Expert Nurses Research Articles

Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication

BackgroundA serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses’ ability to detect patient clinical deterioration.MethodsThe SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick’s framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis).ResultsThe content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups’ high rating of the game’s realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study.ConclusionWhile it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool.Trial registrationClinicalTrials.gov ID: NCT03092440

Factors influencing the nurse’s decision to set and modulate alarm parameters of bedside monitoring in intensive care : an integrative review of literature

Introduction : In critical care units, improper alarm settings for bedside monitoring systems promotes numerous alarms and may lead to nurse fatigue. Purpose : Achieve an integrative review of the literature to identify the factors that influence the nurse in her decision to set and modulate the alarm parameters of bedside monitoring systems in the intensive care unit. Method : An integrative review of the literature according to the five steps of the Whittemore and Knafl method was carried out from the literature related to the field of critical care. Results : The factors related to the nurse’s decision to set or modulate the alarm parameters of the monitoring systems are divided into two themes : personal factors and contextual factors. Discussion : Certain factors identified in this integrative review were also identified as elements that contribute to the clinical surveillance process carried out by expert nurses in a critical care context. Conclusion : The results of this study suggest the need to focus empirically on the factors influencing the nurse’s decision to adjust and modulate alarm parameters in critical care monitoring systems.

The effect of the implementation of institutional checklist on expert opinion of oxytocin use in labor

Oxytocin is a commonly used drug in the labor and delivery unit. There are wide variations in oxytocin use between countries and medical centers, which may reflect the lack of structured guidelines. The aim of our study was to evaluate the need of oxytocin checklist in labor and delivery unit, while assessing the management of oxytocin with and without such a checklist. This study was conducted in a single, university-affiliated medical center in two phases: before and after the implementation of an oxytocin checklist in the labor and delivery unit (2016-2017). Six experts reviewed cardiotocographs of deliveries performed in an urgent Cesarean delivery due to non-reassuring fetal heart rate, after completing at least 4h of oxytocin infusion for induction or augmentation of labor. The experts included three obstetricians, a midwife, and two obstetrical expert nurses, who were tasked to conclude whether oxytocin was managed properly or not. Each case was reviewed by two reviewers separately. A total of 100 cases were reviewed; 50 before the oxytocin checklist implementation, and 50 after that implementation. We did not find a difference in the reviewers' assessment of oxytocin management before and after the institutional implementation of the checklist. Additionally, there were significant inconsistencies and inter-observer variations in their assessment before and after the checklist implementation. The implementation of an institutional oxytocin checklist did not affect expert assessment of the use of oxytocin in labor.

Management of pyrexia in metastatic melanoma patients: A real-world clinical experience survey study.

e22102 Background: Patients with BRAF+ metastatic melanoma (MM) have more options for treatment, including targeted therapy and immunotherapy. However, the risk of toxicities may contribute to lower treatment rates and duration. Pyrexia is a reversible adverse event commonly associated with BRAF/MEK inhibitors. However, little is known about the features, management strategies, as well as variations in pyrexia management in clinical practice. Methods: The study was conducted over two phases. Phase 1 was a qualitative study conducted with expert nurses to develop a pyrexia management questionnaire. The questionnaire was further enhanced through a pre-test with nurses to improve reliability and internal validity of the responses captured for this study. During Phase 2, a cross-sectional web-based questionnaire was administered to oncology registered nurses, nurse practitioners and physician assistants. All respondents were required to have managed pyrexia in patients with MM receiving dabrafenib+trametinib (D+T). Results: Respondents (N = 201, 57.2% academic center and 42.8% community based), on average, had 12.5 years of experience and &gt;50% had managed more than 10 patients with BRAF-MEK inhibitor in the past 12 months. Almost all respondents (97.5%) discussed pyrexia with patients at D+T initiation. At the onset of the first episode of pyrexia in a patient, most respondents either try to keep patients on the starting dose (34.9% for D, 42.8% for T) or withhold the medication only temporarily (52.4% for D and 47.8% for T), even with a fever of 104°F. Mean time to treatment reinitiation was 1.5 days and, in more than half of the instances (52.3% for D and 51.4% for T), respondents would ask the patients to reinitiate at the starting dose. Respondents also asked patients to initiate antipyretics (87.5%) or corticosteroids (34.5%) to manage pyrexia symptoms. Even at pyrexia recurrence, respondents generally preferred keeping patients on treatment, with only 4.2% recommending permanent discontinuation. In general, respondents were very comfortable in managing pyrexia-related symptoms in their patients (mean score 7.8, 1 = very uncomfortable, 10 = very comfortable). Conclusions: In clinical practice, respondents were very comfortable in managing pyrexia. They tried to keep patients on D+T as long as possible. Experienced oncology nurses, nurse practitioners and physician assistants are able to manage pyrexia symptoms and keep patients on treatment for a longer duration to help obtain maximum clinical benefit.

