Carol G. Kelley

Use of advance directives in the chronically critically ill.

Although it would be ideal that all patients have the presence of an advance directive documented in their medical chart, it is especially important in the chronically critically ill, a patient population with an in-hospital mortality rate of 40%. How has the documentation of advance directives in the medical chart of chronically critically ill patients changed from 1997 to 2003? This article describes the patient characteristics and patterns of death in chronically critically ill patients, with or without an advance directive, enrolled in 2 consecutive studies.

Case histories in the education of advanced practice nurses.

Case histories--rich, anecdotal narratives--are theorized to support the acquisition of cognitive, social, cultural, and emotional knowledge and motor skills through active learning. This manuscript focuses on the value of case histories in teaching and evaluating acute and critical care advanced practice nursing students. Information about the use of case histories in advanced critical care education and clinical practice is limited. Case histories support student-centered learning and development of clinical reasoning. An exemplar of a case history is provided, and application of case histories to both electronic and classroom settings is explored.

Age differences in survival outcomes and resource use for chronically critically ill patients

PURPOSE Chronically critically ill (CCI) patients use a disproportionate amount of resources, yet little research has examined outcomes for older CCI patients. The purpose of this study was to compare outcomes (mortality, disposition, posthospital resource use) between older (> or =65 years) and middle-aged (45-64 years) patients who require more than 96 hours of mechanical ventilation while in the intensive care unit. METHODS Data from 2 prospective studies were combined for the present examination. In-hospital as well as posthospital discharge data were obtained via chart abstraction and interviews. RESULTS One thousand one hundred twenty-one subjects were enrolled; 62.4% (n = 700) were older. Older subjects had a 1.3 greater risk for overall mortality (from admission to 4 months posthospital discharge) than middle-aged subjects. The Acute Physiology Score (odds ratio [OR], 1.009), presence of diabetes (OR, 2.37), mechanical ventilation at discharge (OR, 3.17), and being older (OR, 2.20) were statistically significant predictors of death at 4 months postdischarge. Older subjects had significantly higher charges for home care services, although they spent less time at home (mean, 22.1 days) than middle-aged subjects (mean, 31.3 days) (P = .03). CONCLUSION Older subjects were at higher risk of overall mortality and used, on average, more postdischarge services per patient when compared with middle-aged subjects.

Nurse practitioners and preventive screening in the hospital.

The purpose of this study was to investigate a reminder to discuss cervical cancer screening with hospitalized females. A quasi-experimental design was used to compare the association of a reminder intervention for nurse practitioners with two outcomes: prevalence of cervical cancer screening as documented in patients’ charts and patients’ self-report of cervical cancer screening 4 months after discharge. Data were collected by chart review and phone survey. The sample consisted of nurse practitioners caring for eligible female patients at a university teaching hospital. Chi-square was used to test all research questions. The rate of documentation of cervical cancer screening increased from 2% to 69% after implementation of the reminder intervention. The reminder intervention did not impact patients actually receiving Pap smears after discharge. The significant increase in documentation of screening associated with the use of the single reminder in the patients’ charts support the use of this low-cost intervention.

End of Life Nursing Education Consortium: A Requirement for Advanced Practice Registered Nursing Students

End-of-life (EOL) content is an essential component in advanced practice registered nursing (APRN) education. Since 2007, an 8-hour ELNEC (End of Life Nursing Education Consortium) course has been a requirement for selected APRN students at the Frances Payne Bolton School of Nursing, Case Western Reserve University. Since the start of the required course, 160 participants have been surveyed to identify their perception of aspects of EOL care in their clinical setting that are done well or need to improve. The use of palliative care and hospice was the most prevalent theme identified for EOL care done well or as an area for improvement. Communication skills and pain and symptom management were identified as areas that participants felt they learned most. The majority of participants recognized the relevance of the ELNEC content to their APRN practice, regardless of their area of clinical specialty. This article is a report of an evaluation of our experience with ELNEC and describes participants’ perceptions of aspects of (EOL) care and views on this EOL education requirement.

