Angela P. Clark

Family Presence During Invasive Procedures and Resuscitation: Hearing the Voice of the Patient

How do patients react to the presence of family during invasive procedures (IPs) or cardiopulmonary resuscitation (CPR)? Until recently, surprisingly little research had addressed the issue of family presence at all, and to our knowledge, no other studies have been published that delineate patients’ perspectives.In February 2000, we first reported in this journal findings from our pioneering study, which demonstrated numerous benefits that bedside visitation confers on the families of patients undergoing these procedures. This article presents our further investigation—aimed at describing the experiences of the patients—using a qualitative research approach to analyzing data collected during that study.The study took place in the emergency department (ED) of a university-affiliated, regional, level-I trauma center. The protocol for family presence was adapted from guidelines developed by the Emergency Nurses Association (ENA). Nine patients (eight who had IPs and one who underwent CPR) were also interviewed approximately two months after the emergency event. A semistructured questionnaire was used to determine their perceptions of the family presence experience.Seven themes emerged from the data. Three of these relate to the positive effects that family presence had on patients: it comforted them; provided help; and served, the patients believed, to remind providers of a patient’s “personhood”—he wasn’t just a patient; he was a person and had a family. Two themes involve how family presence reflects the reciprocal nature of patient–family bonds and the patient’s right to have family members present. The remaining two themes characterize how patients perceived the effects of the experience on their family members and on the health care environment. Patients saw both positive and negative effects on those who were present but believed the benefits to families outweighed the potential problems. Although further study is needed, family presence indeed appears to deliver many benefits, with apparently few drawbacks or adverse effects, to patients, their families, and their providers. In 1999, our institution, Parkland Health & Hospital System, approved a hospital-wide protocol for family presence during IPs and CPR.Corresponding author:Theresa MeyersPresbyterian Hospital of Dallas, Emergency Department8200 Walnut Hill LaneDallas, TX 75231TheresaMeyers@texashealth.org

Health Status and Self-care Outcomes After an Education-Support Intervention for People With Chronic Heart Failure.

Background:The rising cost of hospitalizations for heart failure (HF) care mandates intervention models to address education for self-care success. The effectiveness of memory enhancement strategies to improve self-care and learning needs further examination. Objective:The objective of this study was to examine the effects of an education-support intervention delivered in the home setting, using strategies to improve health status and self-care in adults/older adults with class I to III HF. Our secondary purpose was to explore participants’ subjective perceptions of the intervention. Methods:This study used a randomized, 2-group design. Fifty people were enrolled for 9 months and tested at 4 time points—baseline; after a 3-month education-support intervention; at 6 months, after 3 months of telephone/e-mail support; and 9 months, after a 3-month period of no contact. Advanced practice registered nurses delivered the intervention. Memory enhancement methods were built into the teaching materials and delivery of the intervention. We measured the intervention’s effectiveness on health status outcomes (functional status, self-efficacy, quality of life, emotional state/depressive symptoms, and metamemory) and self-care outcomes (knowledge/knowledge retention, self-care ability). Subjects evaluated the usefulness of the intervention at the end of the study. Results:The mean age of the sample was 62.4 years, with a slight majority of female participants. Participants were well educated and had other concomitant diseases, including diabetes (48%) and an unexpected degree of obesity. The intervention group showed significant improvements in functional status, self-efficacy, and quality of life (Kansas City Cardiomyopathy Questionnaire); metamemory Change and Capacity subscales (Metamemory in Adulthood Questionnaire); self-care knowledge (HF Knowledge Test); and self-care (Self-care in Heart Failure Index). Participants in both groups improved in depressive scores (Geriatric Depression Scale). Conclusions:An in-home intervention delivered by advanced practice registered nurses was successful in several health status and self-care outcomes, including functional status, self-efficacy, quality of life, metamemory, self-care status, and HF knowledge.

