Andrea P. Marshall

The effect of a short one-on-one nursing intervention on knowledge, attitudes and beliefs related to response to acute coronary syndrome in people with coronary heart disease: A randomized controlled trial

BACKGROUND Coronary heart disease (CHD) and acute coronary syndrome (ACS) remain significant public health problems. The effect of ACS on mortality and morbidity is largely dependent on the time from symptom onset to the time of reperfusion, but patient delay in presenting for treatment is the main reason timely reperfusion is not received. OBJECTIVES We tested the effect of an education and counseling intervention on knowledge, attitudes and beliefs about ACS symptoms and the appropriate response to symptoms, and identified patient characteristics associated with changes in knowledge, attitudes and beliefs over time. METHODS We conducted a two-group randomized controlled trial in 3522 people with CHD. The intervention group received a 40 min, one-on-one education and counseling session. The control group received usual care. Knowledge, attitudes and beliefs were measured at baseline, 3 and 12 months using the ACS Response Index and analyzed with repeated measures analysis of variance. RESULTS Knowledge, attitudes and beliefs scores increased significantly from baseline in the intervention group compared to the control group at 3 months, and these differences were sustained at 12 months (p=.0005 for all). Higher perceived control over cardiac illness was associated with more positive attitudes (p<.0005) and higher state anxiety was associated with lower levels of knowledge (p<.05), attitudes (p<.05) and beliefs (p<.0005). CONCLUSION A relatively short education and counseling intervention increased knowledge, attitudes and beliefs about ACS and response to ACS symptoms in individuals with CHD. Higher perceived control over cardiac illness was associated with more positive attitudes and higher state anxiety was associated with lower levels of knowledge, attitudes and beliefs about responding to the health threat of possible ACS.

Experiences of using the Theoretical Domains Framework across diverse clinical environments: a qualitative study.

Background The Theoretical Domains Framework (TDF) is an integrative framework developed from a synthesis of psychological theories as a vehicle to help apply theoretical approaches to interventions aimed at behavior change. Purpose This study explores experiences of TDF use by professionals from multiple disciplines across diverse clinical settings. Methods Mixed methods were used to examine experiences, attitudes, and perspectives of health professionals in using the TDF in health care implementation projects. Individual interviews were conducted with ten health care professionals from six disciplines who used the TDF in implementation projects. Deductive content and thematic analysis were used. Results Three main themes and associated subthemes were identified including: 1) reasons for use of the TDF (increased confidence, broader perspective, and theoretical underpinnings); 2) challenges using the TDF (time and resources, operationalization of the TDF) and; 3) future use of the TDF. Conclusion The TDF provided a useful, flexible framework for a diverse group of health professionals working across different clinical settings for the assessment of barriers and targeting resources to influence behavior change for implementation projects. The development of practical tools and training or support is likely to aid the utility of TDF.

Nursing considerations to complement the Surviving Sepsis Campaign guidelines

Objectives:To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis. Design:Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus. Methods:We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding. Results:Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points. Conclusion:Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.

Implementation of safety checklists in surgery: a realist synthesis of evidence

AimThe aim of this review is to present a realist synthesis of the evidence of implementation interventions to improve adherence to the use of safety checklists in surgery.BackgroundSurgical safety checklists have been shown to improve teamwork and patient safety in the operating room. Yet, despite the benefits associated with their use, universal implementation of and compliance with these checklists has been inconsistent.Data sourcesAn overview of the literature from 2008 is examined in relation to checklist implementation, compliance, and sustainability.Review methodsPawson’s and Rycroft-Malone’s realist synthesis methodology was used to explain the interaction between context, mechanism, and outcome. This approach incorporated the following: defining the scope of the review, searching and appraising the evidence, extracting and synthesising the findings, and disseminating, implementing, and evaluating the evidence. We identified two theories a priori that explained contextual nuances associated with implementation and evaluation of checklists in surgery: the Normalisation Process Theory and Responsive Regulation Theory.ResultsWe identified four a priori propositions: (1) Checklist protocols that are prospectively tailored to the context are more likely to be used and sustained in practice, (2) Fidelity and sustainability is increased when checklist protocols can be seamlessly integrated into daily professional practice, (3) Routine embedding of checklist protocols in practice is influenced by factors that promote or inhibit clinicians’ participation, and (4) Regulation reinforcement mechanisms that are more contextually responsive should lead to greater compliance in using checklist protocols. The final explanatory model suggests that the sustained use of surgical checklists is discipline-specific and is more likely to occur when medical staff are actively engaged and leading the process of implementation. Involving clinicians in tailoring the checklist to better fit their context of practice and giving them the opportunity to reflect and evaluate the implementation intervention enables greater participation and ownership of the process.ConclusionsA major limitation in the surgical checklist literature is the lack of robust descriptions of intervention methods and implementation strategies. Despite this, two consequential findings have emerged through this realist synthesis: First, the sustained use of surgical checklists is discipline-specific and is more successful when physicians are actively engaged and leading implementation. Second, involving clinicians in tailoring the checklist to their context and encouraging them to reflect on and evaluate the implementation process enables greater participation and ownership.

