Judith A. Tate

Methods to Improve Reliability of Video Recorded Behavioral Data

Behavioral observation is a fundamental component of nursing practice and a primary source of clinical research data. The use of video technology in behavioral research offers important advantages to nurse scientists in assessing complex behaviors and relationships between behaviors. The appeal of using this method should be balanced, however, by an informed approach to reliability issues. In this article, we focus on factors that influence reliability, such as the use of sensitizing sessions to minimize participant reactivity and the importance of training protocols for video coders. In addition, we discuss data quality, the selection and use of observational tools, calculating reliability coefficients, and coding considerations for special populations based on our collective experiences across three different populations and settings.

Nurse-Patient Communication Interactions in the Intensive Care Unit

BACKGROUND The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured. OBJECTIVES To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit. METHODS Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication. RESULTS Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the communication sessions with nurses as somewhat difficult to extremely difficult. Assistive communication strategies were uncommon, with little to no use of assistive communication materials (eg, writing supplies, alphabet or word boards). CONCLUSIONS Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials.

Bidirectional Relationship between Cognitive Function and Pneumonia

RATIONALE Relationships between chronic health conditions and acute infections remain poorly understood. Preclinical studies suggest crosstalk between nervous and immune systems. OBJECTIVES To determine bidirectional relationships between cognition and pneumonia. METHODS We conducted longitudinal analyses of a population-based cohort over 10 years. We determined whether changes in cognition increase risk of pneumonia hospitalization by trajectory analyses and joint modeling. We then determined whether pneumonia hospitalization increased risk of subsequent dementia using a Cox model with pneumonia as a time-varying covariate. MEASUREMENTS AND MAIN RESULTS Of the 5,888 participants, 639 (10.9%) were hospitalized with pneumonia at least once. Most participants had normal cognition before pneumonia. Three cognition trajectories were identified: no, minimal, and severe rapid decline. A greater proportion of participants hospitalized with pneumonia were on trajectories of minimal or severe decline before occurrence of pneumonia compared with those never hospitalized with pneumonia (proportion with no, minimal, and severe decline were 67.1%, 22.8%, and 10.0% vs. 76.0%, 19.3%, and 4.6% for participants with and without pneumonia, respectively; P < 0.001). Small subclinical changes in cognition increased risk of pneumonia, even in those with normal cognition and physical function before pneumonia (β = -0.02; P < 0.001). Participants with pneumonia were subsequently at an increased risk of dementia (hazard ratio, 2.24 [95% confidence interval, 1.62-3.11]; P = 0.01). Associations were independent of demographics, health behaviors, other chronic conditions, and physical function. Bidirectional relationship did not vary based on severity of disease, and similar associations were noted for those with severe sepsis and other infections. CONCLUSIONS A bidirectional relationship exists between pneumonia and cognition and may explain how a single episode of infection in well-appearing older individuals accelerates decline in chronic health conditions and loss of functional independence.

Exemplars of mixed methods data combination and analysis

Background: Mixed methods research approaches can be applied to nursing and healthcare. Multiple perspectives and different types of data (e.g., social-behavioral data, numerical outcome measures, or clinical variables) often are needed to examine complex clinical problems and health behaviors fully. Although qualitative and quantitative methods are recognized widely as complementary for studying and explaining human phenomena, methodological techniques for combining and analyzing mixed methods data have received less attention. Objectives: To describe techniques for mixed methods data combination and analyses using three different design approaches. Methods: Data combination and analysis techniques are presented using the following approaches: (a) mixed methods event analysis, (b) concurrent-mixed analysis for complementarity and completeness, and (c) concurrent nested analysis to provide a broader understanding of phenomena and enrich the description of participants. Results: Research exemplars from topical areas such as weaning from long-term mechanical ventilation, medication-taking among community-dwelling persons with dementia, health control beliefs after lung transplantation, and recovery from subarachnoid hemorrhage are presented. Simple and complex matrix construction and a variety of graphical displays are used to illustrate data combination and analysis techniques for mixed methods research. Discussion: The techniques for mixed methods data combination and analysis presented have the potential to advance the use and refinement of mixed methods research, thereby expanding the repertoire of methodologies to study complex phenomena of interest to nurses.

Anxiety and Agitation in Mechanically Ventilated Patients

During an ethnography conducted in an intensive care unit (ICU), we found that anxiety and agitation occurred frequently and were important considerations in the care of 30 patients weaning from prolonged mechanical ventilation. We conducted a secondary analysis to (a) describe characteristics of anxiety and agitation experienced by mechanically ventilated patients, (b) explore how clinicians recognized and interpreted anxiety and agitation, and (c) describe strategies and interventions used to manage anxiety and agitation with mechanically ventilated patients. We constructed the Anxiety/Agitation in Mechanical Ventilation Model to illustrate the multidimensional features of symptom recognition and management. Patients’ ability to interact with the environment served as a basis for identification and management of anxiety or agitation. Clinicians’ attributions about anxiety or agitation, and “knowing the patient,” contributed to their assessment of patient responses. Clinicians chose strategies to overcome either the stimulus or the patient’s appraisal of risk of the stimulus. This article contributes to the body of knowledge about symptom recognition and management in the ICU by providing a comprehensive model to guide future research and practice.

Videorecording in clinical research: mapping the ethical terrain.

