Knowledge Transfer and Dissemination of Advanced Practice Nursing Information and Research to Acute-Care Administrators.

The objective of this study was to ascertain the information needs and knowledge-dissemination preferences of acute-care administrators with respect to advanced practice nursing (APN). Supportive leadership is imperative for the success of APN roles and administrators need up-to-date research evidence and information, but it is unclear what the information needs of administrators are and how they prefer to receive the information. A survey tool was developed from the literature and from the findings of a qualitative study with acute-care leaders. Of 107 surveys distributed to nursing administrators in 2 teaching hospitals, 79 (73.8%) were returned. Just over half of respondents reported wanting APN information related to model of care and patient and systems outcomes of APN care; the majority expressed a preference for electronic transmission of the information. Researchers need multiple strategies for distributing context-specific APN evidence and information to nursing administrators.

L'objectif de cette étude était de déterminer les besoins en information et les préférences en matière de transmission du savoir des administrateurs de soins actifs en ce qui concerne les pratiques infirmières avancées (PIA). Les infirmières et infirmiers en PIA doivent impérativement bénéficier du soutien de leur direction pour accomplir adéquatement leur travail. Les administrateurs ont quant à eux besoin d'information et de résultats de recherche à jour pour offrir ce soutien, mais l'information dont ils ont besoin et la façon dont ils souhaitent la recevoir demeurent incertains. Un outil de sondage a été élaboré à partir de la littérature sur le sujet et des résultats d'une étude qualitative menée auprès de dirigeants de services de soins actifs. Sur un total de 107 formulaires distribués à des administrateurs de soins infirmiers dans deux hôpitaux d'enseignement, 79 (73,8 %) ont été remplis et retournés. Un peu plus de la moitié des répondants ont indiqué vouloir de l'information liée aux PIA portant sur les modèles de soins et les résultats des PIA pour les patients et le système, et la majorité d'entre eux ont dit avoir une préférence pour l'information transmise par voie électronique. Les chercheurs doivent user de stratégies multiples pour diffuser auprès des administrateurs de soins infirmiers l'information et les résultats de recherche sur les PIA propres à divers contextes.

The nurse as bricoleur in falls prevention: learning from a case study of the implementation of fall prevention best practices.

BACKGROUND: Falls prevention in "real-life" clinical practice is a complex undertaking. Nurses play an active and essential role in falls prevention. AIM: This discussion paper presents a picture of the nurse as a bricoleur in falls prevention, requiring knowledge in many areas and the ability to perform multiple diverse tasks. METHODS: Building on a qualitative case study with nurses at various levels in three acute care facilities, this paper posits that the concept of nurse as bricoleur has the potential to broaden our understanding of the complexity of falls prevention. FINDINGS: The nurse as bricoleur within the Promoting Action Research in Health Services framework as the provider of person- or patient-centered evidence-based care is conceptualized. Within this framework, the nurse uses his or her professional knowledge or clinical experience while considering research, local data, and information, and the patient's experience and preferences to provide this care, the bricolage. Each of these areas is discussed as well as the impact on the nurse when a fall does occur. LINKING EVIDENCE TO ACTION: Recognizing this complexity of the nurses' world has important implications for both service delivery and education, including preparation of students, and the implementation of new organizational initiatives and supports for nurses when falls do occur despite the best efforts of all involved.

Using Stake's qualitative case study approach to explore implementation of evidence-based practice.

Although the use of qualitative case study research has increased during the past decade, researchers have primarily reported on their findings, with less attention given to methods. When methods were described, they followed the principles of Yin; researchers paid less attention to the equally important work of Stake. When Stake's methods were acknowledged, researchers frequently used them along with Yin's. Concurrent application of their methods did not take into account differences in the philosophies of these two case study researchers. Yin's research is postpositivist whereas Stake's is constructivist. Thus, the philosophical assumptions they used to guide their work were different. In this article we describe how we used Stake's approach to explore the implementation of a falls-prevention best-practice guideline. We focus on our decisions and their congruence with Stake's recommendations, embed our decisions within the context of researching this phenomenon, describe rationale for our decisions, and present lessons learned.

The real world journey of implementing fall prevention best practices in three acute care hospitals: a case study.

