Kristen E. Pecanac

Frequency and Duration of Nursing Care Related to Older Patient Mobility

PURPOSE To evaluate the frequency and duration of nursing care activity related to mobilizing older patients in acute care settings and determining who initiates the mobility event (patient or nurse). METHODS This was an observation study using time and motion. Observers shadowed 15 registered nurses (RNs) each for two to three 8-hr periods using hand-held computer tablets to collect data on frequency and duration of six mobility events (standing, transferring, walking to and from the patient bathroom, walking in the patient room, and walking in the hallway) that occurred in the nurses presence. Chart reviews were conducted on 47 adult patients (> 65 years of age) who were cared for by the nurses during the observation periods. Descriptive statistics (mean, median, standard deviation, frequency, and proportion) were used to describe the occurrence of mobility events among all 47 patients and among a subgroup of 16 patients identified as dependent (needing human assistance of another to ambulate) at the time of admission. RESULTS Thirty-two percent of older patients were not engaged by an RN in any mobility event during an 8-hr period. For all patients, standing and transferring were the most frequent mobility activity. Mean duration for ambulation was less than 2 min per observation period. Patients who were dependent had fewer mobility events with no events related to ambulation initiated by nurses. The majority of mobility events were initiated by patients. CONCLUSIONS Nurses infrequently initiated mobility events for hospitalized older patients and most often engaged patients in low-level activity (standing and transferring). CLINICAL RELEVANCE Limited mobility (standing and transferring only) is an independent predictor of negative outcomes for hospitalized older patients. Nurses are in a key position to improve outcomes for hospitalized older patients by engaging them in mobility activity, particularly ambulation, but further research is needed to determine how best to engage nurses in these activities.

Patient-reported Limitations to Surgical Buy-in: A Qualitative Study of Patients Facing High-risk Surgery.

Objective: To characterize how patients buy-in to treatments beyond the operating room and what limits they would place on additional life-supporting treatments. Background: During a high-risk operation, surgeons generally assume that patients buy-in to life-supporting interventions that might be necessary postoperatively. How patients understand this agreement and their willingness to participate in additional treatment is unknown. Methods: We purposively sampled surgeons in Toronto, Ontario, Boston, Massachusetts, and Madison, Wisconsin, who are good communicators and routinely perform high-risk operations. We audio-recorded their conversations with patients considering high-risk surgery. For patients who were then scheduled for surgery, we performed open-ended preoperative and postoperative interviews. We used directed qualitative content analysis to analyze the interviews and surgeon visits, specifically evaluating the content about the use of postoperative life support. Results: We recorded 43 patients’ conversations with surgeons, 34 preoperative, and 27 postoperative interviews. Patients expressed trust in their surgeon to make decisions about additional treatments if a serious complication occurred, yet expressed a preference for significant treatment limitations that were not discussed with their surgeon preoperatively. Patients valued the existence or creation of an advance directive preoperatively, but they did not discuss this directive with their surgeon. Instead they assumed it would be effective if needed and that family members knew their wishes. Conclusions: Patients implicitly trust their surgeons to treat postoperative complications as they arise. Although patients may buy-in to some additional postoperative interventions, they hold a broad range of preferences for treatment limitations that were not discussed with the surgeon preoperatively.

Conflict in the intensive care unit Nursing advocacy and surgical agency

Background: Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy—a responsibility to support the patient’s best interest; surgeons have a sense of agency—a responsibility to keep the patient alive. Objectives: The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as “advocates” and “agents,” and (2) apply these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit. Research design: Articles, books, and professional documents were explored to obtain descriptions of nurses’ and surgeons’ responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases. Findings: Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient’s outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery. Discussion: These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other’s responsibilities. Conclusion: Interventions that improve understanding of each profession’s responsibilities may be helpful to reduce intra-team conflict in the intensive care unit.

Communicating Delicately: Introducing the Need to Make a Decision About the Use of Life-Sustaining Treatment

ABSTRACT The purpose of this study was to explore how clinicians introduce the need to make a decision about the use of life-sustaining treatment and how surrogates respond to these introductions during family conferences in the intensive care unit. This article focuses on the use of the perspective-display sequence as a way to introduce the decision-making conversation. In the family conferences, the perspective-display sequence involved (a) the clinician’s perspective-display invitation of the surrogates’ assessment of the patient’s wishes, (b) the surrogates’ reply or assessment, and (c) the clinician’s decision proposal, which often incorporates the surrogates’ assessment. Asking about the patient’s wishes is a delicate way to ease into the decision-making conversation. By using the perspective-display sequence, clinicians are also participating in shared decision making; their decision proposal is co-constructed with surrogates’ understanding of the patient’s wishes regarding the treatment.

Treatment decision making involving patients with dementia in acute care: A scoping review

OBJECTIVE To summarize the evidence regarding the factors and processes of treatment decision making involving a person with dementia (PWD) in the acute care setting. METHODS We conducted a scoping review, searching 4 databases (PubMed, CINAHL, Web of Science, & PsychINfo) for articles that contained primary data from a quantitative or qualitative study involving treatment decision making in the acute care setting for PWD and were published in English. We categorized the factors and processes of decision making identified in each article using inductive content analysis. We also consulted with healthcare practitioners to receive stakeholder input on our findings. RESULTS Our search initially revealed 12,478 articles, of which 28 were included in the review. We identified 5 categories of factors that influence the decision-making process: knowing the patient, culture and systems, role clarity, appropriateness of palliative care in dementia, and caregiver need for support. CONCLUSION Our findings highlight the complexities of the decision-making process and the importance of attending to the needs of the caregiver, healthcare practitioners, and the patient. PRACTICE IMPLICATIONS It is important to address beliefs of involving palliative care for a PWD and the role of each healthcare discipline.

Using timed event sequential data in nursing research.

BackgroundMeasuring behavior is important in nursing research, and innovative technologies are needed to capture the “real-life” complexity of behaviors and events. PurposeThe purpose of this article is to describe the use of timed event sequential data in nursing research and to demonstrate the use of this data in a research study. DiscussionTimed event sequencing allows the researcher to capture the frequency, duration, and sequence of behaviors as they occur in an observation period and to link the behaviors to contextual details. Timed event sequential data can easily be collected with handheld computers, loaded with a software program designed for capturing observations in real time. ConclusionTimed event sequential data add considerable strength to analysis of any nursing behavior of interest, which can enhance understanding and lead to improvement in nursing practice.