Attitudes of Nursing Students About Pressure Injury Prevention.

PURPOSE: The objective of this study was to examine the attitudes of baccalaureate nursing students toward their role in pressure injury prevention (PIP) and describe how clinical experiences influence their attitudes. Understanding students' attitudes and experiences related to PIP may facilitate development of evidence-based interventions for PIP by nurses. DESIGN: Qualitative exploratory descriptive design. SETTING AND SUBJECTS: Participants were 16 senior nursing students enrolled in a prelicensure baccalaureate nursing program in an accredited school of nursing. Half of the participants had completed their first 2 years of the nursing major in the baccalaureate program. The remaining participants completed their first 2 years in a community college associate degree nursing program. METHOD: Semistructured, in-depth, open-ended interviews were conducted. Interviews were digitally recorded and transcribed verbatim; data were analyzed for key themes using content analysis. RESULTS: Four categories of attitudes about PIP were identified: (1) ambivalence, (2) emerging awareness, (3) committed, and (4) passionate. Diverse clinical experiences in pediatrics, the operating room, trauma units, and long-term care facilities enhanced nursing students' learning related to PIP. Experiences observing WOC nurses and other staff role models engaged in PIP were associated with student commitment and passion for PIP. CONCLUSIONS: Findings from this study can be used to guide interventions to enhance attitudes of commitment to PIP. WOC nurses, clinical preceptors, and clinical staff can involve nursing students in intentional PIP learning activities to improve clinical practice and patient outcomes. Intentionally incorporating key learning activities about PIP in the nursing curriculum is recommended.

Peer-reviewed Web-based gerontological resources for nursing faculty.

Faculty members are expected to integrate content about older adults into undergraduate curricula. Although numerous gerontological education resources exist on the Internet, educators often lack awareness of these resources or the time to explore them. We describe a project that used a peer-review process to organize resources into a searchable, online catalog that includes suggestions for using the content in different courses (http://www.ohsu.edu/son/ecleps). Implications are discussed for developing and maintaining the interactive catalog of Web-based instructional resources.

Investigators' successful strategies for working with Institutional Review Boards.

This study was designed to identify successful strategies used by investigators for working with their Institutional Review Boards (IRBs) in conducting human subjects research. Telephone interviews were conducted with 46 investigators representing nursing, medicine, and social work. Interview transcripts were analyzed using qualitative descriptive methods. Investigators emphasized the importance of intentionally cultivating positive relationships with IRB staff and members, and managing bureaucracy. A few used evasive measures to avoid conflict with IRBs. Few successful strategies were identified for working with multiple IRBs. Although most investigators developed successful methods for working with IRBs, further research is needed on how differences in IRB culture affect human subjects protection, and on best approaches for obtaining IRB approval of multi-site studies.

Strategies to promote safe medication administration in assisted living settings.

Assisted living (AL) provides lower cost, less institutional environments than skilled nursing facilities, yet less professional oversight, despite the high prevalence of chronic conditions among residents. Unlicensed staff administer large quantities of medications daily, and medication management is one of the three top quality issues in AL, with error rates ranging from 10% to 40%. This qualitative study described AL provider views on medication safety and strategies used to promote safety in medication administration. The sample included 96 participants representing all parties involved in medication administration (i.e., medication aides, administrators, RNs, consulting pharmacists, primary care providers) in 12 AL settings in three states. Core themes were the importance of medication safety, unique contextual factors in AL, and strategies used to promote medication safety. This study has implications for research on interventions to improve medication safety at the individual, facility, and policy levels.

Compassion and vigilance: investigators' strategies to manage ethical concerns in palliative and end-of-life research.

BACKGROUND: Ethical concerns were identified as a potential barrier to advancing palliative and end-of-life science at the 2004 National Institutes of Health State of the Science Meeting. However, data are lacking about the nature of ethical concerns and strategies for balancing the need to advance science with human subjects protections. METHODS: A qualitative case-study design was used to follow 43 end-of-life studies from proposal development through the review process and implementation. Investigators participated in semi-structured telephone interviews and provided document data regarding their experiences with grant and IRB reviews. Using constant comparative analysis within and across cases, the investigators identified commonly encountered and unique concerns and strategies for managing these concerns. FINDINGS: Investigator strategies fell into two broad categories: 1) Recruitment and consent strategies related to subject identification and enrollment; and 2) Protocol-related strategies related to the process of data collection. These strategies shared the overarching meta-themes of compassion, as evidenced by a heightened sensitivity to the needs of the population, coupled with vigilance, as evidenced by close attention to the possible effects of study participation on the participants' well-being, clinical care, and the needs of research staff. CONCLUSIONS: Ethical concerns have led to the development of compassionate and vigilant strategies designed to balance the potential for risk of harm with the need to advance the science of palliative and end-of-life care. These strategies can be used by investigators to address ethical concerns and minimize barriers to the development of palliative and end-of-life care science.