Self-reported sleep disturbance of patients with heart failure in Taiwan

Background: Western research studies have found that sleep disturbances reduced quality of life and daily functioning of patients with heart failure; however, information about sleep disturbance is lacking in Taiwanese people with heart failure. Objectives: The objective of this study was to investigate predictors of self-reported sleep disturbances in Taiwanese people with heart failure. The hypothesis was that health-related quality of life (HRQOL) could have significant effect on sleep disturbances, after controlling for demographics, heart failure characteristics, and health-related characteristics. Methods: A cross-sectional, descriptive, correlational design was used. A purposive sample of 125 participants was recruited from the outpatient departments of two hospitals located in southern Taiwan. Participants were interviewed individually to complete the Pittsburgh Sleep Quality Index, Kansas City Cardiomyopathy Questionnaire, Charlson Comorbidity Index, and Perceived Health Scale instruments. Results: Self-reported sleep disturbances were prevalent (74%) among people with heart failure in Taiwan. Five predictors were identified using hierarchical multiple regression analyses with forward methods, accounting for 26.9% of variance in sleep disturbances. They were education, New York Heart Association functional classification, perceived health, HRQOL social functioning, and physical symptoms. After controlling for demographics, heart failure characteristics, and health-related characteristics, the analysis showed that two variables of HRQOL accounted for 9.8% of the variance in sleep disturbances. Discussion: The importance of ongoing screening for sleep disturbances in people with heart failure is highlighted based on the study findings about the prevalence of sleep disturbances among the participants in this study. Healthcare providers must understand the often multifactorial nature of sleep disturbances to achieve a better and more effective management.

Interruptions and medication errors: part I.

The human brain is heralded for its amazing complexity and information processing capacity. Purportedly containing about a hundred-billion neurons and several-hundred-trillion synaptic connections, the brain processes information in a matter of milliseconds. However, for all of this processing power, we can barely attend to more than a few things and have difficulty performing more than 1 task at a time! The technological era forces constant stimuli on us all. What happens in the brain when we are distracted or interrupted? Recent media alerts about the dangers of texting or talking on cell phones while driving are alarming, yet many professional people pride themselves on the ability to multitask and deal with interruptions, perhaps failing to recognize the parallel circumstances. The aim of this manuscript is to review brain physiology associated with interruptions and prompt clinical nurse specialists (CNSs) to consider implications within their own areas of practice. (This article is a companion to an article published in volume 24, issue 6, of this journalVInterruptions and Medication Errors, Part I). A plethora of studies have reported medication errors partially linked to interruptions. A variety of concepts in the literature describe similar phenomena that have the potential to influence medication errors and patient safety. These concepts and terms include interruptions, multitasking, lack of focus, task switching, and distractions (Table 1). Along with other professionals (including physicians and attorneys), nurses are considered ‘‘knowledge workers’’V people who are valued in society for their education, knowledge, and experience in a specific subject area. Cooper has described knowledge workers as people who ‘‘think for a living.’’ High-quality cognitive processing activity is critically important for health professionals. Patients may think that clinicians are not focusing on themat timeswhen our brains are busy cognitively juggling dozens of clinical issues, fearful of dropping a critical one. The resulting neuronal overload may cause us to appear to be distracted and have patients interpret that as our not listening or caring about their communication.

Sleep disturbances in people living with heart failure.

Approximately 10% to 70% of people living with chronic heart failure (HF) experience significant sleep disturbances, which have been shown to impair their health-related quality of life and overall functional performance. Research findings, however, report inconsistent conclusions about sleep disturbances and their adverse effects on HF. The purpose of this article is to review several research studies addressing sleep disturbances in patients with HF and to highlight contradictory and inconsistent findings. Further nursing research about the phenomena related to sleep disturbances in people with HF is warranted so that evidence-based assessments and interventions can be tested in the future.

Cognitive impairment in heart failure.

Heart failure is reaching epidemic proportions in the United States, causing a constellation of disabling symptoms. Cognitive impairment in people with heart failure may be more common than previously known with multiple etiologies from both the disease process and the treatment. Exemplars from a research study are used to illustrate the perspective of heart failure patients. Given the critical importance of memory deficits on patient education, potential nursing interventions to address the issue of cognitive impairment are described.

