A Dedicated Education Unit and a Novel Resident Nurse Transition-to-Practice Program in an Ambulatory Oncology Setting.

OBJECTIVE: To summarize an innovative initiative in oncology nurse workforce development that addresses critical current and future gaps and encompasses use of dedicated education units for student nurse rotation and a transition-to-practice residency program. DATA SOURCES: Review of institutional data including original pilot analysis and ongoing programmatic metrics (N=8 years), consensus, professional guidelines, and published literature. CONCLUSION: The dedicated education unit serves as a conduit for recruitment into institutional oncology nurse residency positions, and retention rates in the residency program continue to exceed national averages. Subsequent mentoring of these nurses in transition to practice has manifested high rates of promotion into nurse leadership roles year over year. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurse practice incorporates state-of-the-science approved therapies, early phase clinical trial implementation, and evidence-based complex oncology patient care management. A new model of student clinical nurse rotations in ambulatory settings, nurse resident transition to practice, and ongoing leadership mentoring is essential in creating a sustainable, highly skilled, and robust oncology nurse work force.

Pain Management Algorithms for Implementing Best Practices in Nursing Homes: Results of a Randomized Controlled Trial.

OBJECTIVE: To enhance pain practices in nursing homes (NHs) using pain assessment and management algorithms and intense diffusion strategies. DESIGN: A cluster, randomized controlled trial. The intervention consisted of intensive training and support for the use of recommended pain assessment and management practices using algorithms (ALGs). Control facilities received pain education (EDU) only. SETTING: Twenty-seven NHs in the greater Puget Sound area participated. Facilities were diverse in terms of size, quality, and ownership. PARTICIPANTS: Data were collected from 485 NH residents; 259 for the intervention and 226 for the control group. MEASUREMENTS: Resident outcomes were nursing assistant (proxy) report and self-reported resident pain intensity. Process outcomes were adherence to recommended pain practices. Outcomes were measured at baseline, completion of the intervention (ALG) or training (EDU), and again 6 months later. RESULTS: Among 8 comparisons of outcome measures between ALG and EDU (changes in 4 primary pain measures compared at 2 postintervention time points) there was only 1 statistically significant but small treatment difference in proxy- or self-reported pain intensity. Resident-reported worst pain decreased by an average of 0.8 points from baseline to 6 months among the EDU group and increased by 0.2 points among the ALG (P = .005), a clinically nonsignificant difference. There were no statistically significant differences in adherence to clinical guideline practice recommendations between ALG and EDU following the intervention. CONCLUSIONS: Future research needs to identify and test effective implementation methods for changing complex clinical practices in NHs, including those to reduce pain.

A mixed-methods approach to investigating the adoption of evidence-based pain practices in nursing homes.

This mixed methods study examined perceived facilitators and obstacles to adopting evidence-based pain management protocols vis-a-vis documented practice changes that were measured using a chart audit tool. This analysis used data from a subgroup of four nursing homes that participated in a clinical trial. Focus group interviews with staff yielded qualitative data about perceived factors that affected their willingness and ability to use the protocols. Chart audits determined whether pain assessment and management practices changed over time in light of these reported facilitators and barriers. Reported facilitators included administrative support, staff consistency, and policy and procedure changes. Barriers were staff attitudes, regulatory issues, and provider mistrust of nurses' judgment. Overall, staff reported improvements in pain practices. These reports were corroborated by modest but significant increases in adherence to recommended practices. Change in clinical practice is complex and requires attention to both structural and process aspects of care.

Addressing methodological challenges in implementing the nursing home pain management algorithm randomized controlled trial.