BACKGROUND: Globally, falls are the second leading cause of unintentional injury. In Canada, falls that occur in hospitals have been ranked second as an area of patient safety concern. Many Canadian hospitals seeking to achieve patient safety, accreditation and resource containment goals are implementing evidence-based practices in fall prevention. However, best practices are reported to be only variably effective in reducing hospital fall rates, indicating a potential gap in our understanding of the implementation process. This study was designed to provide insight into the real world of implementation of best practices in fall prevention in acute care Canadian hospitals. APPROACH: Using case study methodology, ninety-five administrative and point-of-care nurses at three hospitals participated in interviews or focus groups and provided documents and artifacts that described their implementation of a falls prevention guideline. FINDINGS AND IMPLICATIONS: Four recommendations with potential to guide others in fall prevention were identified: (1) the need to listen to and recognize the expertise and clinical realities of staff, (2) the importance of keeping the implementation process simple, (3) the need to recognize that what seems simple becomes complex when meeting individual patient needs, and (4) the need to view the process as one of continuous quality improvement.

Designing a falls prevention strategy that works.

In implementing an evidence-based falls prevention strategy in acute care, planners are frequently pressed to meet organizational targets while allowing staff flexibility to match interventions with patient population needs and clinical realities. We describe the process of how one hospital creatively used evidence, systems change, staff engagement, expert consultation, policy and protocols, staff and patient education, marketing, and celebration to design and implement a falls prevention strategy on 60 clinical units that reduced annual fall rates by 20%.

A Sustainability Oriented and Mentored Approach to Implementing a Fall Prevention Guideline in Acute Care Over 2 Years.

The purpose of this study was to assess the impact of a mentored guideline implementation (Registered Nurses' Association of Ontario Prevention of Falls and Falls Injuries in the Older Adult Best Practice Guideline) focused on enhancing sustainability in reducing fall rates and number of serious falls and the experience of staff in three acute care hospitals. The National Health Service (NHS) Sustainability Model was used to guide the study. Interviews and focus groups were held with 82 point-of-care professional staff, support staff, volunteers, project leaders, clinical leaders, and senior leaders. Study results supported the importance of the factors in the NHS model for sustainability of the guideline in these practice settings. There were no statistically significant decreases in the overall fall rate and number of serious falls. The results supported strategies of participating hospitals to become senior friendly organizations and provided opportunities to enhance staff collaboration with patients and families.

Integrating self-efficacy and aging theories to promote behavior change and reduce stroke risk.

The increasing incidence of stroke has resulted in the establishment of secondary stroke prevention clinics. Such clinics have successfully reduced wait-to-treatment times for individuals diagnosed with transient ischemic attack or minor stroke. In addition to improving access to consultation, diagnosis, and treatment, healthcare clinics need to implement behavioral risk-reduction programs tailored to older adults to help them better adhere to treatment regimens. The integration of two social-psychological theories--(a) self-efficacy and (b) selection, optimization, and compensation-provide the foundation for an approach that could lead to the development of evidence-based behavioral risk-reduction programs for older adults at high risk of stroke.

Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II).

BACKGROUND: Reduction of blood pressure (BP) after stroke or TIA decreases stroke recurrence and is a major goal ofsecondary Stroke Prevention Clinics (SPCs). Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication. METHODS: This multicentred, randomized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits (e.g., lack of confidence in the utility of medications, poor memory, mild cognitive impairment) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program (monthly telephone calls, motivational interviewingfor lifestyle change, plus home BP monitoring and use ofdosettes for medication administration) would improve BP measures and adherence to medications. RESULTS: Both intervention (n=29) and usual care groups (n=27) showed a trend-for'reduced BP at six months (Median ql-q3, Systolic BR p=0.46; Diastolic BR p=0.37). Diabetic patients, irrespective of the group to which they were randomized, were less likely to meet Best Practice Guideline targets than those without diabetes (Chi Square test, p=0.0001). CONCLUSION: Stroke and TIA patients with diabetes may require additional resources and support in order to reach BP target values.

Knowledge gaps regarding APN roles: what hospital decision-makers tell us.

The implementation of advanced practice nursing (APN) roles can yield improvements in patient and health system outcomes, and supportive leadership is integral in facilitating the implementation of such roles. The purpose of this study was to explore the awareness and understanding of APN roles among hospital decision-makers, and to learn about the information they require and the ways in which they prefer to receive that information. Fifteen administrators and leaders from two multi-site acute care organizations were interviewed. Their practical knowledge of APN roles was based on experience developing the roles or working with APNs in hospital programs. The most common sources of APN information were internal contacts (i.e., APNs) and documents from nursing organizations. Participants reported difficulty distinguishing between the roles of nurse practitioners (NPs) and clinical nurse specialists (CNSs), and identified knowledge regarding CNS roles as their greatest need. They required specific information regarding the "value-added" benefits offered by an APN role. Strategies to address the knowledge gaps of healthcare leaders are urgently needed in order to support the implementation of new APN roles and to sustain existing ones.