The diversity of critical care nursing education in Australian universities.

A range of critical care nursing educational courses exist throughout Australia. These courses vary in level of award, integration of clinical and academic competence and desired educational outcomes; this variability potentially leads to confusion by stakeholders regarding educational and clinical outcomes. The study objective was to describe the range of critical care nursing courses in Australia. Following institutional ethics approval, all relevant higher education providers (n=18) were invited to complete a questionnaire about course structure, content and nomenclature. Information about desired professional and general graduate characteristics and clinical competency was also sought. A total of 89% of providers (n=16) responded to the questionnaire. There was little consistency in course structure in regard to the proportion of each programme devoted to core, speciality or generic subjects. In general, graduate certificate courses concentrated on core aspects of critical care, graduate diploma courses provided similar amounts of critical care core and speciality content, while masters level courses concentrated on generic nursing issues. The majority of courses had employment requirements, although only a small proportion specified the minimum level of critical care unit required for clinical experience. The competency standards developed by the Australian College of Critical Care Nurses (ACCCN) were used by 83% of providers, albeit in an adapted form, to assess competency. However, only 60% of programmes used personnel with a combined clinical and educational role to assess such competence. In conclusion, stakeholders should not assume consistency in educational and clinical outcomes from critical care nursing education programmes, despite similar nomenclature or level of programme. However, consistency in the framework for speciality nurse education has the potential to prove beneficial for all stakeholders.

Nutritional intake in the critically ill: Improving practice through research

Enteral feeding is the preferred method of nutritional support in the critically ill; however, evidence suggests that many critically ill patients do not meet their nutritional goals. The implementation of enteral feeding protocols has improved nutritional delivery, although protocols can be widely variable. Similarly, enteral feeding related nursing practice is also inconsistent within and between intensive care units (ICUs). These variations in enteral feeding practice can be linked to the shortage of reliable and valid research into the many issues associated with the effective delivery of enteral nutrition. In the absence of a strong research tradition and practice, rituals are embraced and rarely challenged, further contributing to the wide variations in enteral feeding practice. Of particular importance are practice issues related to the commencement of enteral feeding and the assessment of feeding tolerance. This article seeks to review the literature related to commencing enteral feeding, with particular reference to the suitability of enteral nutrition, methods of enteral feeding and adjustment of enteral feeding rates. Issues relating to feeding intolerance, including the assessment of gastric residual volume and the development of diarrhoea, will also be explored.

Eyecare in the critically ill: Clinical practice guideline

OBJECTIVE The Intensive Care Collaborative project was established with the specific aim of developing recommendations for clinical practice that are underpinned by the best available evidence to support the objective of improving the standard of care delivered in NSW Intensive Care Units. The eyecare clinical practice guideline for intensive care patients were developed as a result of this initiative. METHODS Search: The bibliographic databases (PubMed; The Cummulative Index of Nursing and Allied Health Literature (CINAHL); Medline and The Cochrane Library) were searched. The search terms used alone and in combination were: intensive care; prevention; eye; eyecare; and guidelines. In addition, reference lists of relevant papers were assessed to identify additional studies and Google Scholar was searched using the keywords eyecare and intensive care. The search strategy was limited to the English language but was not limited by year of publication. Study selection criteria: All relevant observational and interventional studies were included, regardless of study design. Review process: Each paper was reviewed by at least two Guideline Development Network (GDN) members independently using a data extraction tool. Papers were assessed against the National Health and Medical Research Council (NHMRC) levels of evidence. Recommendations were assigned using a modified Delphi process to ensure consensus. SUMMARY OF RECOMMENDATIONS We recommend that each patient is assessed for the risk factors of iatrogenic ophthalmologic complications; the ability to maintain eyelid closure; for iatrogenic ophthalmologic complications. It is also recommended that; the rates of iatrogenic ophthalmologic complications are monitored; referral is made in a timely manner for any suspected iatrogenic ophthalmologic complications; eyelid closure is maintained if eyelid closure cannot be maintained passively; all patients who cannot achieve eyelid closure independently should receive eye care every 2h. CONCLUSIONS The recommendations from this clinical practice guideline were peer-reviewed and examined by ophthalmology experts. Despite the heavy reliance on only a small number of studies and low level of evidence, the recommendations have the potential to positively affect patient outcomes by encouraging clinicians to assess and monitor for ophthalmological complications and to provide appropriate preventative interventions if implemented extensively.