Nurses' contribution to end-of-life family conferences in critical care: A Delphi study.

Family conferences (FCs) in the intensive care unit play an important role in reducing the psychological burden of patients' families at the end of life. However, no studies have clarified the specific roles and contributions of nurses related to FCs for terminally ill patients in critical care and their families. To clarify nurses' contribution to FCs for terminally ill patients in critical care and their families and examine the priority of each item. A modified Delphi method was used. This study consisted of two phases. In phase 1, an initial list was developed based on a literature review, individual interviews, and a focus group interview. Phase 2 involved two rounds of the Delphi survey. Practitioners (N = 55) from hospitals across Japan were recruited to the Expert Panel for phase 2. They were asked to rate each nurse's contribution in terms of its importance using a 9-point Likert scale (1 being "not important at all" to 9 being "very important"). Fifty participants responded to round 1 of the survey, and 46 participants completed round 2. If at least 80% of the panellists chose an importance level of 7 or higher, the item was considered "important". The 65 items of the potential list were classified into three domains: preparation (16 items), discussion and facilitating meaning during a FC (32 items), and follow up after a FC (17 items). The expert panel determined that, of 65 items, 49 items on the proposed list of nurses' contribution were considered important. This study clarified nurses' contribution to FCs, with consensus on their importance by expert nurses. This study could be useful for improving and ensuring the quality of nurses' contribution to FCs and promoting collaboration between nurses and other medical professionals.

Nurses' Perspective of Treating Patients With an Amputation Due to Diabetic Foot Syndrome.

Expert nurses must provide both physical and emotional care to patients with diabetic foot syndrome (DFS) who require an amputation. This includes helping patients and families to cope with this situation, while ensuring the maximum level of comfort. The aim of this study was to explore the perspective of expert nurses on the needs and hospital care of people requiring an amputation due to DFS. This was a qualitative multicenter study involving 8 hospitals in Spain and Portugal. In-depth interviews with expert nurses were transcribed verbatim to enable content analysis. Twenty-four expert nurses were interviewed about their knowledge and experience of treating patients with diabetic foot disease. Two themes emerged from the qualitative analysis: (1) poor self-care and the disease trajectory, and (2) effective hospital care. The results of this study highlight the key role that expert nurses play in the care of patients with DFS. Expert nurses considered that amputation leaves the individual physically and psychologically vulnerable, especially upon discharge from hospital. It is therefore essential to provide these patients with comprehensive and multidisciplinary care that includes emotional support.

Satisfaction survey within the context of remote iconographic follow-up of wounds in an oncology centre

Over 40 patients benefited from remote iconographic follow-up of wounds in an oncology centre. This system is piloted by three expert nurses. They carry out an initial analysis of the photographs received, seek medical expertise if necessary and liaise with the city's professionals. This system makes it possible to expertly accompany professionals and patients while avoiding unnecessary travel. The satisfaction survey conducted in 2018 established full satisfaction of patients and professionals (> 95%) and a guarantee in terms of the safety and quality of care of the wounds.

