Diane L. Carroll

Barriers and Facilitators to the Utilization of Nursing Research

The nurse in clinical practice must demonstrate a scientific base for practice grounded in research findings. The purpose of this study was to explore the nurses perception of the barriers and facilitators to using research findings in nursing practice. A survey methodology was used, and a sample of 356 practicing registered nurses responded. Data were collected using a scale that rated the barriers and facilitators to research utilization. The greatest barriers were insufficient time on the job to implement new ideas, lack of knowledge of nursing research findings, and inaccessibility of relevant literature. The advanced practice nurse is in a pivotal position to decrease the barriers to research utilization.

The importance of self-efficacy expectations in elderly patients recovering from coronary artery bypass surgery

OBJECTIVE To describe and test a model of recovery in the elderly after coronary artery bypass surgery derived from Self-Care and Self-Efficacy Theory. DESIGN Prospective, longitudinal, repeated measures. SETTING Two large urban teaching hospitals on the East Coast. PATIENTS One hundred thirty-three adults over the age of 65 years who had coronary artery bypass surgery on hospital admission. There were 32 women and 101 men with an age range of 65 to 87 years (M = 71.8 years +/- 4.8 years) in whom 77.5% were in a New York Heart Association class of 3 or 4, indicating significant functional limitations. OUTCOME MEASURES Self-care agency, self-efficacy expectations, and the performance of self-care/recovery behaviors at discharge, 6, and 12 weeks after coronary artery bypass surgery. INSTRUMENTS The exercise of self-care agency was measured with the Exercise of Self-Care Agency Scale, self-efficacy expectation, and the performance of self-care/recovery behavior by the Jenkins Self-Efficacy Expectation Scales and Activity Checklists. Data were collected at discharge, 6 weeks, and 12 weeks after surgery for the specific behaviors of walking, climbing stairs, resuming general activities, and the performance of roles. RESULTS Repeated measures analysis of variance revealed significant changes in self-care agency, the self-efficacy expectations for all behaviors, and the performance of the behaviors for walking, resuming general activities, and performance of roles over the recovery period (p < 0.01). CONCLUSIONS In support of the model, self-efficacy expectations mediated between self-care agency and all self-care/recovery behaviors at selected times. Comparison of the performance of self-care/recovery behaviors with other samples from the literature found recovery in the elderly to be protracted. Nurses can be pivotal in providing the elderly with accurate projections of recovery and an environment to support the initial mastery of self-care/recovery behaviors to promote optimal health in this vulnerable population.

The effects of a collaborative peer advisor/advanced practice nurse intervention: cardiac rehabilitation participation and rehospitalization in older adults after a cardiac event.

Background: After the cardiovascular events of myocardial infarction (MI) and coronary artery bypass surgery (CABS), unpartnered older adults are a vulnerable group that may benefit from interventions to improve health outcomes. The purpose of this analysis is to determine if a community-based collaborative peer advisor/advanced practice nurse intervention increased participation in cardiac rehabilitation programs and reduced hospital readmissions after MI and CABS and determine whether the type of cardiovascular event influenced rehospitalization. Subjects and Methods: This study was a randomized clinical trial that enrolled 247 unpartnered older adults who were single, widowed, or divorced. Subjects were randomized into 4 groups: standard of care group for MI and for CABS and standard of care plus the treatment groups for MI and for CABS, for 12 weeks after discharge. There were 163 women/84 men, with a mean age of 76.4 years, who were admitted for MI (n = 93) or CABS (n = 154) and who were enrolled from 5 academic medical centers. The treatment consisted of a community-based intervention of a home visit within 72 hours and telephone calls at 2, 6, and 10 weeks from an advanced practice nurse and 12 weekly telephone calls from a peer advisor. Participation in a cardiac rehabilitation program and rehospitalizations were collected at 6 weeks and 3, 6, and 12 months by telephone interview. Results and Conclusions: There were significantly more participants in cardiac rehabilitation programs after 3 months in the treatment group, and this increase was seen up to 1 year after MI and CABS. There were no statistical differences, although there were fewer rehospitalizations between 3 and 6 months after MI and CABS in the treatment group compared with the standard of care group. Overall, the evidence from this study suggests that a community-based collaborative peer advisor/advanced practice nurse intervention can play a role in promoting active participation in cardiac rehabilitation programs and fewer rehospitalizations in unpartnered older adults after MI and CAGS.