End-of-life care for rural-dwelling older adults and their primary family caregivers.

Older adults dying from chronic illness in rural areas are understudied and of concern because of their limited access to health services. The purpose of this qualitative descriptive study was to describe the perspectives of primary family caregivers regarding experiences with formal and informal care at the end of life for dying older adults in one rural, agricultural county. Semi-structured interviews were conducted with 23 caregivers following the death of an older relative. Major themes that emerged from the data were the benefits and challenges associated with care services. Benefits included neighbors, friends, and other volunteers who offered household help and provided respite care. Challenges included limited resources for continuity of care, geographical service boundaries, and lack of knowledge about end-of-life care by paid caregivers. Further research that addresses the perspective of rural service providers is needed to better understand the benefits and challenges of end-of-life care in this setting.

Enhancing the capacity to teach gerontological nursing: a faculty development project.

This article describes a faculty development initiative implemented by baccalaureate school of nursing faculty to address the urgent need for education and development in gerontological nursing. The Gerontological Nursing Education Curriculum (G-NEC) project was implemented in five states between 2006 and 2009 to (a) increase faculty knowledge of gerontological nursing, and (b) increase gerontological content in participating schools of nursing. A 4-hour workshop presented at 11 schools introduced key concepts and instructional activities related to care of older adults. Participants rated content and format highly; follow-up reports indicated that many made curriculum changes to incorporate gerontological content. The authors describe workshop content and teaching strategies, curriculum changes participants made to incorporate gerontological content, and implications for faculty development.

Hospice in assisted living: promoting good quality care at end of life.

PURPOSE: The purpose of this study was to describe good quality care at the end of life (EOL) for hospice-enrolled residents in assisted living facilities (ALFs). DESIGN AND METHODS: A qualitative descriptive design was used to obtain detailed descriptions of EOL care provided by ALF medication aides, caregivers, nurses, and hospice nurses in urban and rural settings. A semistructured interview guide facilitated interviews where 38 participants described specific examples of care that "went well." RESULTS: Findings indicated that the quality and nature of resident-staff and assisted living-hospice staff relationships are critical in promoting good care at EOL for ALF residents on hospice. Length of the resident's stay in the facility and how well staff knew the resident were associated with the quality of the resident-staff relationship. Respectful collaboration, clear communication, use of complementary knowledge and skills of staff, and shared expectations about the care were associated with positive staff relationships. Also important was ALF administrator support for residents' dying in place with hospice services. IMPLICATIONS: ALFs choosing to support residents dying in their facility will benefit from developing systems of care that promote resident-staff relationships and optimize communication and collaboration among ALF care providers and with hospice staff. Hospice programs should design their services to support ALF staff as well as patients and families. Now needed are development and testing of models of care by hospice and ALF to support the care needs of ALF residents at EOL.

Administrators' perspectives on ethical issues in long-term care research.

ETHICAL ISSUES ARE A SIGNIFICANT potential barrier to much-needed research in long-term care settings. LTC stakeholder perspectives are largely absent from the development of regulation and guidelines. Fifteen long-term care administrators were interviewed as part of a study of ethical issues in community-based, long-term care research. Established qualitative procedures for conducting content analysis were used to organize the data. Findings suggest that existing mechanisms to protect human subjects do not take into account important differences between academic and long-term care settings. The full potential of LTC research will not be realized until supportive processes to enhance human subjects protections are developed in a way that is reflective of the LTC environment.

Conducting research in community-based care facilities: ethical and regulatory implications.

Successful research in community-based care settings requires collaboration between facility staff and researchers. The ethical conduct of research involves respect for persons, beneficence, and justice. Research must comply with specific federal regulations and state laws. Interviews with 15 community-based care facility administrators revealed differences in understanding how research is regulated and the influence that research might have when a facility provides access to researchers. A Facility Bill of Rights describes principles related to the ethical conduct of research and questions to consider when deciding whether to provide researchers with access to a facility.

Symptom experiences of residents dying in assisted living.