Competitive neural layer-based method to identify people with high risk for diabetic foot

Background and objectiveTo automatically identify patients with diabetes mellitus (DM) who have high risk of developing diabetic foot, via an unsupervised machine learning technique. MethodsWe collected a new database containing 54 known risk factors from 250 patients diagnosed with diabetes mellitus. The database also contained a separate validation cohort composed of 73 subjects, where the perceived risk was annotated by expert nurses. A competitive neuron layer-based method was used to automatically split training data into two risk groups. ResultsWe found that one of the groups was composed of patients with higher risk of developing diabetic foot. The dominant variables that described group membership via our method agreed with the findings from other studies, and indicated a greater risk for developing such a condition. Our method was validated on the available test data, reaching 71% sensitivity, 100% specificity, and 90% accuracy. ConclusionsUnsupervised learning may be deployed to screen patients with diabetes mellitus, pointing out high-risk individuals who require priority follow-up in the prevention of diabetic foot with very high accuracy. The proposed method is automatic and does not require clinical examinations to perform risk assessment, being solely based on the information of a questionnaire answered by patients. Our study found that discriminant variables for predicting risk group membership are highly correlated with expert opinion.

Toward 2020 the International Year of the Nurse and the Midwife: Linking Taiwan Nursing With the World

To commemorate the 200th birthday of Florence Nightingale, the World Health Organization announced 2020 as the "International Year of the Nurse and the Midwife." Nursing is in the frontline of transformational care. The actions of nurses help bring positive changes to the world. Taiwan cannot stand outside of the global community. The Taiwan Nurses Association is also involved actively in international affairs. The expertise and enthusiasm of Taiwan's nurses may be highlighted by attending and responding to various meetings, conferences, and global nursing events organized by the International Council of Nurses (ICN) such as the Council of National Nursing Association Representatives (CNR), ICN Congress, and Nursing Now campaign. This article shares important information and insights on the 2019 ICN CNR meeting and the ICN Congress to expand the international perspective of nurses and to inspire and explore the future development of the nursing profession in Taiwan.

Risks at the Intersection of Research and Oncology Nursing

To describe the increasing complexity and scope of clinical trials research, convergent research, and the clinical nurse roles and responsibilities to ensure safe patient care and study data integrity. Textbooks, journal publications, federal regulations, US Food and Drug Administration documents, clinical practice guidelines. The immune system, genetics, and molecular pathology are not new in the context of oncology treatments. The reliability and clinical validation of in vitro diagnostic medical devices is, however, becoming increasingly more important in the development of marker driven targeted therapies, immunotherapy, and adoptive T-cell transfer. Protecting patients and preserving the integrity of clinical trials is of utmost importance. The role and scope of oncology and research nurses will intersect and shift as clinical care continues to involve high-acuity patients who participate in complex in vitro diagnostic and therapeutics clinical trials. The expertise of oncology nurses may vary in skills and knowledge domain; however, all scopes of practice are underpinned by the nursing code of ethics to ensure accountability for all aspects of patient care.

Expert nurses’ practices of family support in intensive care unit: A literature review

本研究は，エキスパート看護師のICUでの家族支援に関する具体的実践が書かれた文献を収集して整理し，既存の研究の傾向をつかみ，今後求められる研究を検討することを目的とした．PubMed，CINAHL，医学中央雑誌Web版を用いて検索し，選定・除外基準にのっとり文献を選定し，マトリックス方式で整理した．分析対象となった文献は25件であった．家族支援の内容から〈終末期患者の家族支援〉〈緊急性の高い患者の家族支援〉〈興奮や混乱状態にある患者の家族支援〉〈面会時の家族支援〉〈家族を力づける支援〉の5つに大別され，【代理意思決定支援】など10の小分類に整理された．エキスパート看護師の家族支援に関する具体的実践が書かれた文献の蓄積には偏りがあり，〈緊急性の高い患者の家族支援〉を記した文献は少なく，なかでも蘇生時の家族の立ち会いに関しては，エキスパート看護師の支援を明らかにし，実践に向けた研究が必要と考えられた．

Nursing practices related to family conferences for terminally ill patients and their families in critical care: difficulty from the perspective of expert nurses

Nursing practices related to family conferences for terminally ill patients and their families in critical care: difficulty from the perspective of expert nurses

Defining Expertise in Cancer Nursing Practice.

