic, simulation, and clinical strategies for incorporating this content into nursing curricula at the undergraduate and graduate levels.

Cultural competency of graduating BSN nursing students.

Providing culturally appropriate care is an essential nursing competency for new graduates. Multiple curricular approaches are being used to achieve this end. When measured by Campinha-Bacote's Inventory for Assessing the Process of Cultural Competency Among Healthcare Professionals-R, graduating students (n = 515) from six different BSN programs scored, on average, in the culturally aware range. These results suggest that no one curricular approach is proving to be more effective than another in achieving essential cultural competency.

Cultural competence in the undergraduate nursing curriculum.

More demands are being put on nursing faculty to incorporate content related to cultural competence in the undergraduate curriculum. Adding more content into an already full curriculum and becoming proficient at teaching cultural competence throughout the curriculum are challenging to nursing faculty. In addition, identifying personal bias to ensure that students are prepared to deliver culturally sensitive care requires a certain amount of self-awareness of personal prejudice. The purpose of this article is to present the implementation of the newly developed Blueprint for Integration of Cultural Competence in the Curriculum (BICCC) into an undergraduate nursing curriculum as a framework for teaching cultural competence in an undergraduate nursing curriculum. This will include defining culture and cultural competence as they relate to teaching, presenting educational standards of cultural competence in accrediting agencies, presenting level objectives for learning cultural competent information, describing a curriculum incorporating cultural competence in an undergraduate nursing program, and providing examples of implementation of cultural competence teaching strategies for nursing faculty.

Cultural competence in the master's curriculum--a course exemplar.

This article focuses on the teaching-learning strategies for integration of cultural competence in the first clinical core course in Primary Care of the Middle Aged and Older Adult, a required course for graduate students enrolled in the Adult Health Nurse Practitioner Program, Gerontology Nurse Practitioner Program, and the Family Health Nurse Practitioner Program at the University of Pennsylvania School of Nursing. Multiple teaching-learning strategies for the first clinical course consisted of preliminary online self-assessment, clinical case scenarios, critique of multicultural clinical vignettes, and cultural assessment of the clinical agency. In the outcomes of these teaching-learning strategies, it was shown, through the use of reflective diaries of nurse practitioner students and course evaluations, that the multiple strategic approaches were effective for cultural competence integration within each of the nurse practitioner programs.

Student perceptions of cultural competence content in the curriculum.

The 31-item Blueprint for Integration of Cultural Competence in the Curriculum (BICCC) was used as an organizing framework and an evaluative tool to survey student perceptions of inclusion of cultural-specific content in undergraduate and graduate courses. Quantitative and qualitative data were used to complete this survey, which provided definitive information about the strengths and deficiencies of the curriculum initiative. Findings show that faculty made considerable progress with the curriculum integrative efforts. With responses of sometimes to quite often on the BICCC survey, 90% of the master's, 87% of senior, and 25% of first-semester freshmen participants reported a sufficient level of teaching in response to the survey items on aspects of culture and health. For all cohorts, the survey showed that content related to critique of health disparities research and theoretical formulation about culture, health, and nursing were not sufficiently addressed. Open-ended comments showed that freshmen reported a solid foundation of culturally related courses in arts and humanities courses; seniors disclosed a high level of knowledge about aspects of culture competence; and master's participants had high levels of self-awareness about values, cultural beliefs, and challenges of cross-cultural communication. The BICCC provided substantial information for faculty to address areas of omission, deficiency, and redundancy in the cultural competence education.

Perception of depot antipsychotics by mental health professionals.

OBJECTIVE: This study examines attitudes of mental health professionals about the use and usefulness of depot antipsychotic medications and determines similarities and differences in attitudes between professional groups. METHODS: Mental health professionals working with patients with severe mental illness completed a questionnaire designed to evaluate their opinions concerning rate of depot use, indications for use of depots, problems with use of depots, common side effects of depots, barriers to switching from depot to oral atypical antipsychotics, impact of staffing levels on drug choice, and relative confidence in various antipsychotics for the management of chronic psychosis. RESULTS: Overall, all professional groups perceived depot antipsychotics as a requirement for the treatment of those with serious mental illness who were poorly adherent. However, there were a number of professional differences in responses to certain items in the survey that probably reflected the degree of direct contact with patients. Medical staff were remarkably uniform in their opinions on the use and usefulness of depots. Mental health staff from all the professional groups surveyed considered extrapyramidal side effects (EPS) a major concern, while few rated cognitive side effects, sexual side effects, and weight gain as significant concerns, even though these problems are reported to be a principal concern of patients. Although all professional groups indicated an awareness of the potential toxicity of depot antipsychotics and there was an overall consensus that atypical antipsychotics are likely to be beneficial in chronic psychosis, limitations in resources were seen as a barrier to switching. CONCLUSIONS: Attitudes concerning the usefulness and rationale for use of depot antipsychotics differ by medical profession. Nursing and allied health workers are more likely than medical staff to note patient specific variables such as weight gain, injection site reactions, and patient preferences as problems with depots. The results also suggest that, in a community-based psychiatric care system, the use of newer and potentially better agents for the management of psychosis is impaired by resource limitations in service delivery as well as by educational disparities between the professions.

Factors associated with distress in urban residential fire survivors.

PURPOSE: To identify factors associated with recovery in a sample of urban residential fire survivors. DESIGN AND METHODS: 440 survivors, of residential fires were interviewed at approximately 3, 6, and 13 months after the fire to measure psychological distress. A set of factors was identified that correlated with survivors' ability to recover from the fire event. Potential predictors of increased distress were identified. Hypotheses were that participants who were lower in socioeconomic status, who were minority members, who had less social support, who engaged in attributional thinking, and had greater concurrent life stresses would have greater psychological distress in response to a residential fire and would be less able to recover from the fire event. FINDINGS: Distress after fire was high at 3 months and decreased for the majority of participants, although one-third of survivors had higher distress at 13 months than at 3 months. Loss of control and attributional variables had the strongest influence on psychological distress over time. CONCLUSIONS: The findings are consistent with stress-response tendencies expected after a stressful event. A set of predictor variables was identified to help clinicians target survivors at high risk for psychological distress after a residential fire.