Exploring Stroke Outcomes Following a Door-to-Needle Quality Improvement Project.

BACKGROUND: Although stroke rates in Canada are expected to increase dramatically over the next decade, time-driven hyperacute stroke care with thrombolysis increases the likelihood of a good clinical outcome. Following a period of suboptimal performance results for stroke care, our tertiary care center undertook a door-to-needle (DTN) quality improvement initiative. The purpose of our study was to determine if the resulting improved median DTN times and greater proportion of patients treated within 60 minutes of arrival at our emergency department were associated with improved clinical outcomes. METHODS: Guided by the Donabedian quality framework, we retrospectively reviewed charts of consecutive patients (n = 324) who received thrombolysis pre- and post-quality improvement initiative. Data on patient characteristics, and process and outcome measures were collected. Primary study outcomes included mortality, adverse events, discharge location, and independence at discharge. Data analysis compared proportions with Chi Square and means using the two-tailed t-test and a 0.05 level of significance. RESULTS: Median DTN times and the percentage of cases with a DTN ≤60 minutes improved significantly post-intervention (p < 0.001). In-hospital mortality decreased (p = 0.013), and the proportion of favorable versus unfavorable discharge locations improved (p = 0.005). Mortality rates for all study patients with DTN ≤60 versus >60 minutes were also significantly lower (p = 0.044) post-intervention. CONCLUSIONS: Our quality improvement initiative resulted in timelier care and positively influenced clinical outcomes. This study highlights the need for ongoing, innovative investment strategies to ensure timely hyperacute stroke care and optimal patient outcomes.

Exploring the Perceptions and Health Behaviours of Patients Following an Elective Ad-hoc Percutaneous Coronary Intervention: A Qualitative Study.

RESULTS: Participants expressed uncertainty about their future health and feared disease recurrence, which appeared to provide motivation for adopting a healthier lifestyle. Although two participants voiced the belief that the elective PCI cured their disease, this perception did not appear to influence their engagement in risk reduction behaviours. However, systemfactors such as a lack of information, direction, and/or support from health care providers appeared to play a limiting role in their ability to move forward with lifestyle change. BACKGROUND: Elective ad-hoc percutaneous coronary interventions (PCIs) are increasingly used to manage the symptoms of coronary artery disease (CAD). However, we have limited understanding of the patients' experiences and health behaviours post-procedure. PURPOSE: Explore the factors that influence the perceptions and health behaviours of patients after elective ad-hoc PCI. METHODS: This interpretive descriptive study used purposive sampling to recruit participants (N = 10) aged 44 to 65 years following an elective ad-hoc PCI from a cardiac catheterization laboratory at a tertiary centre in Winnipeg, MB. Participants were interviewed 11 to 35 days following their procedure. Recruitment continued until no new substantive themes emerged. The Health Belief Model provided the frameworkfor developing, exploring, interpreting, and analyzing the data. PRACTICE IMPLICATIONS: Nurses have a key role in the education of patients and in providingpatient-centred care that supports lifestyle change. Nurses need to develop strategies that decrease barriers to engaging in risk reduction behaviours following elective ad-hoc PCI if patients are to experience improved health and longevity.

Emergency Nurses' Perspectives: Factors Affecting Caring.

UNLABELLED: Caring is a universal phenomenon. However, as a result of higher patient acuity and staff shortages within the chaotic ED environment, caring behaviors may be in peril. The purpose of this study was to gain insight into the meaning of caring from the perspective of emergency nurses. Exploring nurses' perspectives of caring is central to improving staffing and retention issues in this unique work environment. METHODS: As part of a larger study, a subsample of emergency nurses who work in public hospitals in Manitoba, Canada (n = 17) were interviewed. A qualitative descriptive design was used to gain insight into the caring perspectives of nurses by asking them, "What does caring meaning to you?" and "What affects caring in your practice in the emergency department?" Emerging themes were extracted through analysis of audio tapes and transcripts. RESULTS: Advocacy and holistic care emerged as major themes in the meaning of caring for emergency nurses. Caring was affected by a number of factors, including workload, lack of time, staffing issues, shift work, and lack of self-care. However, lack of management support was the most consistent hindrance to caring identified by study participants. DISCUSSION: Caring continues to be a unifying concept in nursing; however, influencing factors continue to undermine caring for emergency nurses. Caring is not subsidiary to nursing; it is the central core of nursing. Therefore, fostering a caring working environment is essential for nurses to practice holistic nursing care. It is also imperative to job satisfaction and the retention of emergency nurses.

