Modifiable pathways from pain to functional status: Confirmatory baseline results from a randomised trial of African American patients with cancer pain.

OBJECTIVE: This study tested a model of cancer-related pain and functional status in African American patients, including beliefs about the ability to control pain as a key determinant of distress and functional status. METHODS: Baseline data from a randomised clinical trial consisting of clinical and patient-reported outcomes were used. Participants were 228 African American patients experiencing moderate to severe pain within the past 2 weeks. The model comprised four latent constructs: pain, perceived control over pain, pain-related distress and functional status. Confirmatory factor analysis was used to validate the factor structure of the measurement model. Structural equation modelling was used to estimate direct and mediated effects. RESULTS: The measurement model fit well (RMSEA = 0.06, SRMR = 0.05) with all loadings significant (p < 0.05). The structural model also fit well (RMSEA = 0.04, SRMR = 0.05). The complex mediated pathway from pain to functional status through perceived control over pain and pain-related distress was strong and significant (specific indirect effect = -0.456, p = 0.004). Mediation by perceived control accounted for a 47% reduction of the effects of pain on functional status. CONCLUSION: If these results hold up longitudinally, interventions to increase perceived control over pain have the potential to improve functional status by decreasing pain-related distress.

Improving Functional Status in African Americans With Cancer Pain: A Randomized Clinical Trial

OBJECTIVES: To determine the efficacy of the Power Over Pain-Coaching (POP-C) intervention to improve functional status among African American outpatients with cancer pain.
. SAMPLE & SETTING: 310 African American patients were recruited from an urban comprehensive cancer center. The study took place in the patients' homes.
. METHODS & VARIABLES: A two-group randomized design with repeated measures was used. Data were analyzed with linear mixed effects regression analysis and structural equation change score models. Variables were pain, pain-related distress, functional status, perceived control over pain, and the following antecedents to control. RESULTS: Functional status was improved in POP-C participants relative to control group participants (p < 0.05). Distress also was differentially decreased (p < 0.05). Pain intensity ratings decreased significantly in all patients (p < 0.05). The largest intervention effects were observed in the living with pain component. 
. IMPLICATIONS FOR NURSING: Perceived control over pain was strongly related to functional status and is amenable to interventions using the POP-C intervention components described in this article.

Applying STAAR interventions in incremental bundles: improving post-CABG surgical patient care.

BACKGROUND: Rehospitalization within 30 days of discharge after coronary artery bypass surgery (CABG) is a contributing factor to higher-than-acceptable overall hospital readmission rates throughout the United States. CABG rehospitalizations are of such concern that they are specifically targeted for action in 2015 under the Patient Protection and Affordable Care Act (2010). The phenomenon of increasing readmission rates has prompted the Institute for Healthcare Improvement to devise the Triple Aim initiative and the STate Action on Avoidable Rehospitalizations (STAAR) initiative to reduce 30-day readmission rates nationally. AIMS: This study explored the impact of implementing STAAR interventions delivered as part of a quality improvement project in incremental bundles on 30-day readmission rates and the experience of care in CABG patients. Specifically, the use of the teach-back patient education method and the scheduling of follow-up cardiology appointments prior to discharge using existing staff were examined. METHODS: A quantitative comparative study was conducted with 189 post-CABG patients at a tertiary care facility in the United States over a 2-year period, comparing outcomes between the group of patients prior to implementation of the STAAR interventions and those who later received them. Outcome variables included 30-day readmission rate and patient perception of experience of care. RESULTS: The overall 30-day readmission rate for CABG patients in the postintervention group was decreased to 12.0%, compared to 25.8% in the preintervention group. Of the demographic and health characteristics explored, only chronic lung disease was significantly related to 30-day readmission rates, and only in the postintervention group. LINKING EVIDENCE TO ACTION: Thirty-day readmission rates among CABG patients can be reduced and the experience of care can be enhanced through the use of targeted interventions utilizing existing staff and resources. The deliberate incremental implementation of bundled initiatives is an effective strategy in reducing 30-day readmissions in post-CABG patients.

