Development of a decision support tool to prevent community acquired pressure injuries for use in the spinal cord injury clinic using the delphi technique.

STUDY DESIGN: Delphi Technique. OBJECTIVES: Describe the development of a decision support tool to prevent community-acquired pressure injuries (CAPrIs) in individuals with spinal cord injury (SCI) for use in SCI clinics, called the Community-Acquired Pressure Injury Prevention-Field Implementation Tool (CAPP-FIT). SETTING: Veteran Health Administration Hospital, Chicago, Illinois, USA. METHODS: Concept mapping of current pressure injury (PrI) guidelines and qualitative research describing risks, actions, and resources needed to prevent CAPrIs associated with SCI were used to develop 40 veteran checklist items (Items) along with 37 associated provider actions (Actions) for the tool. The Delphi technique was used to refine Items and Actions with a panel of interprofessional SCI providers (n = 15), veterans with SCI (n = 4), and caregivers (n = 3) to determine consensus on a 4-point Likert scale (strongly agree-strongly disagree) for each Item and Action. A 75% agreement was set for responses rated as strongly agree or agree. RESULTS: Panelists were 60% female, 62% White, 33% veterans with SCI or caregivers, 33% wound care certified with a mean age of 59 years. Two survey rounds were required for consensus for 41 Item and 38 Action CAPP-FIT. Response rate was 95% for both rounds. Delphi round 1 showed all but two Actions affirming agreement above 75%. Substantive comments from panelists required revision to 5 Items and 9 Actions and one additional Item/Actions related to coping, meeting threshold percent agreement in Round 2. CONCLUSIONS: The CAPP-FIT could become a useful tool for Veterans living with SCI, caregivers, and SCI providers.

Effectiveness of an interprofessional ambulatory care model on diabetes: evaluating clinical markers in a low-income patient population.

The purpose of this study was to determine whether a new ambulatory care model, interprofessional collaborative care-coordinated team model (interprofessional model), based on the Wagner Care Model improved clinical indicators in a low-income population. This study was a retrospective 12-month pre-post (n = 204) and propensity matched (n = 171) comparative study of the interprofessional model in a primary clinic for patients with type 2 diabetes. Secondary data were collected from June 2014to February 2017 in an academic medical centre in a large Midwestern city. Findings demonstrated statistically and clinically significant improvement in A1C in both the pre/post arm of the study (↓ 0.8%) and the intervention/propensity matched arm (↓ 0.53%). Within the intervention group, there was a significant decrease in weight in the pre/post arm with 55% of cases losing weight, whereas 45% did not lose weight (p = .02). Diastolic blood pressure less than 90 also significantly improved in the pre/post arm of the study (10.1% n = 18, versus 3.9%, n = 7, p = .04). The interprofessional model showed that an ambulatory healthcare redesign incorporating an interprofessional team approach to optimise the health of this type 2 diabetes patient population can be effective. This study demonstrates the importance of using interprofessional collaborative practice teams to guide healthcare and improve patient outcomes.

Health provider identified barriers and facilitators to weight management for individuals with spinal cord injury.

STUDY DESIGN: Qualitative descriptive study using semi-structured interviews OBJECTIVE: The purpose of this study was to examine the barriers and facilitators of weight management in individuals with spinal cord injury (SCI) from the perspective of SCI health care providers. SETTING: Veterans Health Administration and Midwest Regional SCI Care Systems. METHODS: Health care providers (n = 25) who care for individuals with SCI completed semi-structured interviews. Thematic analysis methodology was used to identify emergent themes around barriers and facilitators to weight management in SCI. RESULTS: Sixteen subthemes emerged for barriers and seven subthemes emerged for facilitators for weight management in SCI. Barriers included individual-level factors (e.g., physical ability/mobility limitations, lack of interest, psychological obstacles, lack of knowledge, poor dietary strategies), socio-environmental factors (e.g., challenges with family support, lack of access to weight management resources, dependency on others, difficulties obtaining weight measurement), and organizational factors (e.g., lack of integration/inconsistent weight management support from healthcare systems, pushing calorie intake early post-injury). Facilitators included individual-level factors (e.g., motivation, education/knowledge, participation in exercise and physical activity) and socio-environmental factors (e.g., positive support network, access to/use of healthy dietary strategies, access to exercise facilities/adaptive equipment, participating in weight management with others). CONCLUSIONS: Healthcare providers identified individual-level, socio-environmental, and organizational barriers and facilitators that influence weight management efforts in individuals with SCI. Future weight management resources and programs should consider addressing common barriers identified by healthcare providers, individuals with SCI, and their caregivers, and develop strategies to promote facilitators to enhance weight management in this population.