Identifying the key predictors for retention in critical care nurses.

AIMS: The aim of this study was to explore the key predictors of retention in nurses working in critical care areas. BACKGROUND: The shortage of critical care nurses is reaching crisis proportions in Canada and throughout the industrialized world. Identifying the key influencing (i.e. person and organizational) factors and intermediary factors (i.e. job satisfaction, engagement, professional quality of life and caring) that affect intent to leave is central to developing optimal retention strategies for critical care nurses. DESIGN: As part of a larger mixed-methods study, we used a quantitative, cross-sectional research design. A novel framework: the Conceptual Framework for Predicting Nurse Retention was used to guide this study. METHODS: On-line survey data were collected from on a convenience sample of 188 registered nurses working in critical care areas of hospitals in the province of Manitoba, CANADA in 2011. RESULTS: Twenty-four per cent of the respondents reported that they would probably/definitely leave critical care in the next year. Based on bivariate and regression analyses, the key influencing factors that were significantly related to the intermediary factors and intent to leave critical care and nursing included: professional practice, management, physician/nurse collaboration, nurse competence, control/responsibility and autonomy. Of the intermediary factors, all but compassion satisfaction were related to intent to leave both critical care and nursing. CONCLUSION: This study highlights the importance of exploring multiple organizational and intermediary factors to determine strategies to retain critical care nurses. The findings also support the Conceptual Framework for Predicting Nurse Retention as a theoretical basis for further research.

Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study.

OBJECTIVE: To determine the feasibility of a cardiac prehabilitation (Prehab) program for patients waiting for elective coronary artery bypass graft (CABG). DESIGN: A two-group parallel randomized controlled trial. SETTING: Medical fitness facility. SUBJECTS: Seventeen preoperative elective CABG surgery patients were randomized to standard care (n = 9) or Prehab (n = 8). INTERVENTION: Standard care: three-hour preassessment appointment. Prehab: exercise and education classes for 60 minutes/day, twice weekly for at least four weeks. MAIN MEASURES: Data were collected at baseline, one week preoperatively, and three months postoperatively. The primary outcome measure was walking distance using a 6-minute walk test. Secondary outcome variables included 5-meter gait speed, and cardiac rehabilitation attendance three months postoperatively. RESULTS: Fifteen patients (standard care, n = 7; Prehab, n = 8) completed the study. No Prehab patients developed cardiac symptoms during study participation. Walking distance remained unchanged in the standard care group; whereas, the Prehab group increased their walking distance to mean ± SD 474 ±101 and 487 ±106 m at the preoperative and three month postoperative assessments (p < 0.05). Gait speed was unchanged in the standard care group, but improved in the Prehab group by 27% and 33% preoperatively and three months postoperatively, respectively (p < 0.05). Enrollment in cardiac rehabilitation three months postoperatively was higher for Prehab participants (100%) than standard care participants (43%; p < 0.05). CONCLUSION: These data provide evidence for the feasibility of a Prehab intervention to improve the health status of patients waiting for elective CABG surgery. A larger trial of 92 patients will be utilized to demonstrate the safety and efficacy of Prehab.

Exploring outcomes of a nurse practitioner-managed cardiac surgery follow-up intervention: a randomized trial.

