Phyllis Skorga

Chemical agents of terrorism: Preparing nurse practitioners

Nurse practitioners must exercise vigilant readiness to properly care for victims of chemical injuries. In this article, appropriate clinical management of each category of chemicals is addressed, including supportive and pharmacologic care. Triage decisions are explained and decontamination concerns are identified. Attention is directed at special populations such as children and the elderly.

Preparing for bioterrorism: category A agents.

September 11, 2001, brought the possibility of biologic acts of terrorism against the United States into the national consciousness. As the American people brace themselves for this new threat to the national well-being, clinicians must understand how to prevent, recognize, and treat the biologic agents that could be used in terrorist attacks. This article discusses the most likely biologic agents, including diagnostic laboratory procedures, treatment options, psychological effects, special populations, and reporting requirements.

Caring for victims of nuclear and radiological terrorism.

As primary care providers, we must consider the manifestations of radiation sickness and syndromes when managing radiological injuries. Assessment and treatment regimens include unique sample handling requirements to avoid self-contamination and further contamination of the environment. Addressing psychological aspects and the needs of pediatric and geriatric populations is also important for effective treatment.

Stage-based interventions for smoking cessation: a review synopsis.

Smoking is a leading cause of preventable illness and mortality. Smoking is also a risk factor for numerous disorders, such as diabetes, some types of cancer, heart, and lung diseases. In addition, smoking is responsible for over 500,000 deaths per year in the United States. Thus, smoking cessation is an important focus for healthcare professionals. One popular method of smoking cessation is built upon the transtheoretical model (TTM). This model proposes that people go through various motivational stages of change to stop smoking. Furthermore, this model suggests that interventions should be tailored to these stages rather than to the individual patient. The stages are: (1) Precontemplation: during which the smoker does not view smoking as a probCharlotte Young Ph.D., R.N., College of Nursing and Health Professions, Arkansas State UniversityJonesboro, Jonesboro, Arkansas. Phyllis Skorga Ph.D., R.N., C.C.M., College of Nursing and Health Professions, Arkansas State University-Jonesboro, Jonesboro, Arkansas. Correspondence to: Charlotte Young, College of Nursing and Health Professions, Arkansas State University-Jonesboro, PO Box 910, Jonesboro, AR 72467. E-mail: astatedryoung@yahoo.com or cyoung@astate.edu

Self‐monitoring and self‐management of oral anticoagulation

Oral anticoagulants are used to minimise the complications of blood clotting. Today they are used in the prevention of thromboembolic complications after cardiac surgery. In addition, they are used to prevent myocardial infarction in high-risk populations. Although maintenance of anticoagulants is complex, their use has been steadily rising. The level of anticoagulation must be measured frequently to prevent bleeding complications, which occur if too much anticoagulant is given. This entails frequent blood sampling and dosage adjustment. The introduction of portable monitors for the management of oral anticoagulants has allowed patients to test themselves at home. Patients may either ‘self-manage’, adjust their medication according to a predetermined dose based on the International Normalised Ratio (INR; the ratio between the patient’s blood sample and standardised coagulation time) or ‘self-monitor’, adjust their medication after calling the clinic for the appropriate dose adjustment. Nursing care within the community entails working with patients and their families to prevent the possible deadly complication of overdose. Fitting anticoagulant therapy into one’s life is difficult. The patient must remember numerous changes such as refraining from using vegetables rich in vitamin K as well as avoiding alcohol and smoking. Nurses must turn their attention to developing guidelines and protocols to guide nursing care of such patients in the community. In addition, nurses must develop and maintain education to update the patient and family members. Coordination of care and case management is also essential to synchronise multidisciplinary patient care.

Hip protectors for preventing hip fractures in older people: a review summary.