An interprofessional process to improve early identification and treatment for sepsis.

The course of sepsis is rapid. Patient outcomes improve when sepsis is diagnosed and treated quickly. The clinical goals of the evidence-based bundled strategies from the International consortium Surviving Sepsis Campaign (SSC) include optimizing timeliness in the delivery of care and creating a continuum for sepsis management that runs from the emergency department (ED) to the acute and critical care settings. Successful implementation of processes that integrate sepsis bundles can improve patient mortality and hospital costs. Improving interprofessional education and collaboration are necessary to facilitate the effective use of bundled strategies. An intervention that included interprofessional education resulted in a statistically significant difference between the three phases studied. There was a statistically significant improvement between the phases for lactate completion X(2) = 16.908 (p < .01) after education. Frequency of blood cultures being obtained before antibiotic administration was nearing statistical significance (p < .054). There was an improvement in time to antibiotic administration between phase 2 (182.09 mean average minutes, SD = 234.06) and phase 3 (91.62 mean average minutes, SD = 167.99).

Challenges to Recruitment of Urban African American Patients with Cancer Pain.

There are many assumptions about recruitment of African Americans to cancer studies. The population is often characterized as older, low income, with limited education, scarce resources, and distrust of the health care system. Support systems for African Americans are reported to be centered on family and church communities. Observations made during recruitment and enrollments for a longitudinal intervention study with urban African Americans with cancer pain are presented. Majority of the subjects being recruited in this study are well educated, knowledgeable about research and very open to healthcare providers and researchers. Our population is younger than anticipated and struggling with an absence of family, faith, or community supports. They are more connected in terms of phone ownership, but often difficult to contact due to interruptions in phone service, housing insecurity and time demands related to medical care for their cancer. We conclude that familiarity with cultural patterns of a population of interest is necessary, but local and individual assessment is critical to successful recruitment to research.

Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner.

PURPOSE: This study identified the perceived user barriers to documentation of nursing practice utilizing standardized nursing language (SNL) in the electronic health record (EHR) by ambulatory care nurse practitioners (NPs). DATA SOURCES: A researcher-developed survey was sent to a randomized sample of ambulatory care NPs in the United States who belonged to the American Academy of Nurse Practitioners (n= 1997). CONCLUSIONS: Surveyed ambulatory care NPs placed a higher value on documenting medical care versus nursing care. Only 17% of respondents currently use SNL and 30% believe that SNL is not important or appropriate to document NP practice. Barriers to using SNL in EHRs included lack of reimbursement for nursing documentation, lack of time to document, and lack of availability of SNL in electronic records. IMPLICATIONS FOR PRACTICE: Respondents identified NP practice as a blend of medical as well as nursing care but NPs have not embraced the current SNLs as a vehicle to document the nursing component of their care, particularly in EHRs. Until these barriers are addressed and discreet data in the form of SNL are available and utilized in the EHR, the impact of the NPs care will be unidentifiable for outcomes reporting.

Cultural sensitivity in patient health education.

Changes in demographics, economic, and political factors have affected health care delivery, while the patient population and the health care providers have continued to increase in diversity. Cultural sensitivity is a necessary component in development of comprehensive patient, family, or community health education plans. Consideration of the ACCESS Model can facilitate the development of successful interactions in providing culturally sensitive patient education programs.

Factors that affect functional status in patients with cancer-related pain.

Cancer-related pain in outpatient adult populations remains high and has a direct effect on functional status. Factors that affect functional status have been explored separately, but the inter-relatedness of those factors has not been examined. Using a cross-sectional design, the purpose of this study was to examine the relationships between pain level, beliefs about pain, symptom distress, perceived control over pain, and functional status in 304 ambulatory cancer patients who experienced cancer-related pain within the past 2 weeks. Participants completed standardized questionnaires during regularly scheduled clinic visits. Patient's pain level was positively related to increased distress and decreased perceived control over pain and functional status. Structural equation modeling indicated that symptom distress mediated the relation between pain level and functional status. Perceived control over pain had a direct effect on symptom distress and mediated the effect of beliefs about pain and pain level on symptom distress. Patients' perceived control over pain may be an important component in pain management. The direct and mediating effects of perceived control and symptom distress suggest areas of further research. Interventions to increase knowledge and decrease barriers to pain control have the potential for increasing perceived control over pain.