Advance directive use and psychosocial characteristics: An analysis of patients enrolled in a psychosocial cancer registry

Advance directives (ADs) refer to a category of documents that enable individuals to state their preferences for future healthcare decisions in the event of incapacitation. The purpose of the study was to examine differences in psychosocial characteristics and AD completion rates in persons newly diagnosed with cancer. This sample comes from data collected for a psychosocial registry for patients with cancer. The following psychosocial data were collected: Functional Assessment of Cancer Therapy-General, Profile of Mood States-short form, and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale. The sample included 312 persons who had been diagnosed with cancer within the previous 5 months. There were no statistically significant differences between completion of an AD and the measured psychosocial characteristics at baseline (mean, 4.2 months); however, at 3 months, patients who reported higher quality of life (Functional Assessment of Cancer Therapy-General) were associated with lower AD completion rates and persons with greater mood disturbances had higher rates of AD completion. Our data suggest the need to develop strategies that would facilitate discussion of ADs for patients entering the cancer care continuum.

Benefits and Challenges in Developing a Program of Research

The ultimate goals of nursing research are knowledge generation and improvement in nursing practice. Designing studies that provide the evidence needed for practice change and that have clear implications for immediate application to current practice environments is particularly challenging. Research programs that consist of sequential studies, each building on and expanding on the results of the previous work, offer the greatest promise for generating understanding of the human phenomenon relevant to nursing practice. The authors review their experience with a series of studies of inpatient and postdischarge needs and interventions associated with chronic critical illness to illustrate the benefits of developing a longitudinal research program as well as the importance of strategies that will foster application of results. Recommendations for developing such a program are discussed.

Mindful Communication: Being Present

OBJECTIVES To review how mindfulness can be elicited in and strategically managed through communication, with a goal toward enhancing the patient/family relationship in the experience of cancer care. DATA SOURCES Published, peer-reviewed literature, research reports, and Web-based resources. CONCLUSION Mindful communication, an active process whereby the health care provider and patient /family unit are attentive to the timing, nature, and context of the dialogue exchange, helps direct care that is patient-centered, reflective, and relational. IMPLICATIONS FOR NURSING PRACTICE Oncology nurses using a patient-centered approach to communication will be more equipped to use mindfulness-based strategies that can potentially shift the way cancer care is delivered.

Research partners: two teams, one study population.

Background:Two large research projects funded by the National Institutes of Health, the Disease Management project and the Thrive study, which examine different phenomena in the chronically critically ill population, have combined research teams. Each study has its own project manager and maintains a separate database and budget. Operational tasks for both grants are streamlined through the collaboration and cross-training of all team members. Methods:The Disease Management project is a randomized clinical trial testing the effectiveness of a care program in improving outcomes for chronically critically ill patients and their caregivers during the first 2 months after discharge. The Thrive study is a prospective longitudinal investigation that aims to describe the weaning patterns of chronically critically ill patients as well as the patterns of illness-related variables. Results:To date, many participants (n = 400) have been enrolled in each study. The results of both studies will be available through future publications. Conclusions:Although much information has been gleaned from gathering longitudinal data across one study population and examining two rich data sets, there are some limitations to this collaboration.

Stress and Coping of Critical Care Nurses After Unsuccessful Cardiopulmonary Resuscitation

Background Participation by a critical care nurse in an unsuccessful resuscitation can create a unique heightened level of psychological stress referred to as postcode stress, activation of coping behaviors, and symptoms of posttraumatic stress disorder (PTSD). Objectives To explore the relationships among postcode stress, coping behaviors, and PTSD symptom severity in critical care nurses after experiencing unsuccessful cardiopulmonary resuscitations and to see whether institutional support attenuates these repeated psychological traumas. Methods A national sample of 490 critical care nurses was recruited from the American Association of Critical‐Care Nurses’ eNewsline and social media. Participants completed the Post‐Code Stress Scale, the Brief COPE (abbreviated), and the Impact of Event Scale‐Revised, which were administered through an online survey. Results Postcode stress and PTSD symptom severity were weakly associated (r = 0.20, P = .01). No significant associations between coping behaviors and postcode stress were found. Four coping behaviors (denial, self‐distraction, self‐blame, and behavioral disengagement) were significant predictors of PTSD symptom severity. Severity of postcode stress and PTSD symptoms varied with the availability of institutional support. Conclusions Critical care nurses show moderate levels of postcode stress and PTSD symptoms when asked to recall an unsuccessful resuscitation and the coping behaviors used. Identifying the critical care nurses most at risk for PTSD will inform the development of interventional research to promote critical care nurses’ psychological well‐being and reduce their attrition from the profession.