Communicating Spiritual Care in the Electronic Health Record.

Chaplains must document their ministry of care in electronic health records that primarily focus on the physical dimension of care. Creating chaplain documentation that reflects the spiritual dimension of care requires chaplains to participate in the screen design. This article describes how chaplain documentation was designed and refined using psychometric methods. The resulting system successfully supported chaplain workflow, provided an ability to aggregate chaplain workload, and integrated the chaplain into the interprofessional team by structuring, linking, and sharing both the chaplain and nursing assessment of spiritual distress in the electronic health record. Documentation used 5-point Likert scales to measure different dimensions of patient spirituality. Reliability and validity were further evaluated as part of a workshop at an Association of Professional Chaplains annual meeting. Findings supported interrater reliability and the ability to predict and discriminate change pre and post encounter. Documentation screen content is presented.

Developing a decision support tool to prevent community-acquired pressure injuries in spinal cord injury in ambulatory care: A nurse-led protocol for mix methods research.

BACKGROUND: There is a lack of formal guidelines and decision support tools to prevent community-acquired pressure injuries (CAPrIs) in Veterans with spinal cord injury (SCI). PURPOSE: In this article we present our research protocol that describes our plans to create and test a decision support tool to prevent CAPrIs in SCI. METHODS: In Aim 1, we identified mental-models of CAPrI prevention from the perspectives of Veterans (using photovoice, guided tours), and Veterans Health Administration SCI providers (using interviews), and triangulation to compare the two mental-models. This led to a decision support tool developed and validated using Delphi approaches in Aim 2 and will be followed by tool automation and system redesign for pilot implementation in Aim 3. FINDINGS: The nurse-led research protocol provides a map to systematically explore, address and translate research into evidence-based practice. DISCUSSION: Refinement of the protocol will guide future research and implementation.

Measuring Overweight and Obesity in Persons with Spinal Cord Injury: What Do Health Providers Use and What are the Challenges?

INTRODUCTION: Obesity is a significant health concern for veterans and individuals with spinal cord injury, yet screening for overweight/obesity can be challenging. This study examines how healthcare providers screen for overweight/obesity and the challenges encountered in identifying overweight/obesity in veterans and persons with spinal cord injury. MATERIALS AND METHODS: Healthcare providers who provide care for persons with spinal cord injury completed a semi-structured interview. The interview explored their perspectives on measuring overweight/obesity in persons with spinal cord injury and the challenges they faced. Thematic analysis was used to identify themes that emerged from the interviews. RESULTS: Twenty-five providers (88% female with an average experience of 9.6 ± 7.3 years in providing care for spinal cord injury patients) participated in the interviews. The themes described the health indicators and equipment used to assess overweight/obesity, provider concerns regarding measurement, and criteria for classifying overweight/obesity. Body weight and body mass index were the most commonly used indicators. However, concerns were raised regarding accuracy of these measures for spinal cord injury patients, as well as issues related to the accessibility, calibration, and usability of the equipment. Many providers reported using standard body mass index ranges and categories instead of those specific to spinal cord injury. CONCLUSION: This study identified the most commonly used indicators of weight or body composition in veterans and persons with spinal cord injury and highlighted providers' concerns with these measures. Future research is needed to identify the most feasible, accurate, and appropriate health indicators that could be used in a clinical setting to identify overweight and obesity in this population.

Provider perspectives of community-acquired pressure injury prevention in veterans with spinal cord injury.