Why Do Patients in Acute Care Hospitals Fall? Can Falls Be Prevented?

Objective: Obtain the views of nurses and assistants as to why patients in acute care hospitals fall. Background: Despite a large quantitative evidence base for guiding fall risk assessment and not needing highly technical, scarce, or expensive equipment to prevent falls, falls are serious problems in hospitals. Methods: Basic content analysis methods were used to interpret descriptive data from 4 focus groups with nurses (n = 23) and 4 with assistants (n = 19). A 2-person consensus approach was used for analysis. Results: Positive and negative components of 6 concepts-patient report, information access, signage, environment, teamwork, and involving patient/family-formed 2 core categories: knowledge/ communication and capability/actions that are facilitators or barriers, respectively, to preventing falls. Conclusion: Two conditions are required to reduce patient falls. A patient care plan including current and accurate fall risk status with associated tailored and feasible interventions needs to be easily and immediately accessible to all stakeholders (entire healthcare team, patients, and family). Second, stakeholders must use that information plus their own knowledge and skills and patient and hospital resources to carry out the plan.

Changes in health status and quality of life and the impact of uncertainty in patients who survive life-threatening arrhythmias

OBJECTIVE The purpose of this study was to describe the changes in perception of health status and quality of life from before treatment to 6 months after and the impact of uncertainty on these variables in survivors of life-threatening arrhythmia. DESIGN AND SETTING A descriptive correlational design at a large urban teaching hospital. MEASURES We measured health status, quality of life, and uncertainty before treatment and 6 months after a life-threatening arrhythmia. RESULTS Survivors included 66 men and 15 women, 41 of whom received pharmacologic therapy and 36 of whom received an implantable cardioverter defibrillator (ICD), completed the Medical Outcomes Survey (SF-36), Ferrans and Powers Quality of Life Index (QLI), and the Mishel Uncertainty in Illness Scale (MUIS-C) before treatment and 6 months after. There were significant improvements in the mental and physical health composite summaries as measured by the SF36 (P <.01). Conversely, there were significant reductions in the overall score and specifically in socioeconomic and psychological/spiritual quality of life domains as measured by the QLI (P <.05). An increased perception of uncertainty was related to decreased perception of health status and quality of life at both measurement times, with higher correlations 6 months later. CONCLUSIONS Survivors demonstrated improvements in perceived health status, although this did not appear to translate into improvements in the subjective domains of quality of life. The overall quality of life and the domains of psychological/spiritual state and socioeconomic status were lower 6 months after a life-threatening arrhythmia. Uncertainty had a significant impact on these perceptions, identifying an area for nursing interventions.

The Peer Advisor Experience Providing Social Support

Research shows a link between increased social support and decreased complications after myocardial infarction (MI). In a current randomized controlled trial (RCT), a social support intervention administered by nurse and peer advisors is being examined to determine its influence on the health outcomes of unpartnered, post-MI elders. This qualitative study (as part of the larger RCT) sought a better understanding regarding the experience of the peer advisor. Data sources included peer advisor logs, a focus group, and telephone interviews with peer advisors. Findings revealed that helping, mutual sharing, committing, and benefiting are characteristics of peer experiences. Primarily because of their personal experience of recovery from MI, peer advisors had a remarkable ability to relate to assigned post-MI elders, offering a unique form of social support complementary to current health practices.

Patients' perspectives of falling while in an acute care hospital and suggestions for prevention

Patient falls and falls with injury are the largest category of reportable incidents and a significant problem in hospitals. Patients are an important part of fall prevention; therefore, we asked patients who have fallen about reason for fall and how falls could be prevented. There were two categories for falls: the need to toilet coupled with loss of balance and unexpected weakness. Patients asked to be included in fall risk communication and asked to be part of the team to prevent them from falling. Nurses need to share a consistent and clear message that they are there for patient safety.