BACKGROUND: Unrelieved pain among nursing home (NH) residents is a well-documented problem. Attempts have been made to enhance pain management for older adults, including those in NHs. Several evidence-based clinical guidelines have been published to assist providers in assessing and managing acute and chronic pain in older adults. Despite the proliferation and dissemination of these practice guidelines, research has shown that intensive systems-level implementation strategies are necessary to change clinical practice and patient outcomes within a health-care setting. One promising approach is the embedding of guidelines into explicit protocols and algorithms to enhance decision making. PURPOSE: The goal of the article is to describe several issues that arose in the design and conduct of a study that compared the effectiveness of pain management algorithms coupled with a comprehensive adoption program versus the effectiveness of education alone in improving evidence-based pain assessment and management practices, decreasing pain and depressive symptoms, and enhancing mobility among NH residents. METHODS: The study used a cluster-randomized controlled trial (RCT) design in which the individual NH was the unit of randomization. The Roger's Diffusion of Innovations theory provided the framework for the intervention. Outcome measures were surrogate-reported usual pain, self-reported usual and worst pain, and self-reported pain-related interference with activities, depression, and mobility. RESULTS: The final sample consisted of 485 NH residents from 27 NHs. The investigators were able to use a staggered enrollment strategy to recruit and retain facilities. The adaptive randomization procedures were successful in balancing intervention and control sites on key NH characteristics. Several strategies were successfully implemented to enhance the adoption of the algorithm. LIMITATIONS/LESSONS: The investigators encountered several methodological challenges that were inherent to both the design and implementation of the study. The most problematic issue concerned the measurement of outcomes in persons with moderate to severe cognitive impairment. It was difficult to identify valid, reliable, and sensitive outcome measures that could be applied to all NH residents regardless of the ability to self-report. Another challenge was the inability to incorporate advances in implementation science into the ongoing study CONCLUSIONS: Methodological challenges are inevitable in the conduct of an RCT. The need to optimize internal validity by adhering to the study protocol is compromised by the emergent logistical issues that arise during the course of the study.

The use of algorithms in assessing and managing persistent pain in older adults.

OVERVIEW: As the U.S. population ages, nurses will care for increasing numbers of older adults, most of whom suffer from at least one chronic illness. The persistent pain associated with many chronic illnesses can have detrimental effects on patients' functioning and quality of life. Algorithms developed from evidence-based clinical practice guidelines are tools that can facilitate the application of research to practice. This article introduces readers to the use of algorithms in guiding the assessment and management of persistent pain in older adults, and provides an illustrative case study.

Nursing home staff adherence to evidence-based pain management practices.

The purpose of this study was to determine the extent to which nursing home staff adhere to current evidence-based guidelines to assess and manage persistent pain experienced by elderly residents. A retrospective audit was conducted of the medical records of 291 residents of 14 long-term care facilities in western Washington State. Data revealed a gap between actual practice and current best practice. Assessment of persistent pain was limited primarily to intensity and location. Although prescribing practices were more in line with evidence-based guidelines, a significant number of residents did not obtain adequate pain relief. Nonpharmacological pain management methods were rarely implemented. Nursing home staff and administrators must critically examine both system and individual staff reasons for failure to comply with best pain management practices. Research is needed to determine factors that contribute to less-than-optimal adherence to evidence-based guidelines for pain management, as well as the best methods for implementing practice change.

Palliative care: misconceptions that limit access for patients with chronic renal disease.

There is an urgent need to incorporate palliative care into the treatment of patients with end-stage renal disease (ESRD). These patients have a shortened lifespan and face end-of-life decisions as renal function declines and renal replacement therapy becomes necessary. They also experience a high symptom burden as a result of the illness as well as its treatment. Why, then, do patients with ESRD rarely receive expert palliative care services that have been shown to enhance the quality of life of patients with other life-limiting illnesses? The lack of access to palliative care can be attributed, in part, to misconceptions about its philosophy and goals. It is hoped that clarification of these misconceptions will facilitate integration of palliative care into routine nephrology practice.

Symptom assessment of patients with chronic obstructive pulmonary disease.

The primary purpose of this secondary data analysis was to evaluate the efficacy and suitability of the Memorial Symptom Assessment Scale (MSAS) for use with patients with severe chronic obstructive pulmonary disease (COPD). Symptoms experienced by patients with severe COPD were assessed in the original investigation using the 32-item MSAS. The sample consisted of 72 individuals with COPD ranging in age from 36 to 79 years. To increase its efficiency for use with severely ill COPD patients, the original MSAS was shortened to include the 19 most frequently reported symptoms. Reliability of the revised tool remained high (Cronbach's alpha = .86). Content and convergent validity of the revised tool were also established. The revised MSAS appears to be an appropriate measure of the multidimensional, multisymptom experience of patients with severe COPD.

The multidimensional characteristics of symptoms reported by patients on hemodialysis.