CONTEXT/OBJECTIVE: Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). Most studies and interventions focus on the prevention of pressure injuries acquired in the hospital. The goal of this study is to better understand SCI provider perspectives of the risks, actions and resources needed to prevent CAPrIs. DESIGN: Qualitative descriptive, semi-structured interviews of SCI providers analyzed using a deductive-inductive approach. SETTING: Three geographically different veteran health administration spinal cord injury/disorder centers. PARTICIPANTS: 30 interprofessional SCI providers. INTERVENTIONS: Not applicable. OUTCOME MEASURES: Provider perspective of risks, actions and resources for CAPrI prevention in veterans with SCI. RESULTS: 30 interviews revealed a model of provider perspectives of CAPrI prevention including veteran risk characteristics, veteran preventive activities and provider, family, community caregiving resources. CONCLUSION: Understanding provider perspectives of Veteran CAPrI preventive risks, actions and resources guides more appropriate interventions to prevent CAPrIs in individuals living with SCI.

Triangulation of veteran and provider models of preventing community-acquired pressure injuries in spinal cord injury to reveal convergence and divergence of perspectives.

CONTEXT/OBJECTIVE: Community-acquired pressure injuries (CAPrI) are a common and costly complication of spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little guidance in CAPrI prevention. This study describes how provider and veteran perspectives of CAPrI prevention converge and diverge. DESIGN: The Farmer triangulation method was used to compare two models from previous qualitative research describing provider and veteran perspectives of CAPrI prevention based on the framework of CAPrI risks, resources, and preventive activities. The previous qualitative research revealed the provider model of CAPrI prevention using semi-structured interviews with interprofessional SCI providers at the Veteran Health Administration (VA) (n = 30). A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) revealed the Veteran model of CAPrI prevention. SETTING: The previous qualitative research was conducted at three geographically different VA spinal cord injury/disorder centers in the United States (north, south, west). PARTICIPANTS: 30 interprofessional SCI providers; 30 Veterans living with SCI at three VA SCI Centers in the United States. INTERVENTIONS: n/a. OUTCOME MEASURES: Provider-Veteran perspectives of CAPrI prevention that demonstrated agreement, partial agreement, divergence, and silence. RESULTS: Providers and veterans agreed on what is basic care, and the importance of family, caregiver and health provider/system supports, but they viewed motivation, veteran role, informal supports, and adequacy of supports differently. CONCLUSION: Understanding how SCI providers and veterans living with SCI view prevention in the community informs how to promote preventive care in the context of veterans' lives.

US Department of Veterans Affairs Post-Baccalaureate Registered Nurse Residency: Developing Nurses Equipped with Knowledge and Skills to Care for Nation's Veterans.

Nurse residency programs were developed to improve novice nurse competencies, mitigate burnout, lower recruitment costs and nurse attrition, and the quality of patient care. The Office of Academic Affiliations (OAA), US Department of Veterans Affairs (VA), established a 12-month postbaccalaureate nurse residency (PB-RNR) program at 49 sites to develop competent, confident, practice-ready registered nurses equipped with the knowledge and skills to care for veterans. The OAA evaluation of the PB-RNR program demonstrated improved new nurse graduate competence, confidence, recruitment, and retention rates after completion of training at participating VA medical facilities.

Development and evaluation of an educational curriculum for healthcare providers on overweight/obesity management in individuals with spinal cord injury based on diverse stakeholder engagement.

BACKGROUND: Spinal cord injury (SCI) healthcare providers are aware of the harmful consequences of overweight/obesity in persons with SCI, but many are unaware of available information and lack training to guide weight management care in the SCI population. OBJECTIVE: Describe the development and content of an educational curriculum for healthcare providers to help individuals with SCI prevent or manage overweight/obesity. METHODS: The biopsychoecological framework guided curriculum planning, data collection, and product development. Thematic analysis of interviews conducted with individuals with SCI, informal caregivers, and SCI healthcare providers pinpointed central educational curriculum topics. SCI healthcare providers evaluated the curriculum. RESULTS: Seven comprehensive topics were developed: 1. Scope and consequences of overweight/obesity in SCI; 2. Classifying and measuring overweight/obesity in SCI; 3. Guidelines related to weight management in SCI; 4. Identifying challenges (and solutions) to weight management in SCI; 5. Strategies for providers to facilitate weight management; 6. Understanding goals, motivators, and desired feedback for weight management; and 7. Knowing how informal caregivers are affected by weight and weight management of care recipients with SCI. High ratings (>80% strong agreement) were achieved on content, word choice, organization, relevance, and actionability. Modification needs were identified and subsequently made to layout, visual aids, and provision of tangible resources. Providers described the curriculum as a scientifically rigorous resource that addresses a knowledge gap, provides population-specific content, and is useful across interdisciplinary teams. CONCLUSION: We developed a self-directed learning educational curriculum addressing topics most salient to stakeholders involved in overweight/obesity management of persons with SCI.

