Mary Beth Happ

Advance care planning and end-of-life care for hospitalized nursing home residents

OBJECTIVES: To describe advance care planning (ACP) and end‐of‐life care for nursing home residents who are hospitalized in the last 6 weeks of life.

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.

Communicating With Mechanically Ventilated Patients: State of the Science

The literature clearly establishes the problems and difficulties of loss of speech among mechanically ventilated patients in the intensive care unit. Critical care nurses typically receive little or no training in the interpretation of nonvocal communication or in the assessment and application of augmentative communication methods. This article presents an integrative review of the research and related literature on communication with adult patients in critical care settings. Clinical issues and technological advancements in assistive and augmentative communication applicable to critical care are discussed and a new research agenda is proposed.

Individualized care for frail elders: theory and practice.

Individualized care for frail elders is defined as an interdisciplinary approach which acknowledges elders as unique persons and is practiced through consistent caring relationships. The four critical attributes of individualized care for frail elders are: 1) knowing the person, 2) relationship, 3) choice, and 4) participation in and direction of care. Cognitively impaired elders can direct their care through the staffs knowledge of individual past patterns and careful observation of behavior for what is pleasing and comfortable to each resident.

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.

Improving Patient-Provider Communication A Call to Action

Patients who are communication impaired are at greater risk of medical error and poorer outcomes. Contributing factors that perpetuate ineffective patient-provider communication include the lack of a systematic method for nursing assessment, evaluation, and monitoring of patient-provider communication needs and interventions; and a lack of standardized training of health care providers. We propose a call to action for nursing administrators to position patient-provider communication as a patient safety-care quality priority within the healthcare organization and incorporate bedside practices that achieve effective patient communication, especially with those most vulnerable to impaired communication. Effective patient-provider communication is an essential component of patient care; and in order for communication to be effective, the information must be complete, accurate, timely, unambiguous, and understood by the patient (1). By formally implementing the assessment of patient communication needs into routine care, nursing administrators will create a sense of accountability among bedside nurses to meet the needs of patients who are communication-vulnerable. A patients right to effective patient-provider communication is supported by accreditation standards (2), regulatory guidelines (3, 4), and patient rights declarations (5, 6). Patients have the right to be informed about the care they receive, make educated decisions about their care, and have the right to be listened to by their providers. However, patient communication needs often go unmet or are addressed inappropriately (7-10). In the case of non-English speaking patients, language access services such as the provision of in-person, telephone, or video interpreters and translated documents are either not available or infrequently used (8-11). Many health care institutions rely on ad hoc interpreters such as family, friends, or administrative and custodial staff to communicate and facilitate patient-provider communication, despite the fact that research has shown that the use of ad hoc interpreters can lead to miscommunication and medical errors (12). For critically-ill or nonspeaking patients, nonverbal behaviors, such as mouthing words, gestures, and head nods, are the principal means of communication; however these methods have been shown to be ineffective, fatiguing and inciting frustration (13-18). Often communication is attempted by simply asking yes/no questions and more appropriate communication interventions are not employed. Limiting the patients communication to yes/no answers restricts the patients responses to predictable messages only or messages that meet the a priori expectation of the patients need as determined by the clinician. The absence of effective patient-provider communication has been cited as a significant factor contributing to adverse outcomes (19, 20). In a 2007 public policy paper focused on health literacy, The Joint Commission recommended that health care organizations “make effective communication an organizational priority to protect the safety of patients” and to “incorporate strategies to address patients communication needs across the continuum of care” (21). Effective patient-provider communication is a vital component of this transformation and must be prioritized to improve patient safety.

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.

Conceptual challenges in the study of caregiver-care recipient relationships.

Background: In the literature on family caregiving, care receiving and caregiving are generally treated as distinct constructs, suggesting that informal care and support flow in a unidirectional manner from caregiver to care recipient. Yet, informal care dynamics are fundamentally relational and often reciprocal, and caregiving roles can be complex and overlapping. Objectives: To illustrate ways care dynamics may depart from traditional notions of dyadic unidirectional family caregiving and to stimulate a discussion of the implications of complex relational care dynamics for caregiving science. Approach: Exemplar cases of informal care dynamics were drawn from three ongoing and completed investigations involving persons with serious illness and their family caregivers. The selected cases provide examples of three unique, but not uncommon, care exchange patterns: (a) care dyads who are aging, are chronically ill, and who compensate for one anothers deficits in reciprocal relationships; (b) patients who present with a constellation of family members and other informal caregivers, as opposed to one primary caregiver; and (c) family care chains whereby a given individual functions as a caregiver to one relative or friend and care recipient to another. Conclusions: These cases illustrate such phenomena as multiple caregivers, shifting and shared caregiving roles, and care recipients as caregivers. As caregiving science enters a new era of complexity and maturity, there is a need for conceptual and methodological approaches that acknowledge, account for, and support the complex, web-like nature of family caregiving configurations. Research that contributes to, and is informed by, a broader understanding of the reality of family caregiving will yield findings that carry greater clinical relevance than has been possible previously.

Development of a tool to assess fidelity to a psycho-educational intervention

AIM This paper is a description of a method to develop and conduct a customized psycho-educational intervention fidelity assessment as part of pilot work for an efficacy study. A tool designed to assess treatment fidelity to a psycho-education intervention for patients with end-stage renal disease and their surrogate decision makers, Sharing the Patients Illness Representations to Increase Trust, is presented as an illustration. BACKGROUND Despite the specificity and idiosyncrasy of individual interventions and the call to systematically evaluate treatment fidelity, how to accomplish this goal has not been clarified. Tools to adequately measure treatment fidelity are lacking. METHODS We developed the Sharing the Patients Illness Representations to Increase Trust Treatment Fidelity Assessment tool by identifying elements that were idiosyncratic to the intervention and those that could be adapted from existing tools. The tool has four components: overall adherence to the intervention content elements; pacing of the intervention delivery; overall dyad responsiveness; and, overall quality index of intervention delivery. The study was undertaken between 2006 and 2008. RESULTS Inter-rater reliability ranged from 0.80 to 0.87 for the four components. The tool showed utility in training and monitoring, such as detecting unplanned content elements delivered and the use of proscribed communication behaviours. CONCLUSION Psycho-educational interventions are one of the most common types of nursing interventions worldwide. Use of fidelity assessment tools customized to the individual interventions may enhance systematic evaluation of training and monitoring treatment fidelity.