AIMS: To describe and compare the outcomes of a nurse practitioner-managed cardiac surgery follow-up model of care with the standard model of primary care provider follow-up for coronary artery bypass graft surgery patients. BACKGROUND: Advances in healthcare have had a favourable impact on length of stay following cardiac surgery; however, the shorter length of stay has not been accompanied by enhanced support to bridge the gap between acute care and the community setting. DESIGN: Prospective (2009-2010) randomized study. METHODS: Elective cardiac surgery patients (N = 200) were randomly assigned to the nurse practitioner follow-up intervention or to the standard model of follow-up care. The main outcomes were health-related quality of life, patient satisfaction, symptoms, and health resource use. Outcome data were elicited via telephone interviews at 2 and 6 weeks postdischarge. RESULTS: Baseline differences between the two groups were non-significant; however, at 2 weeks postdischarge, the intervention group reported significantly fewer symptoms and higher physical functioning status. At 2 and 6 weeks postdischarge, the intervention group was significantly more satisfied with the amount of help, as well as the quality of the services received. Differences in healthcare resource use were not statistically significant. CONCLUSION: This evidence suggests that the nurse practitioner-managed model of follow-up care effectively bridges the gap between institutional and primary care in the cardiac surgery population.

Building emotional intelligence: a strategy for emerging nurse leaders to reduce workplace bullying.

Bullying is one of the most concerning forms of aggression in health care organizations. Conceptualized as an emotion-based response, bullying is often triggered by today's workplace challenges. Unfortunately, workplace bullying is an escalating problem in nursing. Bullying contributes to unhealthy and toxic environments, which in turn contribute to ineffective patient care, increased stress, and decreased job satisfaction among health care providers. These equate to a poor workforce environment, which in turn increases hospital costs when nurses choose to leave. Nurse managers are in positions of power to recognize and address negative workplace behaviors, such as bullying. However, emerging leaders in particular may not be equipped with the tools to deal with bullying and consequently may choose to overlook it. Substantive evidence from other disciplines supports the contention that individuals with greater emotional intelligence are better equipped to recognize early signs of negative behavior, such as bullying. Therefore, fostering emotional intelligence in emerging nurse leaders may lead to less bullying and more positive workplace environments for nurses in the future.

Exploring the key predictors of retention in emergency nurses.

AIM: To explore the factors that predict the retention of nurses working in emergency departments. BACKGROUND: The escalating shortage of nurses is one of the most critical issues facing specialty areas, such as the emergency department. Therefore, it is important to identify the key influencing and intermediary factors that affect emergency department nurses' intention to leave. METHODS: As part of a larger study, a cross-sectional survey was completed by 261 registered nurses working in the 12 designated emergency departments within rural, urban community and tertiary hospitals in Manitoba, Canada. RESULTS: Twenty-six per cent of the respondents will probably/definitely leave their current emergency department jobs within the next year. Engagement was the key predictor of intention to leave (P < 0.001). Engagement was also associated with job satisfaction, compassion satisfaction, compassion fatigue, and burnout (P < 0.05). In an ordinal least-squares model (R(2) = 0.44), nursing management, professional practice, collaboration with physicians, staffing resources and shift work emerged as significant influencing factors for engagement. CONCLUSIONS: Engagement plays a central role in emergency department nurses intention to leave. Addressing the factors that influence engagement may reduce emergency department nurses' intention to leave. IMPLICATIONS FOR NURSING MANAGEMENT: This study highlights the value of research-based evidence as the foundation for developing innovative strategies for the retention of emergency department nurses.

My abstract was accepted--now what? A guide to effective conference presentations.

Although conference presentations are central to the dissemination of new nursing knowledge, public speaking can be a daunting prospect. The purpose of this article is to provide nurses with the essential tools to deliver a successful conference presentation. Accordingly, the all-too-familiar steps of assessment, planning, implementation, and evaluation provide an organizational framework for a practical guide to developing and executing a relatively stress-free, effective presentation.

Risk assessment for hereditary breast cancer: BRCA1 and BRCA2.