Developing Clinical Nurse Specialist Practice Competencies

Background: In 1998, the National Association of Clinical Nurse Specialist (NACNS) developed the first ever core competencies for clinical nurse specialist (CNS) practice. Purpose: This article describes the method used to develop, validate, and revise CNS core practice competencies. Methods: The stepwise method of identifying core CNS competencies included content analysis of CNS position/job descriptions, extensive literature review, development by role experts, first-tier corroboration, second-tier corroboration encompassing stakeholder review, final review/editing, approval by the board of directors, and dissemination. Discussion: The process used by professional organizations to develop competencies and standards varies; however, it should be transparent and consist of adequate review and validation for accuracy and applicability by members of the representative group for whom the standards and competencies apply. Conclusions: The stepwise method used by the National Association of Clinical Nurse Specialist generated valid CNS core competencies and may be instructive to professional organizations interested in developing competencies and standards.

Developing rapid response teams: best practices through collaboration.

A report from the Institute of Medicine called attention to the dangers of hospital care in the United States. This landmark document focused on the national problem of death from preventable clinical errors. According to the experts, an estimated 44,000 to 98,000 patients die each year in the United States as a result of preventable clinical errors.1,2 Earlier studies reflected similar problems in the United Kingdom and Australia. Preventable adverse events and patient deaths are a common reason for malpractice claims in hospitals today. One proposed solution to improve patient safety is the international movement to establish rapid response teams (RRTs) as recommended by the Institute for Healthcare Improvement (IHI) and supported by the National Registry of Cardiopulmonary Resuscitation. The purpose of this brief article is to describe the phenomenon of RRTs and potential ideas for the clinical nurse specialist (CNS) in facilitating this intervention.

A description of clinical nurse specialist programs in the United States.

Changes have occurred in clinical nurse specialist educational requirements in recent years, and it is not known how programs have responded. The purpose of this descriptive survey was to identify the number of clinical nurse specialist programs in the United States, describe curricula, and examine enrollment and employment trends. This report contains data from 157 separate clinical nurse specialist programs/majors representing 139 different schools. The mean number of credit hours for semester- and quarter-based programs was 41.4 and 52.2, respectively. The mean number of clinical/practica clock hours was 416.2. Approximately half of the respondents (56%) used the National Association of Clinical Nurse Specialists Statement on Clinical Nurse Specialist Practice and Education to guide curricula. Nearly 66% of the programs had from 1 to 10 applicants during the previous year. The majority (68%) indicated that their graduates do not have difficulty finding employment after graduating. These findings indicate that efforts to revise curricula and clarify the CNS role must continue.

A vision of the future for clinical nurse specialists: prepared by the National Association of Clinical Nurse Specialists, July 2007.

This document represents a compilation of thought from the past, present, and future leaders of the National Association of Clinical Nurse Specialists (NACNS) and clinical nurse specialists in both Canada and the United States. It is our presentation of the vision of what the future holds for clinical nurse specialists (CNSs) as seen from the present. It has been a labor of love that has taken 17 months to create, validate, and edit into the document you see today. The work involved volunteers from a variety of backgrounds and represented CNS students, educators, and clinicians from a diverse set of specialties. These individuals may be invisible in the author list, but their contributions are invaluable. A call to the membership attending the annual conference held in Salt Lake City in March 2006 initiated the creation of this document. More than 100 volunteers stepped up to assist in the creation of a vision of the preferred future for CNSs. Past, present, and future leaders of NACNS were then commissioned to write sections of the paper, including content on education, practice, certification, and regulation of CNSs as visioned into the future. Once edited into a single document, the full paper was sent to a task force of NACNS members who volunteered to serve as reviewers. We are grateful for their comments, feedback, and edits. Those edits were incorporated, and the document was further scrutinized by a broad variety of stakeholders through a call on the CNS listserve for additional comments, feedback, and edits. This additional feedback was incorporated into the document, which was reviewed and approved by the NACNS Board of Directors in June 2007. Heartfelt thanks to the unnamed volunteers who spent time in thoughtful edit of the concepts presented here and how they fit with their current CNS practice. It is with honor that this author team is able to present to you the work of our members.