Specialist nursing training in Poland: applications for neuroscience nursing.

BACKGROUND: Nurses have a pivotal role in providing facilitating, advocating and promoting the best possible care and outcome for the client. To ensure decisions and actions are based on current standards of practice, nurses must be accountable for participation in ongoing education in their area of practice. AIM: To present a description of the current state of Polish nursing education and specialized model for neurological and neurosurgical nursing that can be utilized for both undergraduate and postgraduate continuing education in Poland. DATA SOURCES: The model of postgraduate training introduced in Poland in 2000 was taken into consideration in developing the framework for neuroscience nursing postgraduate continuing education presented here. The framework for neurological continuing education is also based on a review of the literature and is consistent with Poland's legally binding professional nursing regulations (normative and implementing regulations). CONCLUSION: The model demonstrates the need for the content of pre- and post-undergraduate degree education in neurological nursing to be graduated, based on the frameworks for undergraduate education (acquiring the knowledge and basic skills for performing the work of nurses) and postgraduate education (acquiring knowledge and specialist skills necessary for providing advanced nursing care including medical acts on patients with nervous system diseases). IMPLICATIONS FOR NURSING: New and advanced skills gained in specialization training can be applied to complex functions, roles and professional tasks undertaken by nurses in relation to care of patients with neurological dysfunctions.

Patients' perceptions of their roles in goal setting in a spinal cord injury regional rehabilitation program.

Goal setting is a common practice in rehabilitation, yet there is a paucity of literature exploring patients' perceptions of their roles in this process. This study was conducted using a qualitative descriptive methodology to explore patients' perceptions of their roles in setting goals in a spinal cord injury regional rehabilitation program. Imogene King's theory of goal attainment was used to frame the study. Data were collected through interviews and analyzed using a content analysis. The results revealed four themes: Visioning, Redefining, Brainstorming, and Rebuilding Participants (n = 13) envisioned their roles as setting an overarching priority goal, defining detailed rehabilitation goals, sharing knowledge with the team, and rebuilding skills to attain goals. Implications for nursing practice include the need to understand patients' experiences and perceptions, share knowledge, and support effective communication to promote collaborative goal setting. A need to enhance health professionals' education to fully understand factors influencing patients' abilities to set rehabilitation goals, and future research in methods to promote patients' engagement in goal setting was also clearly indicated.

Stroke prevention care delivery: predictors of risk factor management outcomes.

BACKGROUND: Internationally, the development and implementation of stroke care guidelines have resulted in the evolution of stroke prevention outpatient clinics designed to accelerate patient access to treatment and behavioral risk reduction following transient ischemic attack or stroke. OBJECTIVES: To examine the extent to which selected demographic, social-psychological, physiological, and adherence characteristics predicted achievement of blood pressure and glucose targets in a group of patients referred to a Canadian stroke prevention clinic with confirmed transient ischemic attack (TIA) or stroke and hypertension and/or diabetes. PARTICIPANTS: A total of 313, English speaking, adult patients who were referred from family or emergency department physicians to a stroke prevention clinic provided demographic data and received social-psychological screening testing at intake. Of these, 93 participants who met criteria of confirmed TIA or stroke plus hypertension and/or diabetes were identified as the study group. Seventy-seven of study group participants completed a 6-month follow-up. METHODS: Admission screening tests included the Modified and Mini-Mental State Examinations, Trail Making Test, Clock Drawing Test, a medication self-efficacy scale, the Lubben Social Network Scale and the Geriatric Depression Scale. Family physician follow-up was ascertained 4-8 weeks after intake. At approximately 6 months after the initial screening measures, 77 study group participants completed additional measures of adherence, blood pressure and/or glycated hemoglobin. RESULTS: Transient ischemic attack was confirmed in 58% and stroke in 42% of the study group. Mean age was 69 years (SD=11); 53% were male; 97% had hypertension; and 25% were diabetic; some had both. Twenty-three percent were not followed-up by family practitioners. At 6-month follow-up, 97% reported ≥80% adherence to medication; only 57% met treatment targets. A logistic regression analysis identified three independent predictors of achieving blood pressure and/or glucose targets: self-efficacy expectations (OR, 1.61; 95% CI, 1.03-2.54; p=0.04), Mini-Mental State (OR, 1.28; 95% CI, 1.06-1.54; p=0.009); and self-reported adherence (OR, 1.14; 95% CI, 1.01-1.29; p=0.03). CONCLUSIONS: Three simple screening measures identified patients at increased risk of not achieving clinical risk factor management targets.

