Marlene Z. Cohen

Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.

Objective:The debilitating and persistent effects of ICU-acquired delirium and weakness warrant testing of prevention strategies. The purpose of this study was to evaluate the effectiveness and safety of implementing the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle into everyday practice. Design:Eighteen-month, prospective, cohort, before-after study conducted between November 2010 and May 2012. Setting:Five adult ICUs, one step-down unit, and one oncology/hematology special care unit located in a 624-bed tertiary medical center. Patients:Two hundred ninety-six patients (146 prebundle and 150 postbundle implementation), who are 19 years old or older, managed by the institutions’ medical or surgical critical care service. Interventions:Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle. Measurements and Main Results:For mechanically ventilated patients (n = 187), we examined the association between bundle implementation and ventilator-free days. For all patients, we used regression models to quantify the relationship between Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle implementation and the prevalence/duration of delirium and coma, early mobilization, mortality, time to discharge, and change in residence. Safety outcomes and bundle adherence were monitored. Patients in the postimplementation period spent three more days breathing without mechanical assistance than did those in the preimplementation period (median [interquartile range], 24 [7–26] vs 21 [0–25]; p = 0.04). After adjusting for age, sex, severity of illness, comorbidity, and mechanical ventilation status, patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle experienced a near halving of the odds of delirium (odds ratio, 0.55; 95% CI, 0.33–0.93; p = 0.03) and increased odds of mobilizing out of bed at least once during an ICU stay (odds ratio, 2.11; 95% CI, 1.29–3.45; p = 0.003). No significant differences were noted in self-extubation or reintubation rates. Conclusions:Critically ill patients managed with the Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility bundle spent three more days breathing without assistance, experienced less delirium, and were more likely to be mobilized during their ICU stay than patients treated with usual care.

Impact of delirium and recall on the level of distress in patients with advanced cancer and their family caregivers.

Delirium has been the most frequent neuropsychiatric complication in patients with advanced cancer. This exploratory study aimed to determine the proportion of patients who were able to recall their experience of delirium and the level of distress experienced by patients, family caregivers, and healthcare professionals.

Validation of the M.D. Anderson Symptom Inventory Brain Tumor Module (MDASI-BT)

Symptom occurrence has been shown to predict treatment course and survival in patients with solid tumors. Primary brain tumor (PBT) patients are unique in the occurrence of neurologic symptoms. Currently, no instrument exists that measures both neurologic and cancer-related symptoms. Patients diagnosed with PBT participated in this study. Data was collected at one point in time and included demographic and clinical factors, and the M.D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT). The study evaluated the reliability and validity of the MDASI-BT in primary brain tumor patients. Two hundred and one patients participated in this study. Mean symptom severity of items as well as cluster analysis was used to reduce the number of total items to 22 (13 core, 9 brain tumor items). Regression analysis showed more than half (56%) of the variability in symptom severity was explained by brain module items. The MDASI-BT measures six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, generalized symptom, and a gastrointestinal related factor. The internal consistency (reliability) of the instrument was 0.91. The MDASI-BT was sensitive to disease severity based on performance status (P<0.001), tumor recurrence (P<0.01), and mean symptom interference (P<0.001). The 22 item MDASI-BT demonstrated validity and reliability in patients with PBT. This instrument can be used to identify symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management.SummaryBackgroundSymptom occurrence has been shown to predict treatment course and survival in patients with solid tumors. Primary brain tumor (PBT) patients are unique in the occurrence of neurologic symptoms. Currently, no instrument exists that measures both neurologic and cancer-related symptoms.MethodsPatients diagnosed with PBT participated in this study. Data was collected at one point in time and included demographic and clinical factors, and the M.D. Anderson Symptom Inventory-Brain Tumor Module (MDASI-BT). The study evaluated the reliability and validity of the MDASI-BT in primary brain tumor patients.ResultsTwo hundred and one patients participated in this study. Mean symptom severity of items as well as cluster analysis was used to reduce the number of total items to 22 (13 core, 9 brain tumor items). Regression analysis showed more than half (56%) of the variability in symptom severity was explained by brain module items. The MDASI-BT measures six underlying constructs including affective, cognitive, focal neurologic deficit, constitutional, generalized symptom, and a gastrointestinal related factor. The internal consistency (reliability) of the instrument was 0.91. The MDASI-BT was sensitive to disease severity based on performance status (P<0.001), tumor recurrence (P<0.01), and mean symptom interference (P<0.001).ConclusionsThe 22 item MDASI-BT demonstrated validity and reliability in patients with PBT. This instrument can be used to identify symptom occurrence throughout the disease trajectory and to evaluate interventions designed for symptom management.

Implementing the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle into everyday care: opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines.