OBJECTIVES: To identify the end-of-life symptom experiences of residents who died in assisted living, to describe family satisfaction with the end-of-life care, and to compare end-of-life symptom distress across 4 settings: assisted living, private home, nursing home, and hospital. DESIGN: In-person interviews with family members of people aged 65 or older who had died 2 to 4 months earlier in an assisted-living facility. Symptom distress reports were compared with data from prior studies in other settings. SETTING: A mixed urban-rural community in the Northwest. PARTICIPANTS: Twenty-five family members who self-identified as closely involved in the care or decision making for a relative who died in an assisted-living facility. MEASUREMENTS: A 28-item interview guide composed of demographic questions, the modified Family Memorial Symptom Assessment Scale-Global Distress Index (FMSAS-GDI), and open-ended items describing the decedent's last days and family satisfaction with care and symptom management. RESULTS: Symptoms experienced by at least 75% of decedents were lack of energy, loss of appetite, dry mouth, drowsiness, and pain. Symptom experiences in assisted living were comparable to those in other settings. Families overall were satisfied with end-of-life care in assisted living, but had concerns about communication among providers, inadequate monitoring of their decedent, and lack of staff knowledge specific to symptom management. CONCLUSION: Residents dying in assisted-living settings have similar symptom distress experiences as people dying in other, more studied settings. As residents and families alike overwhelmingly support resident deaths in their assisted living "home," policies, structures, and processes are needed to ensure that end-of-life care needs are met.

Navigating federalwide assurance requirements when conducting research in community-based care settings.

There is an urgent need for research on quality of life and healthcare delivery for older adults living in community-based care settings, yet implementing current federalwide assurance (FWA) requirements can be a challenge in these settings. This paper discusses FWA requirements for engagement in federally funded research as the requirements pertain to community-based care settings. Factors that impede community facilities in achieving FWA approval include lack of organizational structure to provide oversight for the ethical conduct of research, administrator concerns regarding potential liability associated with obtaining the FWA, lack of resources to complete required paperwork, and lack of staff knowledge about human subjects protection and federal requirements for participating in research. Effects of the FWA process on investigators include the burden of extra time needed to support community-based facilities to acquire a FWA and concerns that studies may be limited to only those community facilities with the resources to complete the FWA process. Investigator-initiated strategies for conducting research in community-based settings include considering study designs that are exempt from the FWA process and proactively assisting community-based facilities to acquire FWA status. Investigators need to work with potential research sites and the office for human research protections to ensure that subjects are protected without shifting the burden of protection to ill-prepared community administrators.

Student perspectives on transitioning to new technologies for distance learning.

This article reports on students' perceptions of their learning experiences when an existing distance-learning master's program transitions to new technologies and new instructional strategies. Unique elements addressed in this article include (1) findings when a program with extensive experience delivering distance education changes to new technologies and (2) findings when a multidimensional format is used to evaluate program delivery. The technology changes involved migrating from a satellite-based technician-supported videoconferencing system to a land-based faculty-operated videoconferencing system and the addition of class Web materials and asynchronous computer conferencing to course delivery. The multidimensional evaluation format examined student experiences within the context of specific interactions among instructional activities, technology applications, and desired learning outcomes. The evaluation process involved (1) open-ended and structured items in course surveys and (2) an end-of-year student focus group discussion. A formative evaluation approach was used; this article reports on efforts to address the problems identified. Findings include (1) program planners should not assume that prior institutional experiences with distance education facilitate a smooth transition to use of different technologies and (2) a formative multidimensional approach to program evaluation is critical for understanding student experiences with technology-mediated distance education.

Nursing homes and assisted living facilities as places for dying.

This chapter reviews the state of knowledge about nursing homes and assisted living facilities as places for dying. Reviewed are 25 published and unpublished research reports by nurse researchers and researchers from other disciplines that address the following questions: (a) What is known about how communication and shared decision-making about end-of-life care preferences occur? (b) How are symptoms assessed and managed at end-of-life? and (c) What are facility characteristics that influence end-of-life care services delivery? Reports were identified through searches of the following databases: MEDLINE, CINAHL, Health Star, PsychLit, Ageline, Ebsco, and PubMed. The following terms guided the search: advance directives, geriatric assessment or nursing, health services for the aged, hospice, residential facilities, palliative care, symptom management, and terminal care. Reports were included if published between 1990 and 2000, if relevant to nursing research on end-of-life care, if conducted on samples age 65 or older and living in nursing home or residential care settings, and if published in English. The studies reviewed were primarily descriptive. The findings indicate that little is known about end-of-life care in these settings, and that family and staff perspectives differ on the nature and quality of the services provided. Both external and internal factors influence the ability of facilities to provide end-of-life care. Recommendations are provided for further research related to nursing homes and assisted living facilities as places for dying.