Marci Nilsen

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.

Nurse and Patient Interaction Behaviors Effects on Nursing Care Quality for Mechanically Ventilated, Older Adults in the ICU

The study purposes were to (a) describe interaction behaviors and factors that may effect communication and (b) explore associations between interaction behaviors and nursing care quality indicators among 38 mechanically ventilated patients (age ≥60 years) and their intensive care unit nurses (n = 24). Behaviors were measured by rating videorecorded observations from the Study of Patient-Nurse Effectiveness with Communication Strategies (SPEACS). Characteristics and quality indicators were obtained from the SPEACS dataset and medical chart abstraction. All positive behaviors occurred at least once. Significant (p < 0.05) associations were observed between (a) positive nurse and positive patient behaviors, (b) patient unaided augmentative and alternative communication (AAC) strategies and positive nurse behaviors, (c) individual patient unaided AAC strategies and individual nurse positive behaviors, (d) positive nurse behaviors and pain management, and (e) positive patient behaviors and sedation level. Findings provide evidence that nurse and patient behaviors effect communication and may be associated with nursing care quality.

Potential for low-value palliative care of patients with recurrent head and neck cancer

Curative treatment for patients with advanced head and neck cancer can be associated with many side-effects, and many patients suffer from persistent treatment-related side-effects. Patients with recurrent cancer bear the burden of these effects along with additional symptoms attributed to the recurrent tumour. To better understand the benefits and burden of palliative treatments for patients with recurrent head and neck cancer, we reviewed the evidence on commonly used palliative treatments and their effect on quality of life. When used for palliative care purposes, chemotherapy and radiotherapy have limited effectiveness in improving quality of life. Moreover, if these treatments are not congruent with a patients end-of-life goals, they could constitute low-value care. We recommend that patients with advanced and recurrent cancer should be offered early, comprehensive palliative and supportive services to maximise benefit. The principles of beneficence and respect for patients in the context of shared decision making must prevail if the trust of this vulnerable patient population is to be honoured.

Adaptation of a communication interaction behavior instrument for use in mechanically ventilated, nonvocal older adults.

Background:Valid and reliable instruments are needed to measure communication interaction behaviors between nurses and mechanically ventilated intensive care unit patients who are without oral speech. Objectives:The aim of this study was to refine and evaluate preliminary validity and reliability of a Communication Interaction Behavior Instrument (CIBI) adapted for use with mechanically ventilated, nonvocal patients in the intensive care unit. Methods:Raters observed nurse–patient communication interactions using a checklist of nurse and patient behaviors, categorized as positive and negative behaviors. Three-minute video-recorded observations of five mechanically ventilated adults (<60 years old) in the intensive care unit and their nurses were used to establish preliminary interrater reliability and confirm appropriateness of definitions (four observations per dyad, n = 20). On the basis of expert input and reliability results, the behaviors and item definitions on the CIBI were revised. The revised tool was then tested in a larger sample of 38 mechanically ventilated intensive care patients (> 60 years old) and their nurses (four observations per dyad, n = 152) to determine interrater reliability. Results:For preliminary testing, percent agreement for individual items ranged from 60% to 100% for nurse behaviors and 20% to 100% for patient behaviors across the five pilot cases. On the basis of these results, 11 definitions were modified and four items were dropped. Using the revised 29-item instrument, percent agreement improved for nurse behaviors (73%–100%) and patient behaviors (68%–100%). Kappa coefficients ranged from 0.13 to 1.00, with lower coefficients for patient behaviors. Conclusion:Preliminary results suggest that the revised CIBI has good face validity and shows good interrater reliability for many of the behaviors, but further refinement is needed. The use of dual raters with adjudication of discrepancies is the recommended method of administration for the revised CIBI.