Objective:The awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle is an evidence-based interprofessional multicomponent strategy for minimizing sedative exposure, reducing duration of mechanical ventilation, and managing ICU-acquired delirium and weakness. The purpose of this study was to identify facilitators and barriers to awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle adoption and to evaluate the extent to which bundle implementation was effective, sustainable, and conducive to dissemination. Design:Prospective, before-after, mixed-methods study. Setting:Five adult ICUs, one step-down unit, and a special care unit located in a 624-bed academic medical center Subjects:Interprofessional ICU team members at participating institution. Interventions and Measurements:In collaboration with the participating institution, we developed, implemented, and refined an awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle policy. Over the course of an 18-month period, all ICU team members were offered the opportunity to participate in numerous multimodal educational efforts. Three focus group sessions, three online surveys, and one educational evaluation were administered in an attempt to identify facilitators and barriers to bundle adoption. Main Results:Factors believed to facilitate bundle implementation included: 1) the performance of daily, interdisciplinary, rounds; 2) engagement of key implementation leaders; 3) sustained and diverse educational efforts; and 4) the bundle’s quality and strength. Barriers identified included: 1) intervention-related issues (e.g., timing of trials, fear of adverse events), 2) communication and care coordination challenges, 3) knowledge deficits, 4) workload concerns, and 5) documentation burden. Despite these challenges, participants believed implementation ultimately benefited patients, improved interdisciplinary communication, and empowered nurses and other ICU team members. Conclusions:In this study of the implementation of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle in a tertiary care setting, clear factors were identified that both advanced and impeded adoption of this complex intervention that requires interprofessional education, coordination, and cooperation. Focusing on these factors preemptively should enable a more effective and lasting implementation of the bundle and better care for critically ill patients. Lessons learned from this study will also help healthcare providers optimize implementation of the recent ICU pain, agitation, and delirium guidelines, which has many similarities but also some important differences as compared with the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle.

Methylphenidate and/or a Nursing Telephone Intervention for Fatigue in Patients With Advanced Cancer: A Randomized, Placebo-Controlled, Phase II Trial

PURPOSE Cancer-related-fatigue (CRF) is common in advanced cancer. The primary objective of the study was to compare the effects of methylphenidate (MP) with those of placebo (PL) on CRF as measured using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) fatigue subscale. The effect of a combined intervention including MP plus a nursing telephone intervention (NTI) was also assessed. PATIENTS AND METHODS Patients with advanced cancer with a fatigue score of ≥ 4 out of 10 on the Edmonton Symptom Assessment Scale (ESAS) were randomly assigned to one of the following four groups: MP+NTI, PL+NTI, MP + control telephone intervention (CTI), and PL+CTI. Methylphenidate dose was 5 mg every 2 hours as needed up to 20 mg per day. The primary end point was the median difference in FACIT-F fatigue at day 15. Secondary outcomes included anxiety, depression, and sleep. RESULTS One hundred forty-one patients were evaluable. Median FACIT-F fatigue scores improved from baseline to day 15 in all groups: MP+NTI (median score, 4.5; P = .005), PL+NTI (median score, 8.0; P < .001), MP+CTI (median score, 7.0; P = .004), and PL+CTI (median score, 5.0; P = .03). However, there were no significant differences in the median improvement in FACIT-F fatigue between the MP and PL groups (5.5 v 6.0, respectively; P = .69) and among all four groups (P = .16). Fatigue (P < .001), nausea (P = .01), depression (P = .02), anxiety (P = .01), drowsiness (P < .001), appetite (P = .009), sleep (P < .001), and feeling of well-being (P < .001), as measured by the ESAS, significantly improved in patients who received NTI. Grade ≥ 3 adverse events did not differ between MP and PL (40 of 93 patients v 29 of 97 patients, respectively; P = .06). CONCLUSION MP and NTI alone or combined were not superior to placebo in improving CRF.

Using the BETTER Model to Assess Sexuality

A component of the American Nurses Association (ANA) and the Oncology Nursing Society (ONS) standards of nursing practice is systematic assessment and collection of data about the health status of each patient; this process includes sexuality (ONS & ANA, 1996). Many tools are available to nurses when obtaining a sexual history, assessing sexual function, and providing interventions that will assist patients in the management of any identified problems. Models such as PLISSIT, PLEASURE, and ALARM can support nurses by providing a guide for appropriate steps to address sexuality with patients (Andersen, 1990; Krebs, 2001; Mick, Hughes, & Cohen, 2003; Shell, 2001). The BETTER model also can be used to provide information to help oncology nurses conduct sexuality assessments more effectively (Mick et al.) (see Figure 1). Test your knowledge of sexuality assessment by answering the following questions, which are based on the BETTER model. 1. Sexuality is best described by which of the following definitions? a. Sexual function b. A composite of feelings and behaviors specific to gender c. Sexual activity and the love and caring that accompany it d. Body image, gender roles, patterns of affection, family and social roles, and genital sex 2. Mrs. A, a 63-year-old woman with stage II breast cancer, comes to the clinic for her chemotherapy follow-up visit. While the nurse performs her assessment, Mrs. A states that she has been feeling very tired most of the time. The nurse can use this comment to bring up the topic of sexuality and accurately provide information by saying, a. “Tiredness can change your sexual life, too. Many women notice changes in their sexual lives. If you have any conJoAnn Mick, RN, MSN, MBA, AOCN®, is a patient care nurse manager at the University of Texas M.D. Anderson Cancer Center in Houston and a doctoral student at Texas Woman’s University in Houston; Mary Hughes, MS, RN, CNS, is a clinical nurse specialist in the Psychiatry Section of the Neuro-oncology Department at the University of Texas M.D. Anderson Cancer Center; and Marlene Z. Cohen, RN, PhD, FAAN, is a John S. Dunn, Sr., distinguished professor in oncology nursing in the School of Nursing at the University of Texas Health Science Center at Houston and the director of applied nursing research at the University of Texas M.D. Anderson Cancer Center.