The recent explosion of hereditary breast cancer genetic research has strengthened our understanding of genetic influences on health and disease. These scientific advances have significant implications for clinical oncology nurses and advanced practice nurses. In this paper, the Human Response to Illness Model (Mitchell, Gallucci, & Fought, 1991) is utilized to gain a comprehensive understanding of breast cancer related to the human response of genetic mutations. Accordingly, the research literature related to the physiological, pathophysiological, behavioural, and experiential perspectives of BRCA-related breast cancer will be highlighted. This research-based evidence will provide oncology nurses with the skills to establish a holistic plan of care for women with an actual or potential genetic risk for breast cancer.

Dyspnea in the thoracic trauma patient: a human response to illness.

Dyspnea is one of the most common presenting symptoms in thoracic trauma patients; therefore, trauma nurses require extensive knowledge of this symptom. The Human Response to Illness model provides an organizing framework to establish a comprehensive understanding of the human response of dyspnea following thoracic trauma. The model is used to describe the physiological, pathophysiological, behavioral, and experiential perspectives of dyspnea in thoracic trauma, while considering personal and environmental factors. This comprehensive overview will provide the trauma nurse with appropriate evidence-based rationale for interventions in the management of acute dyspnea in the thoracic trauma population.

Clinical placement anxiety in undergraduate nursing students: A concept analysis.

OBJECTIVE: The primary aim of this review was to complete an in-depth analysis of clinical placement anxiety in undergraduate nursing students. Our overall goal was to establish a strong foundation for clinical education strategies and future research on clinical placement anxiety in nursing education. DESIGN & METHODS: We utilized Walker and Avant's systematic 8-step approach to concept analysis as a framework to develop a comprehensive understanding of clinical placement anxiety in undergraduate students. DATA SOURCES: A review of existing literature on clinical placement anxiety was conducted using the electronic databases of PubMed, CINAHL, and PsychInfo, as well as a grey literature and snowball search. Search terms included clinical placement, clinical experience, nursing students, undergraduate nursing students, and anxiety. RESULTS: The literature search resulted in 81 articles that met the inclusion criteria. Five defining attributes were identified: a vague or unknown threat, psychological-emotional responses, psychological-cognitive responses, physiological responses, and unfamiliar environments or situations. Antecedents, consequences, and empirical referents of the concept were also highlighted. CONCLUSIONS: Insights gleaned from this concept analysis may enhance the ability of clinical nursing educators to effectively prevent and manage student anxiety in the clinical setting. By contextualizing anxiety, we have also validated the importance of further exploration of the anxiety experienced by undergraduate nursing students during their clinical experiences. Thus, this concept analysis establishes the foundation for educational strategies, as well as future research in nursing education.

Differences in coronary artery disease complexity and associations with mortality and hospital admissions among First Nations and non-First Nations patients undergoing angiography: a comparative retrospective matched cohort study.

BACKGROUND: First Nations people are more likely than the general population to experience long-term adverse health outcomes after coronary angiography. Our aim was to quantify the extent of coronary artery disease among First Nations and non-First Nations patients undergoing angiography to investigate differences in coronary artery disease and related health disparities. METHODS: We conducted a retrospective matched cohort study to compare health outcomes of First Nations and non-First Nations adult patients (> 18 yr) who underwent index angiography between Apr. 1, 2008, and Mar. 31, 2012, in Manitoba, Canada. The SYNTAX Score was used to measure and compare severity of coronary artery disease between groups. Primary outcomes of all-cause and cardiovascular mortality were compared between groups using Cox proportional hazard models adjusted by SYNTAX Score results and weighted by the inverse probability of being First Nations. Secondary outcomes included all-cause and cardiovascular-related hospital admissions. RESULTS: The cohort consisted of 277 matched pairs of First Nations and non-First Nations patients undergoing angiography; the average age of patients was 56.0 (standard deviation 11.7) years. The median SYNTAX Score results and patient distributions across categories in the matched paired cohort groups were not significantly different. Although proportionally First Nations patients showed worse health outcomes, mortality risks were similar in the weighted sample, even after controlling for revascularization and SYNTAX Score results. Secondary outcomes showed that adjusted risks for hospital admission for acute myocardial infarction (adjusted hazard ratio [HR] 3.03, 95% confidence interval [CI] 1.40-6.55) and for congestive heart failure (adjusted HR 3.84, 95% CI 1.37-10.78) were significantly higher among First Nations patients in the weighted sample. INTERPRETATION: The extent of coronary artery disease among matched cohort groups of First Nations and non-First Nations patients appears similar, and controlling for baseline sociodemographic characteristics, coronary artery disease risk factors and SYNTAX Score results explained higher mortality risk and most hospital admissions among First Nations patients. Although there is a need to decrease risk factors for coronary artery disease among First Nations populations, addressing individuals' behaviour without considering root causes underlying risk factors for coronary artery disease will fail to decrease health outcome disparities among First Nations patients undergoing angiography.