Experiences Surrounding an Early-Stage Cognitive Diagnosis in Rural-Dwelling Older Adults

Misdiagnosis, lack of specialists, and patient dismissal of symptoms can contribute to delayed detection of early cognitive impairment. Understanding patient perspectives during and around time of cognitive diagnosis is crucial, as reactions to diagnosis can impact disease management and overall health. The current study conducted semi-structured interviews to explore the experiences of rural-dwelling older adults (n = 9) and their caregivers (n = 10) surrounding diagnosis of mild cognitive impairment or early-stage Alzheimers disease at a specialty research center (SRC). Content analysis was performed. Overall, researchers found that older adult participants experienced various cognitive symptoms pre-diagnosis and dyads experienced diagnostic uncertainty prior to the SRC visit. All individuals displayed a range of reactive and information-seeking actions. Nurses play significant roles in the diagnostic and post-diagnostic periods for patients with early-stage cognitive impairment, and clinical diagnostic expertise, appropriate and timely direction of resources, and identification and targeting of early interventions to promote cognitive health are particularly important to this underserved population. [Res Gerontol Nurs. 2018; 11(4):181-189.].

Pain in Head and Neck Cancer Survivors: Prevalence, Predictors, and Quality-of-Life Impact

Objectives Pain is common among patients with cancer, stemming from both malignancy and side effects of treatment. The extent to which pain persists after treatment has received little attention. We examined the prevalence, predictors, and impact on quality of life (QOL) caused by pain among survivors of head and neck cancer. Study Design Cohort study. Setting Tertiary head and neck cancer survivorship clinic. Subjects and Methods We identified survivors of head and neck cancer ≥1 year after diagnosis and examined the prevalence and risk factors for development of pain. Pain and QOL were assessed with multiple QOL instruments. Ordinal regression modeling examined predictors of pain in survivors. Results We identified 175 patients at a median of 6.6 years after diagnosis. Among survivors, 45.1% reported pain, and 11.5% reported severe pain. Among patients with current pain, 46% reported low overall QOL versus only 12% of those without pain (P < .001). On multivariable analysis after adjustment for age, sex, and stage of disease, pain was associated with trimodality treatment (odds ratio [OR], 3.55; 95% CI, 1.06-12.77). Multivariable analysis of QOL issues revealed that pain was associated with major depression (OR, 3.91; 95% CI, 1.68-9.11), anxiety (OR, 4.22; 95% CI, 2.28-7.81), poor recreation (OR, 3.31; 95% CI, 1.70-6.48), and low overall QOL (OR, 2.20; 95% CI, 1.12-4.34). Conclusions Years after head and neck cancer treatment, pain remains a significant problem and is associated with worse QOL. Future efforts should focus on preventing pain from treatment and comprehensive management.

Evaluating the Usability and Acceptability of Communication Tools Among Older Adults

Acutely ill patients may have trouble communicating their symptoms and needs verbally. The current study evaluated the usability and acceptability of six commercially available communication tools with older adults in a non-clinical, controlled setting. Participants evaluated various communication boards and communication applications (apps) by using the tools to communicate needs and symptoms in various scenarios. Participants completed a modified technology acceptance questionnaire and selected the tool they perceived as most useful and easy to use. Bivariate analysis was used to compare communication boards and apps. Performance on most tasks was significantly better using communication boards compared to communication apps. However, participants reported that given more time and training, the apps could be used effectively. A feasibility study is needed to determine whether acutely ill older adults can use these communication tools to successfully convey their symptoms and needs in a hospital setting [Journal of Gerontological Nursing, 44(9), 30-39.].

Perceived social determinants of health among older, rural-dwelling adults with early-stage cognitive impairment:

Limited access to resources and delayed detection of subtle cognitive changes may negatively impact the long-term cognitive health of rural-dwelling adults. This study explored perceived social determinants of health among older, rural-dwelling adults with early-stage cognitive impairment. Semi-structured interviews were conducted with older, rural-dwelling adults with early-stage cognitive impairment and their care partners. Thematic content analysis was performed. Participants (n = 9) were 73.7 ± 6.0 years of age with 14.2 ± 3.1 years of education; care partners (n = 10) were 70.9 ± 7.4 years of age with 15.6 ± 2.3 years of education. Data analysis revealed six themes: Staying active, Eating well, Living with cognitive changes, Living rural, Connecting with neighbors and community, and Relying on children. Dyads’ depictions of perceived social determinants of health focused on the adoption of a healthy lifestyle, description of relationships, and advantages of living in a rural area. Emergent themes may be used to promote adoption of self-management and prevention behaviors, particularly lifestyle changes.