Clinical credibility and trustworthiness are key characteristics used to identify colleagues from whom to seek information.

AIMS AND OBJECTIVES To explore the use of information by nurses making decisions in clinically uncertain situations in one aspect of critical care nursing practice (enteral feeding). In this paper, we report the characteristics, which participants identified as important, of the people from whom they sought information for the purpose of making clinical decisions. BACKGROUND Registered nurses have a plethora of information sources available to assist them in making clinical decisions. Identifying and selecting the best information to support these decisions can be difficult and is influenced by factors such as accessibility, usefulness and variations in quality of the information. DESIGN An instrumental case study design using multiple case study analysis. METHOD Twenty-two critical care nurses from two intensive care units contributed to the data through multiple methods of data collection including concurrent verbal protocols (think aloud), retrospective probing and focus group interviews. RESULTS Nurses preferentially used colleagues as a source of information when faced with uncertainty about their clinical practice. Most participants placed greater emphasis on evaluating the individual providing the information rather than on evaluating the information itself. Key features used for identifying an individual as a source of information included experience, clinical role, trust and approachability. CONCLUSION Establishing clearly what clinical credibility means, and to what extent trustworthiness and expertise play a role in the establishment of credibility, is an important debate for nursing. We need to carefully consider what defines the construct of clinical credibility and how this aligns with the concept of clinical currency, to allow clinicians to determine in others the characteristics associated with clinical credibility to access quality information through social interaction. RELEVANCE TO CLINICAL PRACTICE Processes to focus on determining the quality of information obtained from colleagues should be emphasised. What these processes are and how they could be implemented into clinical practice remains unknown and is highlighted as an area for future research.

Daily Interruption of Sedation in Patients Receiving Mechanical Ventilation

BACKGROUND Daily interruption of continuous infusion of sedatives has improved outcomes in patients receiving mechanical ventilation in open-label studies. OBJECTIVES To assess the feasibility of a protocol for a double-blind, randomized, controlled trial study on the impact of routine daily interruption of sedation in patients receiving mechanical ventilation. METHODS A total of 50 patients receiving mechanical ventilation were randomized to daily interruption of fentanyl and/or midazolam infusions for up to 6 hours or to usual management of sedation. Blinding was achieved by using replacement infusions (saline or active drug in saline). RESULTS The recruitment target of 80 patients was not met in an extended time frame. Propofol was used outside the protocol in 27% of patients in the intervention group and 17% of patients in the control group (P = .10). A total of 15% of the intervention group and 12% of the control group never had replacement infusions started (P = .77), and replacement infusions were started on only approximately one-third of eligible days in patients who received replacement infusions. The mean doses of fentanyl and midazolam were similar. The blinding strategy was safe and effective: no patients had unplanned extubations, and the most frequent reason for ending replacement infusions was completion of the maximum 6-hour period. CONCLUSIONS The double-blinded design for assessment of sedation interruption in patients receiving mechanical ventilation was safe and effective. Slow recruitment of patients and frequent noncompliance with the protocol suggest that modifications to the protocol are needed.

Understanding descriptive statistics

There is an increasing expectation that critical care nurses use clinical research when making decisions about patient care. This article is the second in a series which addresses statistics for clinical nursing practice. In this article we provide an introduction to the use of descriptive statistics. Concepts such as levels of measurement, measures of central tendency and dispersion are described and their use in clinical practice is illustrated.