NURSING IMPLICATIONS Over the last 20 years, nurses and other clinicians have paid increasing attention to the growing incidenceof hip fractures particularly in the older population. As society ages, the numbers of elderly peoplewith coexisting diseases increase, and the potential for increased morbidity and mortality related to hip fractures increases. Hip fractures usually result from falls, and use of hip protection devices to reduce the impact of falls and consequent hip fractures has been enthusiastically supported by health professionals. Hip protectors are available in 2 main types. The first type is a hard plastic shell covering the lateral aspect of the hip that acts by shunting the force of impact away from soft tissues. The second type of hip protector is a soft compressible pad designed to absorb the force of impact. Both types of hip protectors are held in place by special underwear. Early clinical trials demonstrated effectiveness of this intervention in reducing the risk of hip fractures, but later studies have not confirmed early results. Nurses are primary caregivers for patients in nursing homes and other institutional settings where a policy of hip protection devices has been endorsed. A systematic review of evidence is needed to critically appraise the effectiveness of hip protection devices in reducing hip fractures.

Happy Anniversary Cochrane Collaboration

Twenty years of progress and still leading – congratulations to the Cochrane Collaboration on achieving this milestone while advancing research in health care and in nursing. As a global leader in research, the Collaboration has paved the way for the delivery of high-quality information about the effectiveness of health care. The Cochrane Collaboration is an international network of more than 31,000 people from over 120 countries working together and dedicated to helping health professionals, patients, policy makers and advocates make healthcare decisions based on the best, current evidence. The Collaboration is named after Archie Cochrane (1909–1988), who advocated the use of randomized controlled trials as a means of informing healthcare practice. The Collaboration produces systematic reviews that form the basis internationally for informed decision-making in health care. Patients benefit directly from improvements in quality of care because the best evidence is translated into clinical practice. Nursing has embraced evidence-based practice as a model for clinical decision-making. Evidence-based practice is a problem-solving method based on the systematic and diligent application of current research to inform practice (Pearson et al. 2011). The Cochrane Collaboration has produced over 5,000 systematic reviews that have yielded valuable scientific evidence and these studies are published online in the Cochrane Database of Systematic Reviews. Although initially seen as focusing on the medical professions, the Cochrane Collaboration has expanded to augment nursing with the establishment of the Cochrane Nursing Care Field (CNCF) – to which we both belong – in 2009. The CNCF promotes systematic reviews that have a direct impact on nursing. Readers of JAN appreciate the advantages of evidencebased practice. New knowledge and evidence inform advanced practice for nursing and propel improvements in education, management and professional policy initiatives in health care. Nursing care is enhanced and the international audience of nurses interested in evidence synthesis is enriched by the development and distribution of systematic research. JAN contributes to scholarly dissemination by regularly publishing systematic reviews like the recent article that reported advanced practice nurses in long-term care facilities are effective in improving satisfaction of family members and reducing patient complications such as depression, incontinence and pressure ulcer formation in older residents (Donald et al. 2013). Systematic reviews provide a rigorous explanation of current knowledge, a robust analysis of evidence and strategies for sharing scholarship in clinical practice and policy formation. Another example of scholarship is the systematic review authored by Hamel and Robbins (2013) that found Webbased interventions can improve eating behaviour and diet-related physical outcomes among children and adolescents, especially when conducted in schools and designed individually. They went further to advise that the results of the interventions may not be sustained over time without reinforcement. Nurses can apply this science in patient care, in education and in developing policy. The value of evidence synthesis is easily recognized as essential to the professional growth of nursing as a discipline. In the future, nursing will be guided by theory development and sound research methods to produce evidence that challenges conventional thinking and practice. There is a growing demand for verifiable healthcare facts that can be trusted, and ideas that improve health care. We are assured that the Cochrane Collaboration and its partners in evidence dissemination will continue to promote new nursing science. Unlimited opportunities await as we strive to practise high-quality nursing care with treatments and interventions based on accurate evidence.

Transdermal fentanyl for cancer pain.

NURSING IMPLICATIONS The evidence base for use of transdermal fentanyl in palliative care is very limited. However, transdermal fentanyl is commonly used to treat chronic pain, and advanced practice nurses, especially those working with cancer patients, are concerned about best practices. This Cochrane Review is part of a series of reviews on individual drug interventions for cancer pain. Pain is experiencedby 24% to 62%of patients at the time of cancer diagnosis and by virtually all patients at end stages of the disease. Transdermal fentanyl is an alternative for pain relief in patientswithmoderate to severe pain from cancer. Fentanyl can be delivered in the transdermal route, which increases its usefulness. Fentanyl patches provide consistent blood and brain drug levels, leading to better control of pain. Fentanyl with the transdermal delivery approach reduces the number of doses required for pain relief, making the medication more convenient for use and thepain controlmore consistent. Bydiminishing andcontrolling pain in patients with cancer, quality of life is enhanced. Fentanyl, a synthetic opioid, is an important medication for pain relief. It has a delayed onset and a prolonged duration of action as each patch lasts 72 hours. Patients report steady-state pain relief within 2 to 4 applications. Transdermal fentanyl is available in generic and brand form (Durogesic, Matrifen, Tilofyl, etc). Hypoventilation is a potential adverse event that requires monitoring.