Development and psychometric testing of the Spiritual Care Inventory instrument.

AIM: This article is a report of the development and psychometric testing of the Spiritual Care Inventory. BACKGROUND: Research supporting the positive association between spirituality and health has lead to interest in providing spiritual care in healthcare settings. Few instruments exist that measure the provision of spiritual care. METHOD: In February/March 2007, a convenience sample of 298 adult and paediatric acute care, ambulatory, home health, hospice staff and rehab nurses at two hospitals (n = 248) and graduate students at a school of nursing (n = 50) completed a 48-item initial version of the Spiritual Care Inventory. In study 2 from July through August 2007, 78 staff nurses at one hospital (n = 30) and a different cohort of graduate students at a school of nursing (n = 48) completed the 18-item second version of the Spiritual Care Inventory. RESULTS: Exploratory factor analysis in study 1 supported a 3-factor solution (spiritual care interventions, meaning making and faith rituals) with internal consistency measures for the subscales above 0·80. In study 2, internal consistency remained high. CONCLUSION: Factor structures identify that spiritual care is a process of intervention, meaning making and faith rituals.

Veteran model of preventing community-acquired pressure injuries associated with spinal cord injury: A qualitative descriptive study.

CONTEXT/OBJECTIVE: Pressure injuries (PrIs) are the second leading cause of hospitalization in people with spinal cord injury (SCI). The majority of PrIs occur in the community, but there is little known about prevention of community acquired PrI (CAPrI). The purpose of this study was to better understand risks, resources, and actions associated with CAPrI prevention from the perspective of veterans living with SCI in the community. METHODS: A qualitative descriptive design using photovoice (n = 30) with or without guided tours (n = 15) was conducted with Veterans living with SCI at 3 sites across the United States to determine environmental/lifestyle risks at home, prevention activities, resources used, and challenges in CAPrI prevention. Interviews were audio-recorded, transcribed and analyzed using thematic analysis, followed by inductive thematic synthesis. RESULTS: Qualitative analyses revealed a model describing veteran's perspective of preventing CAPrIs associated with SCI. The model included 3 themes and 9 subthemes: Factors that Lead to Risk for Pressure Injury (Challenges and Barriers), Factors that Affect Chosen Actions (Veteran Motivators, Veteran Values, Veteran Satisfaction with Provider Relationships, and Veteran Supports), and Preventive Activities within Context of Life (Physical Care, Coping, Advocacy). CONCLUSION: Incorporating the veteran model of prevention within the context of life into clinical care could support provider-veteran collaboration to identify and integrate successful strategies that prevent CAPrIs while also improving veteran quality of life.

Grief and Loss Among Veterans With Spinal Cord Injury: A Qualitative Study.

PURPOSE: The objective of this study was to understand veteran perspectives of grief/loss associated with their spinal cord injury (SCI). DESIGN/METHODS: Qualitative descriptive design using semistructured interviews with veterans with SCI (n = 15) was performed using interview questions informed by the literature. Analysis was conducted using a deductive/inductive approach. RESULTS: The 15 participants' mean age was 64 years; six had paraplegia, eight had tetraplegia, one had unknown level of injury, six were ambulatory, and nine were not ambulatory. The grief/loss experience was individual and constant, consisting of seven phases: experiencing shock, releasing emotion, withdrawing, focusing on losses, problem solving, realizing strength and motivation, and accepting a new life. Veteran coping strategies used in each phase of the grief experience were also identified, as well as triggers that increased or decreased the grief/loss experience. CONCLUSIONS/CLINICAL RELEVANCE: A better understanding of veterans living with SCI grief experience, coping strategies, and triggering events can help healthcare providers support veterans with SCI.