Thirty-five years ago, Benner defined an expert nurse as one who applies deep knowledge and experience across different contexts and clinical situations. Since that time, there has been little exploration of expertise in cancer nursing. To explore and describe characteristics of expert cancer nurses and to consider whether Benner's typology of an expert nurse remains relevant in today's complex oncology settings. An exploratory, descriptive study using audio-recorded focus group methodology was undertaken. Audio-recordings were transcribed, and an inductive thematic analysis approach applied to the data. Nurses also documented key characteristics of expert practice on Post-it notes to illustrate dominant characteristics. Twenty-four registered nurses from a comprehensive cancer center in Australia took part in 1 of 3 focus groups. Seven key themes were identified: knowledge, leadership, adaptability, communication, motivation, patient-centered care, organization, and culture. Key word cloud characteristics included knowledge, compassion, motivation, experience, and communication. Many of the expert characteristics identified in this study reflect traits common to other nursing specialty groups. Of particular relevance to cancer nurses was "adaptability," reflecting the complexity of contemporary cancer care and reaffirming Benner's definition of an expert nurse as one who can fluidly connect knowledge and experience to unfamiliar practice contexts. Understanding characteristics of expert cancer nurses may help inform and support professional practice advancement and guide future research about select characteristics of expert cancer nurses to patient- and system-level outcomes.

Lessons Learned in Implementation of an Expert Nurse Mentor Program.

Experienced critical care nurses have the expertise to respond quickly and appropriately in emergency situations. New graduate nurses, however, typically lack this expertise and may benefit from mentoring as they learn to manage rapidly deteriorating patients. The purpose of this article is to describe the lessons learned during implementation of an Expert Nurse Mentor Program. Nurse educators may benefit from this information as they strive to establish and maintain mentoring programs.

Evidence-Based Review and Discussion Points.

Evidence-Based Review and Discussion Points.

Predictors of Nursing Clinical Judgment in Simulation.

This was a pilot study of novice and expert nurses participating in a simulation to determine the predictors of clinical judgment. Covariates included age, nursing experience, simulation experience, and six measures of pupil dilation as a measure of stress with scores on the Lasater Clinical Judgment Rubric as the dependent variable. A stepwise linear regression found years of RN experience was the only predictor of better clinical judgment. Despite evidence of stress, only years as a nurse was a statistically significant predictor.

33 Improving Mortality with An Integrated Model of Care for Cervical Spine Fracture in Patients Over 75 Years Old

Abstract Introduction Cervical spine injury is a potentially life threatening trauma. Given the increase in the number of patients presenting to the emergency department (ED) who are elderly and who have fallen and sustained trauma, it has become ever so challenging to manage this cohort of patients. In addition to diagnostic challenges in the elderly population, a robust, integrated care pathway and comprehensive geriatric assessment with involvement of a geriatrician is essential to provide effective care to these patients who require cervical collar after cervical spine injury to prevent morbidity and mortality. Intervention Data was gathered about the patient’s demographics, nature of cervical spine injury, care required from January 2013 till November 2016 (pre intervention) and from November 2016 till October 2017 (post intervention). Current practice was reviewed which showed significant variability in care provision to patients with cervical spine injury including collar care. An integrated care pathway was designed with involvement of multidisciplinary team (MDT) members to standardise the care of this cohort of patients in our hospital. This included early identification of patients with cervical spine injury, co locating all patients, developing nursing expertise for cervical collar care, sitting up early to prevent complications like aspiration, pressure area care, early nutritional support, training staff in post discharge collar care with developing interface with primary care team. Outcome measures in patients over 75 years including length of stay (LOS) inpatient mortality and at 6 and 12 months were recorded respectively. Results Total: 54 patients, average age: 86.6 years Conclusions Cervical spine injuries are common in older patients, who are at greater risk of falls and thus sustaining injuries. Early identification and management of these patients in a clinical area with multidisciplinary approach with appropriate expertise is key to reducing LOS and adverse outcome including mortality.

Efficacy of Posture Awareness and Neck Exercise Program on Reducing Cervical Pain Among Elderly Patients at Assiut University Hospital, Egypt

Cervical pain is a common condition in the elderly population. It affects the physical health status in persons over 65 years and interferes with their daily activities. Study Aim: Evaluate the efficacy of posture awareness and neck exercise program on reducing cervical pain among elderly patients. Subject & method: Quasi-experimental research design was used. The study was conducted in outpatient clinic of Rheumatology and Rehabilitation Department at Assiut University Hospital. The total sample size was 189 elderly. Two tools were used. The 1st tool: An interview sheet including personal characteristics, medical history and elderly knowledge, the 2nd tool: The Northwick Park Neck Pain scale and jury were done by 3 expertise in erotological nursing. Results: The present study showed that the majority of studied patients aged (60 - < 65) years, with mean age 62.48± 3.43 and there was a highly significant difference between pre and post-program of both isometric neck exercises and good neck posture (p=0.0001). Conclusion: It was concluded that isometric neck exercises and good neck posture are effective in the management of neck pain in elderly population. Recommendation: Implementation of isometric exercise and good neck posture among elderly population should be expanded as a community based intervention.