Formulating a clinical question.

NURSING IMPLICATIONS Question formulation is a skill that is essential to nursing practice as it begins the critical-thinking process. Healthcare knowledge and skills developed through basic professional education fail to sustain competency in nursing throughout one’s career. It is incumbent on the professional nurse to update knowledge to remain current in practice through evidence-based literature and lifelong self-directed learning. Fundamental to meaningful learning is the ability to formulate the clinical question. This review showed that various training methods generated some improvement in the quality of questions developed by healthcare professionals. However, it remains uncertain how long the improvement lasts. With so little evidence, no specific conclusions can be made. Because question formulation is essential to competent nursing practice and self-directed learning, evidence related to improvement of this skill is essential to nurses. Further research is suggested. STUDY CHARACTERISTICS Randomized controlled trials, controlled clinical trials, and control exercised before and after intervention studies of any language were selected for the review. All studies had a specific point of time when the intervention occurred and 3 or more data points before and after the intervention. Researchers engaged in searching for evidence through electronic methods as well as hand searching. Participants included all healthcare professionals (such as physicians, nurses, etc) involved in direct patient care. Undergraduate students and transcriptionists were excluded as participants. Interventions developed by healthcare professionals to increase quality and/or frequency of question development were included in the study. Many studies included evidence-based medicine training and/or were comparative studies. Comparative studies included only control groups without interventions. The primary outcomes included frequency of questions, quality of questions generated, practitioner competency, delivery of care outcomes such as blood pressure monitoring, patient-related outcomes such as satisfaction, knowledge-seeking practice such as sources of information, and evidence-based medicine. Secondary outcomes such as self-efficacy and increased success in answering questions were also considered. Objective measurements of reliability and validity were given greater consideration when data permitted. Data collection was done by 2 reviewers who resolved any differences between themselves. Both dichotomous and continuous data were reported for data analysis. A template was generated to guide abstraction of data. This template included such things as characteristics of participants, setting, teaching format, reliability and validity of outcome measurement tools, withdrawals, and dropouts. The Cochrane Collaboration’s Risk of Bias Assessment tool was used to assess bias. Overall, the reviewers assessed studies as having enough risk of bias to affect the interpretation of results. Pooled estimates were not possible because of heterogeneity between study results such as differences in healthcare professionals (physicians, nurses) Author Affiliations: Professors (Drs Young and Skorga), College of Nursing and Health Professions, Arkansas State University, Jonesboro. Susan B. Fowler, PhD, RN, is the column editor and facilitated the submission. All authors adhere to ethical guidelines in writing and submitting this article. The authors report no conflicts of interest. Correspondence: Susan B. Fowler, PhD, RN, CNRN, FAHA, NYEE, 310 E 14th St, New York, NY 10003 (njfowlers761@msn.com). DOI: 10.1097/NUR.0b013e31825aea56

Motorcycle Rider Training for the Prevention of Road Traffic Crashes: A Review Synopsis

Injury prevention is a major goal of public health nursing practice within communities and across populations. Injuries and deaths from road crashes continue to climb across the world every year. Motorcycle riding is a popular form of road transportation and in lower and middle income countries, motorcycles constitute one of the most frequent means of transportation. However, motorcycles are less crashworthy than closed vehicles and serious injuries and deaths occur at a much higher rate. From Australia to the United States, death rates from motorcycle accidents have been reported at 30–39 times the rate for car occupants. Serious injuries associated with motorcycle crashes are even more prevalent. Operating a motorcycle requires a different set of physical and mental skills than driving a four wheel vehicle. Investigators have cited lack of experience as a potential reason for accidents. Motorcycle rider training courses are suggested as an important measure to reduce the number of crashes and the severity of injuries.