Strategies used by providers to support individuals with spinal cord injury in weight management: a qualitative study of provider perspectives.

STUDY DESIGN: This is a descriptive qualitative study. OBJECTIVES: To explore recommended strategies employed by healthcare providers to support individuals with SCI in weight management. SETTING: Fourteen veteran administration hospitals in the United States and the Shirley Ryan AbilityLab (SRALab) SCI Model Systems in Illinois. METHODS: Semi-structured interviews were conducted with interprofessional SCI providers involved in weight management with individuals living with SCI. Thematic analysis methods were used. RESULTS: A total of 25 interprofessional providers were interviewed. Providing clinical expertise to assist in weight management included (1) checking progress or status of weight over time, (2) monitoring and tracking other health-related indicators, (3) stressing weight-related health risks, (4) providing education, (5) encouraging healthy behaviors, and (6) identifying and accessing resources. Fostering provider-patient relationships included (1) establishing and maintaining rapport and (2) tailoring/individualizing weight management treatment. Coordinating a team approach included (1) involving a dietitian or nutritionist, (2) communicating the same message, and (3) involving the informal caregiver/family. CONCLUSION: Weight management strategies should incorporate patient preferences and goals, informed through provider expert and personalized clinical advice, and supported within the context of interprofessional team collaboration that includes caregivers and family.

Perceptions of Pediatric Hospital Safety Culture in the United States: An Analysis of the 2016 Hospital Survey on Patient Safety Culture.

INTRODUCTION: Medical errors in the pediatric population can quickly cause harm. Research identified that hospitals with positive safety cultures work collaboratively to reduce errors. Strategies that identify gaps in hospital's safety culture within the pediatric milieu have not been initiated. This study addressed this gap from an interprofessional perspective. METHODS: This cross-sectional descriptive study used data from the Agency for Healthcare Research and Quality's 2016 Hospital Patient Safety Culture survey measuring 12 safety culture dimensions for registered nurses (RNs), physician assistants/nurse practitioners (PAs/NPs), physicians (MDs), and administrators/managers (n = 6682) in the United States that were employed in 287 (42%) pediatric hospitals or specialty units. RESULTS: Findings indicated that in the United States, the overall safety culture had low levels of agreement. Pairings between pediatric RNs, PAs/NPs, and MDs had similar levels of agreement for all dimensions but the perceptions of these three practitioners differed when compared with pediatric administrators/managers in nine of the 12 dimensions. The perceptions of pediatric RNs and MDs differed in six of the 12 dimensions, with MDs indicating higher levels of agreement. All four professional groups rated teamwork within hospital units with the highest level of agreement (mean, 4.14), with hospital handoffs and transitions rated the lowest (mean, 2.64). All four professional groups found punitive cultures (mean, 2.71) throughout the pediatric specialty. CONCLUSIONS: Variations regarding pediatric professional's perception of safety culture exist within U.S. hospitals. Effective and creative management will support cultures that prevents harm and improves the overall safety of children's care with initiatives that are dedicated to excellence.

Validation of the BOOST Risk Stratification Tool as a Predictor of Unplanned 30-Day Readmission in Elderly Patients.

INTRODUCTION: Risk stratification tools can identify patients at risk for 30-day readmission, but available tools lack predictive strength. One of these tools is the Better Outcomes by Optimizing Safe Transitions (BOOST) 8 P's tool. OBJECTIVES: The primary objective of this study was to validate the 8 P's tool as well as measure the predictive strength of variables within this tool. METHODS: This was a quantitative study that included 1 year of hospitalized elderly patients (n = 6849). Odds ratios were used to determine the strength of the association between variables individually with readmission. Multivariable logistic regression was used to evaluate the predictive strength of the BOOST risk stratification tool. RESULTS: This study demonstrated that 5 of the 8 variables in the BOOST risk stratification tool showed significant association with 30-day readmission including the variables of health literacy (P = .030), depression (P = .003), problem medications (P = .001), physical limitations (P ≤ .001), and prior hospitalization (P ≤ .001). Combining variables using multivariable logistic regression, the BOOST 8 P's tool had limited predictive capability with a C-statistic of 0.631. CONCLUSION: This study was the first attempt to validate the BOOST 8 P's tool and to utilize nursing documentation within an electronic medical record to capture social determinants of health.