Contemporary theoretical models conceptualize symptoms as multidimensional interactive phenomena. This research examined the symptoms experienced by patients on hemodialysis within this paradigm. The intensity (severity), timing (frequency and duration), distress (bother), and concurrence (co-occurring symptoms) associated with symptoms were explored. A multidimensional profile constructed for each of the symptoms demonstrated that those rated as the most severe were not necessarily the most frequently occurring, longest lasting, or most distressing to patients. Symptoms also occurred in groups. Patients reported individual symptoms as increasingly troublesome and quality of life progressively lower as they experienced more of the symptoms in a grouping. These findings suggest the need to view patients' symptom experiences more broadly. Symptom assessment should include the full complement of symptoms patients experience and move beyond the current practice of assessment of severity alone to include all symptom dimensions.

The illness trajectory of end-stage renal disease dialysis patients.

Chronic illness is the number one health problem in the United States. As a consequence, health care professionals have assumed an increasingly important role in helping patients and families manage illness over an extended period of time. Familiarity with the evolution of chronic illness is needed to increase the effectiveness of these efforts. The concept of a trajectory provides a way for clinicians to gain a fuller understanding of the changing nature of chronic illness. The trajectory model has not yet been used to define the experience of end-stage renal disease (ESRD). ESRD is typically viewed as the static end point of chronic renal failure. The new paradigm suggests that the experience of ESRD continues to evolve from the time of diagnosis until death and that it follows a trajectory that can be described. This article represents the first attempt to delineate the ESRD illness trajectory, including the characteristics of each phase relative to the dimensions of life. The significance of the trajectory for clinical practice is discussed as well as the need for further research to validate and refine the model.

Symptom clusters in elderly patients with lung cancer.

PURPOSE/OBJECTIVES: To identify the number, type, and combination (cluster) of symptoms experienced by patients with lung cancer. DESIGN: A secondary analysis of data collected as part of a larger study. SETTING: 24 sites that included community hospitals, medical clinics, oncology clinics, and radiation-oncology clinics. SAMPLE: 220 patients newly diagnosed with lung cancer, ranging in age from 65-89 years (mean = 72 years, SD = 5.02), 38% with early-stage and 62% with late-stage lung cancer. METHODS: Subject self-report. FINDINGS: Factor analysis found that the symptoms of fatigue, nausea, weakness, appetite loss, weight loss, altered taste, and vomiting form a cluster. Initial staging of cancer, the number of comorbid conditions, and being treated with chemotherapy emerged as significant predictors of the symptoms reported. Few differences were noted between men and women. Correlation was found among the numbers of symptoms reported, symptom severity, and limitations attributed to symptoms. CONCLUSIONS: Patients with lung cancer report multiple distressing symptoms related to symptom severity and limitations. IMPLICATIONS FOR NURSING: Assessment of multiple symptoms is recommended in patients with lung cancer.

A cluster of symptoms over time in patients with lung cancer.

BACKGROUND: Patients with lung cancer present late in the disease and have multiple symptoms. Previous research has shown the symptom cluster of fatigue, weakness, weight loss, appetite loss, nausea, vomiting, and altered taste to be present at time of lung cancer diagnosis. OBJECTIVES: The study determined whether the symptom cluster identified at the time of diagnosis remained 3 and 6 months later, and whether there was a difference in the mean number of symptoms and the mean level of symptom severity over time. The relation of the severity rating for individual symptoms at the time of diagnosis and at 3 and 6 months after diagnosis was examined. Predictors for the number of symptoms and whether the symptom cluster was predictive of death were determined. METHODS: Secondary analysis of an existing data set for 112 patients with newly diagnosed lung cancer assessed at diagnosis and at 3 and 6 months was performed and determined whether they were alive or dead 19 months after diagnosis. RESULTS: The cluster of seven symptoms had internal consistency that remained at 3 and 6 months. The mean symptom severity and the number of symptoms at diagnosis were correlated with later ratings, but decreased in severity over time. A similar decrease in severity rating was seen for the individual symptoms in the cluster. The stage of cancer at diagnosis was the most predictive of the number of cluster symptoms reported. Death 6 to 19 months after diagnosis was predicted by age, stage of cancer at diagnosis, and symptom severity at 6 months. CONCLUSIONS: The symptom cluster remains over the course of lung cancer and is an independent predictor of the patient's death. Symptom severity, the number of symptoms reported, and the severity of the individual symptoms decreased over time. The stage of cancer at diagnosis is the best predictor of symptoms later in the disease.