Abstract TP355: A Valiant Effort to Improve Stroke Education

Background and Purpose: Increasing knowledge of pertinent aspects of stroke disease may improve outcomes for stroke survivors and family members. Patients and families are educated in a large integrated health system on Joint Commission required elements of stroke education which include: importance of calling 911, stroke signs and symptoms, disease processes, risk factor management, and follow up. In 2018, despite 95% documented rates of education, 40 to 50% of stroke survivors in the health system replied “No” to three Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs) "staff explained stroke..." questions. The purpose of this project was to improve stroke education as measured by an increase in HCAHPs scores. Methods: Current literature was reviewed. Stroke survivors spoke to a regional stroke coordinator group about their experiences. Staff nurses were surveyed on barriers to stroke education. Based on information from the literature, stroke survivors, staff nurses and neuroscience nursing, neurology and education experts, two interventions were undertaken. A flyer was designed using a well-spaced layout with required stroke education elements written at fourth grade reading level and translated into four common languages in the patient population. Community feedback was integrated after the initial design. A training module for teaching stroke education was completed by 886 nurses in eight facilities. The pre and post intervention HCAHPs scores were aggregated from the eight hospitals. The results were analyzed using a Chi2 statistical tool. Results: Unfortunately, a statistically significant increase in HCAHPs scores was not achieved. For question #1; “staff explained stroke diagnosis”, the percentage yes went from %53 (n=49) to %59 (n=59). Question #2; “staff explained risk factors” went from %52 (n=50) to %43 (n=58). Question #3 “staff explained stroke signs/symptoms” went from %47 (n=48) to %53 (n=69). Conclusion: This work supports literature and local stroke survivor feedback indicating stroke survivors and their families are too overwhelmed in the hospital to absorb education. Resources should be put into follow-up phone calls or other modalities after trauma from the stroke event has subsided.

Abstract WP439: "You Gotta Troll to Enroll!" Nurses Actively Scouting Patients for Clinical Trials

Problem/ Background: Evidence- based practice is the cornerstone in delivery of stroke care to optimize outcomes for patients. Research is the foundation to build and advance clinical practice. As a Comprehensive Stroke Center, we are charged with participating in IRB approved research. In 2016 the SUCCEED trial was stopped here as a result of low enrollment. The stroke nurses were not directly involved in that trial. In 2017, the stroke nurses partnered with our physicians and began the ARAMIS trial. This is a multicenter study of acute stroke patients taking anticoagulation therapy prior to admission and suffering a stroke. We recognized the need for our stroke nurses to collaborate, participate and use their expertise in identifying appropriate research patients for this study. Quality Question: Will tasking Stroke Nurses with identifying patients improve the enrollment of patients in ARAMIS trial? Methods: Stroke nurses attended an ARAMIS training session for physicians. Included in the meeting was review of inclusion/exclusion criteria for patient enrollment. A group e-mail was created for all participating in the study to help identify potential patients. When a patient was discovered an email was sent to the group alerting those responsible for obtaining consent for the study and data collection for the registry. Results: After one trial was ended due to low enrollment, the new ARAMIS trial opened. The stroke team nurses took the lead on identifying patients. Reviewing retrospective data starting in November 2017 until March 2019, 56 patients were enrolled in Aramis. Stroke nurses identified 43 patients (77%), Neurology fellows 10 (18%) and Faculty physicians 3 (5%). Conclusion: When including expert nurses in the patient identification process, the nurse plays a pivotal role in identifying appropriate patient for the MDs to enroll, thus, increasing enrollment in clinical trials. While additional tracking and trending needs to take place as new trails open, this trial makes clear the need for nurse involvement in identifying appropriate patients.