Spiritual Care in Nursing Practice in Veteran Health Care.

Spiritual care is important in nursing practice, and spiritual well-being and spiritual care are associated with better health. Military veterans, a unique patient population, want spiritual care to cope with chronic conditions. It is unclear whether spiritual care is provided in veteran health care in the United States. This study used a qualitative descriptive method, guided by the Spiritual Care in Nursing Practice (SCNiP) theory, to describe spiritual care in nursing practice and facilitators/barriers in veteran health care. Individual interviews were conducted with 39 registered nurses (RNs) at a U.S. veteran health system. Findings were consistent with the SCNiP theory but revealed additional categorical attributes and processes as it applied to veteran health care. Facilitators that promoted spiritual care include nurse professionalism, collegial support, and available spiritual resources. Barriers included lack of time, task-oriented culture, unclear knowledge of accessing resources, and unclear organization policy in providing spiritual care. Findings further refined the theory.

Alerting Doctors About Patient Life Challenges: A Randomized Control Trial of a Previsit Inventory of Contextual Factors.

Objective. Effective care attends to relevant patient life context. We tested whether a patient-completed inventory helps providers contextualize care and increases patients' perception of patient-centered care (PCC). Method. The inventory listed six red flags (e.g., emergency room visits) and if the patient checked any, prompted for related contextual factors (e.g., transportation difficulties). Patients were randomized to complete the inventory or watch health videos prior to their visit. Patients presented their inventory results to providers during audio-recorded encounters. Audios were coded for physician probing and incorporating context in care plans. Patients completed the Consultation and Relational Empathy (CARE) instrument after the encounter. Results. A total of 272 Veterans were randomized. Adjusting for covariates and clustering within providers, inventory patients rated visits as more patient-centered (44.5; standard error = 1.1) than controls (42.7, standard error = 1.1, P = 0.04, CARE range = 10-50). Providers were more likely to probe red flags (odds ratio = 1.54; confidence interval = 1.07-2.22; P = 0.02) when receiving the inventory, but not incorporating context into care planning. Conclusion. A previsit inventory of life context increased perceptions of PCC and providers' likelihood of exploring context but not contextualizing care. Information about patients' life challenges is not sufficient to assure that context informs provider decision making even when provided at the point of care by patients themselves.

An experiential theory of spiritual care in nursing practice.

Spiritual care has been recognized as integral to nursing care for centuries, as described by Florence Nightingale, and has been studied in both medicine and sociology. Health care institutions, particularly faith-based health systems, also have recognized the importance of spiritual care. Both qualitative and quantitative research support the importance of spirituality in patient health. Although the profession, health care institutions, and research support spiritual care, there is no empirically derived theoretical framework to guide research in spiritual assessment and spiritual care. We used focus group data from registered nurses who care for the chronically ill (n = 25) in a large Midwestern academic health center to generate a grounded theory of spiritual care in nursing practice. What emerged from this study was a beginning theoretical framework to guide future spiritual care research.

Integrating preventive care and nursing standardized terminologies in nursing education: a case study.

This study investigated the development of a community-focused curriculum integrating primary, secondary, and tertiary prevention and nursing standardized terminologies as an organizing infrastructure. This is a case study of the curriculum redesign of the Marcella Niehoff School of Nursing, Loyola University Chicago. Faculty developed a conceptual framework integrating core concepts into curriculum design, course content, and clinical applications. A coherent curriculum was designed using a community-focused approach; primary, secondary, and tertiary prevention strategies; and standardized terminologies as the organizing infrastructure to teach and apply nursing practice. The curriculum provides a meaningful correlation between the classroom and clinical experience. Students journey with their patients throughout the health care experience, applying nursing concepts using standardized terminologies. Clinical experiences provide students with the opportunity to transfer knowledge to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students in developing critical thinking skills through the use of standardized nursing terminologies.