Detecting cognitive impairment in clients with mild stroke or transient ischemic attack attending a stroke prevention clinic.

Twenty clients diagnosed with probable transient ischemic attack (TIA) or stroke attending a stroke prevention clinic (SPC) were screened for cognitive function, as one inclusion criteria for a pilot study examining medication adherence and hypertension management. The Mini Mental State Examination (MMSE) was administered at study admission followed by a second screening within two weeks using the Montreal Cognitive Assessment (MoCA) tool. Individual scores for the MMSE and MoCA were compared. Results demonstrated that the majority (90%) of participants scored in the normal range (> or = 26) on the MMSE (m = 27.9 sd 2.15). However, more than half (55%) of participants had some degree of cognitive impairment based on MoCA scores of < 26 (m = 23.65 sd = 4.082). MoCA scores demonstrated a wider range (Range = 16) compared to the range of MMSE scores (Range = 8). MoCA scores were significantly (p = < 0.05) lower than the MMSE scores. Findings from this pilot study suggest that the MoCA test will identify more deficits in cognition among SPC clients diagnosed with cerebrovascular disease. Further investigation is underway to determine the implications of these deficits on SPC clients' abilities to follow medication and other treatment regimens.

Nurse case management to improve risk reduction outcomes in a stroke prevention clinic.

Stroke prevention clinic health care professionals are mandated to provide early access to neurological consultation and treatment, diagnostic testing, and behavioural risk factor management for clients with transient ischemic attack or mild non-disabling stroke. Clinic nurses collaborate with clients and interprofessional teams to support risk factor reduction to prevent recurrent stroke events. Although hypertension is the most important modifiable risk factor for stroke, broader evidence indicates that adherence to prescribed medications may be less than 50%. One clinic identified a need to improve risk factor outcomes through identifying clients with uncontrolled hypertension, cognitive, self-eficacy and/or adherence characteristics predictive of non-achievement of blood pressure targets. To address this need, an expanded nurse case management care delivery model was pilot tested for feasibility in a participant sample of 20 clients. Motivational interviewing and self-management approaches were combined with interventions designed to improve adherence:facilitation of the simplification of medication routines, providing memory cues and home self-monitoring equipment, counselling, and six-month nursing follow-up. Results demonstrated that an expanded nurse case management model of care delivery is feasible with only a modest impact on clinic resources. At six months, there were significant reductions in blood pressure and increases in medication self-efficacy and adherence for selected clients identified with high risk for stroke and non-achievement of treatment outcomes.

Shampoo after craniotomy: a pilot study.

OBJECTIVES: The primary goal of this study was to assess the effect of postoperative hair-washing on incision infection and health-related quality of life (HRQOL) in craniotomy patients. The objectives of this study were to 1) determine the effect of postoperative hair-washing on incision infection and HRQOL, 2) provide evidence to support postoperative patient hygienic care, and 3) develop neurosurgical nursing research capacity RESEARCH QUESTION: Does hair-washing 72 hours after craniotomy and before suture or clip removal influence postoperative incision infection and postoperative HRQOL? METHODS: A prospective cohort of 100 adult patients was randomized to hair-washing 72-hours postoperatively (n = 48), or no hair washing until suture or clip removal (n = 52). At five to -10 days postoperatively, sutures or clips were removed, incisions were assessed using the ASEPSIS Scale (n = 85) and participants were administered the SF-12 Health Survey (n = 71). At 30 days postoperatively, incisions (n = 70) were reassessed. RESULTS: No differences were found between hair-washing and no hair-washing groups for ASEPSIS scores at five to 10 days and 30 days, and total SF-12 scores at five to 10 days postoperatively (p > or = 0.05). CONCLUSIONS: Postoperative hair-washing resulted in no increase in incision infection scores or decrease in HRQOL scores when compared to no hair-washing in patients experiencing craniotomy.