Chronic neuropathic pain in women after breast cancer treatment.

Chronic neuropathic pain affects between 20% and 50% of women after their breast cancer treatment. The Human Response to Illness (HRTI) model provides a comprehensive theoretic framework to guide the assessment and management of this pain in women with breast cancer. Knowledge of the physiologil, pathophysiologic, behavioral, and experiential perspectives, as well as personal and environmental factors, will assist nurses and other health care professionals to develop better assessment tools and improve interventions and treatment modalities. This will provide guidance for nursing practice, education, and research and ultimately improve the quality of life, optimize outcomes, and reduce the incidence of chronic neuropathic pain in the breast cancer population.

Coronary artery bypass graft surgery: exploring a broader perspective of risks and outcomes.

Although the literature is replete with evidence related to physiological predictors and short-term outcomes of coronary artery bypass graft (CABG) surgery, there is still a paucity of data that encompass a broader perspective of risk and outcomes. The primary objective of this prospective cohort study was to explore the physiological and psychosocial dimensions of preoperative status that may be predictive of the short- and longer term outcomes of CABG surgery. Patients (N = 136) scheduled for elective/urgent CABG surgery were followed from the time of placement on the waiting list until 6 months after the surgery. Significant predictors of intensive care unit length of stay (LOS) included the following: age, urgency of operation, and perioperative complications. Hospital LOS was best predicted by baseline unemployment, longer bypass time, and perioperative complications. Baseline unemployment and less optimism regarding surgery outcomes were predictive of postdischarge home care utilization. Lower baseline physical functioning predicted postdischarge emergency room visits. Sex and baseline mental status predicted quality of life/health satisfaction scores at 6 weeks and 6 months after discharge. The ability to predict patient outcomes has implications for program planning, patient education, and policy development. The findings of this study provide rationale for clinicians, educators, and administrators to consider a broader scope of physiological and psychosocial parameters to predict outcomes of CABG surgery. Although the sample size was relatively small, the broader perspective on risk and outcomes provides insight for strategies to optimize overall outcomes for the CABG surgery population. These findings also establish the cornerstone for ongoing CABG surgery outcomes evaluation and research.

Improving outcomes following elective percutaneous coronary intervention: the key role of exercise and the advanced practice nurse.

Percutaneous coronary intervention (PCI) is a safe, effective, non-surgical treatment for coronary artery disease (CAD). The demand for PCI has increased exponentially since the 1980s and it has become the treatment of choice for many individuals with CAD. Since PCI is not a cure, secondary prevention strategies are critical to prevent disease progression. Unfortunately, current strategies ignore the specific needs of the elective PCI population. In this article, the authors highlight the unique characteristics of these patients, which may contribute to their lack of engagement in healthy lifestyles. Elective PCI patients are vulnerable due to limited knowledge and follow-up, and lack of enrolment in secondary prevention programs. Exercise is a central component of any cardiac prevention strategy. Individualized exercise programs that incorporate physical activity and counselling can potentially improve the clinical outcomes of these patients. Advanced practice cardiovascular nurses play a key role in developing, implementing, and evaluating exercise programs in this population.