Event-free Survival Following Nonemergency Myocardial Revascularization during Hypothermic Fibrillatory Arrest

To better assess the late results of hypothermic fibrillatory arrest during myocardial revascularization, 1,000 consecutive patients having nonemergency coronary artery grafting during hypothermic fibrillatory arrest from August, 1979, through November, 1984, were studied to determine event-free survival. Hospital mortality was 0.4% and the rate of perioperative myocardial infarction, 1.8%. At follow-up (mean, 30.5 months), 11 patients had sustained an interval nonfatal myocardial infarction, 3 had had percutaneous angioplasty, and 2 had undergone reoperative revascularization. Actuarial survival at five years was 91.6 +/- 2.0%. Actuarial event-free rates at five years were 97.7 +/- 0.8% for myocardial infarction, 99.4 +/- 0.4% for percutaneous transluminal coronary angioplasty, 99.5 +/- 0.4% for reoperative revascularization, and 88.6 +/- 2.2% for all combined morbidity and mortality. Among the 122 patients meeting randomizable admission criteria of the Coronary Artery Surgery Study, there were no operative deaths and no perioperative infarctions, and the actuarial survival was 97.5% at five years. Hypothermic fibrillatory arrest is effective for myocardial preservation during coronary revascularization and when combined with complete revascularization, yields excellent event-free survival.

Cluster analysis of symptoms in pulmonary arterial hypertension: a pilot study

Background: Pulmonary arterial hypertension (PAH) is characterized by elevated pulmonary artery pressures leading to right heart failure and death. Aims: The aim of this study was to use cluster analysis to describe the symptom profile in PAH and differences in the health outcomes of health status, health-related quality of life (HRQoL) and psychological states in the cluster groups. Methods: A cross-sectional descriptive design was used. A convenience sample completed a socio-demographic and clinical data form, a PAH Symptom Severity and Interference Scale, the Medical Outcomes Study Short Form (SF-36), the United States Cambridge Pulmonary Hypertension Outcome Review (US CAMPHOR) and the Short Form of the Profile of Mood States (POMS). Results: Of the 151participants, the mean age was 53.5 ± 15.1 with the majority female (n = 128, 85%). Fifty-eight (41%) were disabled and 67 (44%) were Functional Class IV. The most prevalent symptoms were shortness of breath with exertion (n = 149, 99%) and fatigue (n = 144, 93%). Three clusters emerged: Cluster 1 diffuse symptoms (n = 93), Cluster 2 severe cardiopulmonary symptoms (n = 32) and Cluster 3 moderate cardiopulmonary symptoms (n = 26). Overall, on the SF-36 the participants had poor general health, reduced physical function, role physical, vitality, and a low composite score for physical health. On the POMS the sample had limited vigor and increased fatigue. Cluster 2 Severe Cardiopulmonary Symptoms had worse SF-36, US CAMPHOR and POMS scores than the other cluster groups. Conclusions: Patients with PAH are experiencing a constellation of symptoms that are interfering with their life and emerging clusters were present.

Symptom experience of pulmonary arterial hypertension patients.

Purpose: To describe symptoms experienced by pulmonary arterial hypertension (PAH) patients and the impact these symptoms have had on their lives. Method: Qualitative descriptive methodology was chosen incorporating semistructured interviews to investigate the symptom experience of ten patients with PAH. Results: All patients were diagnosed with WHO Group 1 PAH and 70% were WHO functional Class III. Two overarching themes emerged: holding back and redefining life. Holding back was represented by three sub-themes: fear, anticipation of worsening symptoms, and treatment effects. Redefining life was characterized by uncertainty, activity restrictions, and making the best of it. Conclusion: This study revealed specific concerns related to the symptom experience of PAH patients and how they redefined their lives to accommodate these symptoms. These findings provide a basis for larger, quantitative studies to examine the extent of symptom impact as well as a framework for development of self management interventions to improve the symptom experience and QOL.