Hope and Related Variables in Italian Cancer Patients

Hope, long considered an essential element for life, has been shown to be important among cancer patients in coping, perceived control over the illness, and psychologic adjustment to the illness. The purpose of this study was (a) to describe the level of hope in Italian cancer patients; (b) to compare the levels of hope during and after hospitalization; (c) to determine whether hope was correlated with quality of life and several symptoms; and (d) to determine whether the variables from the international literature also pertain to Italian cancer patients. A descriptive correlational design using repeated measures was chosen to study 80 Italian cancer patients during hospitalization and then at home. The following instruments were used: a Sociodemographic Questionnaire, the Hope Related Variable Questionnaire, the Nowotny Hope Scale, the Rotterdam Symptom Checklist, and the Hospital Anxiety and Depression Scale. Overall, patients were moderately hopeful and the level of hopefulness was similar in the hospital and at home. Hope was positively correlated with quality of life, self-esteem, coping, adjustment to the illness, well-being, comfort in the hospital, satisfaction with information received, relationship with, and support from family, healthcare professional, and friends. Hope was negatively correlated with anxiety, depression, and boredom during hospitalization. Time since diagnosis, illness stage, and knowing or not knowing the diagnosis and treatment were not correlated with hope. Similarities and differences with the international literature are discussed, and implications for caring for Italian cancer patients are drawn.

Content Validity of Self-Report Measurement Instruments: An Illustration From the Development of the Brain Tumor Module of the M.D. Anderson Symptom Inventory

PURPOSE/OBJECTIVES To illustrate one technique for establishing content validity of measurements using the initial development and testing of the M.D. Anderson Symptom Inventory Brain Tumor Module. DATA SOURCES Published articles, book chapters, and subjective judgments of experts. DATA SYNTHESIS Content validity is the essential first step in the development of items to be included in a measurement instrument. Content validity is a criterion-referenced process that is judged by how well each item in a newly developed instrument reflects its respective objective or content domain. The stages in addressing content validity include a developmental stage and a judgment-quantification stage. Steps involved in the developmental stage include domain identification, item generation, and instrument formation. The judgment-quantification stage is when experts review the items and either report validity of the items subjectively or with an empirically referenced method, such as calculation of the content validity index. The content validity of a set of questions designed to measure symptoms in a population of patients with primary brain tumors was ascertained by using the calculation of the content validity index. CONCLUSIONS The final version of the M.D. Anderson Symptom Inventory Brain Tumor Module consists of the 13 core items and 18 additional items designated as valid by a panel of experts. The instrument will be administered to a group of patients to determine construct validity and reliability of the items. IMPLICATIONS FOR NURSING Self-report instruments are used to measure various health outcomes in oncology. Oncology nurses are in a key position to develop such instruments to be used in clinical care and research of symptoms associated with cancer. Understanding the process of content validation is an essential first step in developing new instruments.

Delphi survey of nursing research priorities.

PURPOSE/OBJECTIVES To identify oncology nurses priorities for topics and issues to be addressed by developing a clinical nursing research program at a large comprehensive cancer center. DESIGN Delphi survey, completed in two rounds. SETTING A large comprehensive cancer center in the southern United States. SAMPLE All 1,500 RNs employed at the cancer center. Round I asked nurses to identify topics they believed needed to be studied, and 642 nurses responded. In round II, 567 nurses ranked these priorities. METHODS Surveys were distributed to all nurses who work in a variety of settings at the cancer center. Open-ended responses from round I were content analyzed, round II rankings of importance were described, and factor analysis was performed. MAIN RESEARCH VARIABLES 120 topics were identified from a content analysis of research areas described by nurses in the cancer center. FINDINGS 120 research priorities were identified. Factor analysis revealed three factors: clinical care, nurses and skills, and administrative aspects. CONCLUSIONS The top five research priorities identified at the cancer center were, in rank order, acute and chronic pain, infection rates and control, job satisfaction, nurse-patient ratios and staffing, and nurse retention. This studys survey included items similar to those on the recently conducted Oncology Nursing Society research priority survey. Pain and issues with infection were among the top five priorities in both surveys. IMPLICATIONS FOR NURSING Conducting a survey to identify nurses perceptions of research was useful in involving nurses in the conduct of research, and the results were useful guides to beginning a coordinated program of nursing research.

Brief cognitive-behavioral audiotape interventions for cancer-related pain: Immediate but not long-term effectiveness.

Few studies have evaluated cognitive‐behavioral interventions as an adjunct treatment for chronic cancer‐related pain. A randomized clinical trial was performed evaluating the efficacy of 3 brief cognitive‐behavioral techniques: relaxation, distraction, and positive mood interventions.