Angina following percutaneous coronary intervention: in-stent restenosis.

Percutaneous coronary intervention (PCI) represents a technical advance in the treatment of coronary artery disease. However, it is not without risks both during and after the procedure. In-stent restenosis (ISR) is the most common complication following PCI. Individuals who experience angina associated with ISR often fail to recognize its seriousness and, therefore, do not respond appropriately to the situation. Individuals with ISR are vulnerable to the consequences of angina, including increased morbidity and mortality, as well as a decreased health-related quality of life. In this article, the authors review the risks for developing ISR, the pathophysiology of angina related to ISR, and the challenges that face patients who develop recurrent angina post-PCI. Cardiovascular nurses play a critical role in the clinical management and education of patients following PCI. The provision of post-PCI follow-up care is key to identifying, managing, and supporting patients with recurrent angina.

Total spinal anesthesia for cardiac surgery: does it make a difference in patient outcomes?

BACKGROUND: Heart disease is a major cause of morbidity and mortality. While cardiac surgery is a viable treatment option, it is a potent physiological stressor. The surgical stress response may result in patient decompensation and negative patient outcomes. The goal of a novel anesthetic approach, which combines high spinal anesthesia with intrathecal morphine and general anesthesia (TSA), is to attenuate this stress response. PURPOSE: The primary purpose of this pilot study (n = 70) was to describe and compare the outcomes of TSA cardiac surgery with a matched control sample of patients who received the "standard general anesthetic" (GA). METHOD: A retrospective, descriptive, correlational design was used for a matched pair total sample of (n = 70). Following ethics approval, patient consents were obtained and chart review data collection was completed. FINDINGS: TSA patients were more likely to be extubated in the operating room (p < 0.0001) and also had significantly shorter overall duration of endotracheal intubation (p < 0.0008). During the initial 24 hours after surgery, the TSA group received significantly less morphine (p < 0.0001). The mean difference in postoperative hospital length of stay did not reach statistical significance. However, on average, the TSA group was discharged three days earlier than the GA group. CONCLUSION: This evidence highlights the clinical nursing relevance of the type of anesthesia on postoperative care and outcomes. The knowledge gained from these findings will help to enable the multidisciplinary critical care team to anticipate TSA patient outcomes and to facilitate the development of appropriate and effective evidence-based, patient-focused plans of care. This pilot study establishes sound rationale for subsequent larger prospective cohort research of the TSA patient population.

Understanding urinary incontinence after radical prostatectomy: a nursing framework.

Prostate cancer is one of the most prevalent malignancies diagnosed in North American men. Typically, men diagnosed with localized prostate cancer have two options for curative treatment: radiation therapy or radical prostatectomy (RP). Many men choose RP to remove the cancer; however, the intervention has two possible side effects that patients dread: erectile dysfunction and urinary incontinence (UI). At least 50% of men who undergo RP suffer from UI, which can lead to embarrassment, loss of a sense of control, depression, and decreased social interactions. The Human Response to Illness Model provides a framework to gain a comprehensive understanding of the physiologic, pathophysiologic, behavioral, and experiential perspectives as well as personal and environmental factors related to UI following RP. Knowledge gained from these perspectives will help nurses design strategies that facilitate coping and improve outcomes in men with UI following RP.

Sleep disturbance in patients with advanced cancer.

Sleep is a complex process, acknowledged to be essential for health and wellbeing. Sleep disturbance is reported to be a significant problem for patients across the cancer care trajectory, including those in the palliative phase of illness. This paper reviews the literature specific to sleep disturbance in patients with advanced cancer. The Human Response to Illness model, which is consistent with the central tenets of palliative care philosophy, provides a valuable framework to examine and organize the current knowledge related to sleep disturbance. The four perspectives of this biopsychosocial nursing model--physiology, pathophysiology, behavioural and experiential, as well as the personal and environmental factors--offer a broad perspective to better understand this multidimensional symptom and create a strong foundation for nursing care and future research directions.