Background: Videography is used increasingly for data collection in clinical research; however, addressing related ethical issues and obtaining institutional review board approval to use videography are often significant and daunting challenges for investigators. Guidelines and specific strategies are extremely limited in the literature. To protect the interests of videorecorded patient and clinician research participants, several ethical issues deserve thoughtful consideration and planning: informed consent, confidentiality and privacy, and participant burden and safety. Approach: The Study of Patient-Nurse Effectiveness with Assisted Communication Strategies is used to illustrate how these ethical issues can be managed in a clinical trial. Excerpts from informed consent documents are included, and special attention is given to the critical care environment, vulnerable patient populations, and clinicians as participants. Results: Ethical issues related to the use of videography for patient-oriented research in the acute care hospital setting are clarified, and specific examples of how these issues can be addressed are provided. Discussion: Ethical issues related to using videorecording in acute care research can be adequately addressed through existing universal human subjects protection strategies when the precise nature of the ethical issues is defined clearly.

Use of the quasi-experimental sequential cohort design in the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS).

This paper describes a quasi-experimental three-phase sequential cohort design used in the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS) to test two interventions to improve nurse-patient communication in the intensive care unit (ICU). The sample consists of 10 nurses and 30 nonspeaking ICU patients in each phase (total n=90 nurse-patient dyads). Observational techniques (video recording, transcription, and rating) measure nurse-patient communication performance. Descriptive and covariate data are collected through clinical assessment tools, questionnaires, and field notes. We discuss the practical and scientific considerations in constructing and implementing this type of clinical trial. Specifically, primary threats to validity, history and the Hawthorne effect, are considered and efforts to minimize and track these potential threats are described.

INFECTION HOSPITALIZATION INCREASES RISK OF DEMENTIA IN THE ELDERLY

Objectives:Severe infections, often requiring ICU admission, have been associated with persistent cognitive dysfunction. Less severe infections are more common and whether they are associated with an increased risk of dementia is unclear. We determined the association of pneumonia hospitalization with risk of dementia in well-functioning older adults. Design:Secondary analysis of a randomized multicenter trial to determine the effect of Gingko biloba on incident dementia. Setting:Five academic medical centers in the United States. Subjects:Healthy community volunteers (n = 3,069) with a median follow-up of 6.1 years. Interventions:None. Measurement and Main Results:We identified pneumonia hospitalizations using International Classification of Diseases, 9th Edition—Coding Manual codes and validated them in a subset. Less than 3% of pneumonia cases necessitated ICU admission, mechanical ventilation, or vasopressor support. Dementia was adjudicated based on neuropsychological evaluation, neurological examination, and MRI. Two hundred twenty-one participants (7.2%) incurred at least one hospitalization with pneumonia (mean time to pneumonia = 3.5 yr). Of these, dementia was developed in 38 (17%) after pneumonia, with half of these cases occurring 2 years after the pneumonia hospitalization. Hospitalization with pneumonia was associated with increased risk of time to dementia diagnosis (unadjusted hazard ratio = 2.3; CI, 1.6–3.2; p < 0.0001). The association remained significant when adjusted for age, sex, race, study site, education, and baseline mini-mental status examination (hazard ratio = 1.9; CI, 1.4–2.8; p < 0.0001). Results were unchanged when additionally adjusted for smoking, hypertension, diabetes, heart disease, and preinfection functional status. Results were similar using propensity analysis where participants with pneumonia were matched to those without pneumonia based on age, probability of developing pneumonia, and similar trajectories of cognitive and physical function prior to pneumonia (adjusted prevalence rates, 91.7 vs 65 cases per 1,000 person-years; adjusted prevalence rate ratio = 1.6; CI, 1.06–2.7; p = 0.03). Sensitivity analyses showed that the higher risk also occurred among those hospitalized with other infections. Conclusion:Hospitalization with pneumonia is associated with increased risk of dementia.

Event analysis techniques.

Event analysis (EA), a qualitative research technique adapted from the fields of anthropology and sociology, can be used to describe and explain social interactions and behaviors associated with complicated clinical situations. Event analysis is useful in limiting the focus of data collection in complex settings and in obtaining and managing multiple perspectives about an event of interest while situating the event within appropriate social and environmental contexts. This article reviews contemporary uses of EA in clinical nursing research, describes the modification and application of EA techniques to common methods of data gathering (observation, interview, and document review) in clinical settings, and presents recommendations for conducting EA in clinical settings by using exemplars from a current study.

SYMPTOM COMMUNICATION DURING CRITICAL ILLNESS: THE IMPACT OF AGE, DELIRIUM, AND DELIRIUM PRESENTATION

Symptom communication is integral to quality patient care. Communication between patients and nurses in the intensive care unit (ICU) is complicated by oral or endotracheal intubation and fluctuating neurocognitive status or delirium. We report the (a) prevalence of delirium and its subtypes in non-vocal, mechanically ventilated, critically ill patients; (b) impact of age on delirium; and (c) influence of delirium and age on symptom communication. Videorecorded interactions between patients (N = 89) and nurses (N = 30) were analyzed for evidence of patient symptom communication at four time points across 2 consecutive days. Delirium was measured at enrollment and following sessions. Delirium prevalence was 23.6% at enrollment and 28.7% across sessions. Participants age >60 were more likely to be delirious on enrollment and during observational sessions. Delirium was associated with self-report of pain, drowsiness, and feeling cold. Patients were significantly less likely to initiate symptom communication when delirious. Symptom identification should be carefully undertaken in older adults with or without delirium.