Doctor of Nursing Practice Program Capacity Building and Scalability: Improving the Capstone Experience.

Innovations in the educational process are required to address the divergent needs of nursing students depending on their point of entry, either postbaccalaureate or postmaster's degree preparation. The requirement of the scholarly doctor of nursing practice (DNP) project demands significant student and faculty resources. With the variability of students' education, practice experience, and interest, the expectations of the project need to fit the needs of the adult learner. Linking these projects to clinical settings is an end goal for these efforts which supports the scalability of these programs.Faculty from Rutgers School of Nursing considers practice change and quality improvement a priority in preparation of the DNP graduate. With curricular enhancements, students are considering patient access, safety, and quality from the beginning of their doctoral education. An innovative course series progression was implemented to prepare students for the scholarly practice evaluation. In addition, capstone and residency courses were reformatted to assist students in evaluating models of evaluation, systems of care, and to further define the issue they wish to address through their scholarly inquiry. Throughout the clinical doctoral preparation, students are encouraged to evaluate practice in a standardized critical format and ultimately, execute a scholarly project.By linking these projects to the clinical setting, the DNP program increases its scalability. Connecting the academic institution with the clinical setting allows for increase student access to learning experiences and the capability of scholarly projects to continue in the setting. Faculty resources are well used in this manner. This process allows for continued capacity building within the academic and clinical setting.

Addressing the Health Care Delivery Needs in the Acute Care Setting by Developing a Postmaster's Acute Care Certification Program.

The state of New Jersey certifies nurse practitioners and clinical nurse specialists from all specialties as advanced practice nurses (APNs). There are more than 4,000 certified APNs in the state in 17 specialty areas. APNs in the state have the privilege of practicing in various settings such as ambulatory, inpatient, and long-term care. The state does not limit the setting where an APN chooses to practice. A trend is emerging in the state to address the concern of primary care-educated APNs to prepare them for the delivery of care in the acute care setting. Some institutions within the state of New Jersey are requiring their primary care educated and certified adult primary care APNs working in an inpatient setting to obtain an acute care certification. Recognizing the needs of these adult primary care APNs, Dr. Helen Miley developed a postmaster's certificate program which has been approved by Rutgers School of Nursing faculty. Although the first cohort has not yet been admitted to the program, it will be implemented in the near future. Because it is important to address the educational needs of adult primary care APNs, this article describes the needs assessment and development plan used for this program.

Choosing the best evidence to guide clinical practice: application of AACN levels of evidence.

Evidence-based nursing care is informed by research findings, clinical expertise, and patients' values, and its use can improve patients' outcomes. Use of research evidence in clinical practice is an expected standard of practice for nurses and health care organizations, but numerous barriers exist that create a gap between new knowledge and implementation of that knowledge to improve patient care. To help close that gap, the American Association of Critical-Care Nurses has developed many resources for clinicians, including practice alerts and a hierarchal rating system for levels of evidence. Using the levels of evidence, nurses can determine the strength of research studies, assess the findings, and evaluate the evidence for potential implementation into best practice. Evidence-based nursing care is a lifelong approach to clinical decision making and excellence in practice.

Incentive spirometry in postoperative abdominal/thoracic surgery patients.

BACKGROUND: Postoperative patients have higher incidences of respiratory complications. Patients undergoing abdominal or thoracic surgical procedures are at greater risk of having such complications. Incentive spirometry is an inhalation-based prophylactic technique that encourages patients to mimic a natural deep sigh to periodically increase lung volume. As this technique is the prophylactic method of choice for many hospitals, several studies have tested its efficacy. METHODS: Five articles, including 4 systematic reviews and 1 clinical practice guideline, are analyzed and summarized. Each article was reviewed by a multidisciplinary team of health care providers and is discussed herein. A clinical recommendation for practice change is provided on the basis of the results. SUMMARY: Incentive spirometry is only as effective as cough/deep-breathing regimens and other means of postoperative pulmonary prophylaxis. No single prophylactic technique clearly outperforms all others in preventing pulmonary complications. Future research is needed to determine the best method to prevent postoperative pulmonary complications.

Implementing the best available evidence in early delirium identification in elderly hip surgery patients.

AIMS: Delirium is a frequent complication in the surgical experience of elderly hip surgery patients. Its impact can be severe and may even include death. Implementation of a delirium predictor tool might focus attention on early recognition of delirium, thereby potentially decreasing its impact. A related aim is to evaluate best practices in implementation strategies in this project. METHODS: After an exhaustive search of the literature, no consensus was found regarding delirium predictors for the elderly hip surgery patient. A local research study was implemented to determine factors that may predict delirium in this population. With evidence secured, a multidisciplinary implementation project augmented by ongoing audit was instituted. A variety of social diffusion and education tools were used. Implementation was guided by the use of the Promoting Action on Research Implementation in Health Services framework assessment tool and the Alberta Context Tool, as well as traditional performance improvement tools, such as fishbone charting. Audit identified the rate of use of the predictor tool and pre- and post-rates of delirium. This project was part of the Joanna Briggs Institute Signature Project, an implementation project consisting of six teams, each representing a different organisation. This overall project was supported by experts in the field of translation and implementation science internationally. RESULTS: Initial compliance to the use of the predictor tool was assessed at 54% within 3 months of implementation and increased to 56% in the ensuing months. Before the study use of the predictor tool, the delirium rate was 10.4% (12 of 115 patients). An interim analysis 4 months after implementation identified a 20% delirium rate (18 of 70 patients) and an updated analysis 8 months into the project showed a 16.3% delirium rate. Delirium predictor tool use was associated with a lower delirium rate (9/76, 11.84%) than no delirium predictor tool (13/60, 21.67%), but the difference was not statistically significant with a sample size of 133 (P = 0.122). CONCLUSIONS: The delirium predictor tool shows promise as a prompt for best practices in prevention of delirium. This study showed a change in delirium rates as a result of its use. Although the results were not statistically significant, they may be clinically meaningful. Comprehensive assessment and implementation planning by a multidisciplinary team contributed to only 56% compliance in use. Despite this low rate, delirium identification rates were higher.

Probiotics for prevention of antibiotic-associated diarrhea and Clostridium difficile-associated disease in hospitalized adults--a meta-analysis.

PURPOSE: A serious complication associated with the use of most antibiotics is antibiotic-associated diarrhea (AAD). The purpose of this article is to report findings from a meta-analysis of available studies on adult hospitalized populations to evaluate efficacy of probiotics for prevention of AAD and Clostridium difficile-associated disease (CDAD). DATA SOURCES: A comprehensive, systematic search was conducted to identify all relevant studies on probiotic efficacy for prevention of AAD and CDAD. Data synthesis was done using MAStARI software from the Joanna Briggs Institute (University of Adelaide, Australia). CONCLUSIONS: AAD affects one in five people on antibiotics. Risk factors for the development of AAD include the use of broad-spectrum antibiotics and host factors such as age, health status, hospitalization status, and exposure to nosocomial pathogens. About a third of AAD cases have CDAD. Meta-analysis showed that administration of probiotics led to a statistically significant relative risk reduction of 44% for AAD and 71% for CDAD. IMPLICATIONS FOR PRACTICE: Extended hospital stays, readmissions, and higher hospital costs are just some of the consequences of ADD and CDAD. Strategies currently used include discontinuing or changing the inciting antibiotic, restricting high-risk antibiotics, and encouraging the use of antibiotics based on sensitivity reports. Healthcare spending, morbidity, and mortality can potentially be reduced considerably by reducing the occurrence of ADD and CDAD by administering prophylaxis with probiotics concurrently with antibiotics.