Knowledge of and barriers to pain management in caregivers of cancer patients receiving homecare.

Cancer treatment is increasingly being provided in outpatient settings, requiring many of the responsibilities for patient care to be undertaken by family caregivers. Pain is one of the most frequent and distressing symptoms experienced by cancer patients and is a primary concern for the family caregiver. Caregivers struggle with many issues that lead to inadequate management of cancer pain. The purpose of this study was to determine pain management knowledge and examine concerns about reporting pain and using analgesics in a sample of primary family caregivers of cancer patients receiving homecare. The Barriers Questionnaire and the Family Pain Questionnaire were administered to 46 primary caregivers. Between 46% and 94% of the caregivers reported having at least some agreement with the various concerns that are barriers to reporting pain and using analgesics, and up to 15% reported having strong agreement. The areas of greatest concern were about opioid-related side effects, fears of addiction, and the belief that pain meant disease progression. Results showed that caregivers with higher pain management knowledge had significantly fewer barriers to cancer pain management, supporting the importance of increasing caregiver's knowledge of management of cancer pain.

Barriers to pain management by home care nurses.

This study examined home care nurses' perceived barriers to pain management. Major barriers included lack of knowledge, inadequate pain assessment, and difficulty managing opioid-related side effects. Home care nurses with more knowledge about pain management had significantly lower scores on the Barriers Questionnaire. The study documented the need for continued pain management education for home care nurses. Practice implications are provided.

Improving cancer pain management by homecare nurses.

PURPOSE/OBJECTIVES: To demonstrate the effects of a program, directed at homecare nurses, of structured educational interventions on the management of pain and opioid-related side effects in homecare patients with cancer. DESIGN: A longitudinal multilevel, randomized, controlled clinical trial. SETTING: Midwestern region in the United States. SAMPLE: 202 nurses caring for patients with cancer recruited from homecare agencies. METHODS: The two-tiered educational program focused on basic and advanced pain management strategies, particularly in the area of pharmacologic options and assertive communication skills. Instruments used were the Nurses' Knowledge and Attitudes Survey Regarding Pain, the barriers questionnaire, perception of control over pain, and a demographic questionnaire. MAIN RESEARCH VARIABLES: Knowledge and attitudes about pain management, barriers to pain management, and perception of control over pain. FINDINGS: Nurses in the intervention group had a significant increase in their knowledge, a more positive attitude about pain management, fewer perceived barriers to pain management, and an increase in perceived control over pain compared to the nurses who did not receive the intervention. CONCLUSIONS: The educational program Power Over Pain has beneficial effects for homecare nurses caring for patients with cancer pain. IMPLICATIONS FOR NURSING: A need exists for homecare nurses to gain more insight into pain management strategies and enhance their advocacy skills to improve pain management for patients with cancer treated in the home.

Neural tube defects.

The purpose of this article is to describe the etiology of neural tube defects (NTDs) and the role of folic acid in their prevention. NTDs are all too common and devastating outcomes of many pregnancies. The brain and spinal cord malformations that develop during gestation in the NTD-affected pregnancies are expressed through various anomalies. Estimates by the Centers for Disease Control and Prevention (CDC) for 1995 reported over 4,000 occurrences of NTDs in the United States alone. Research has demonstrated that the preconception and prenatal addition of folic acid can greatly reduce the incidence of NTDs. Recent advances in genetic studies have increased awareness of the important role of folic acid in preventing NTDs. Identification of a genetic marker will allow for specific treatment of those women at high risk for NTDs. Despite recommendations from the CDC for folic acid supplementation, there is insufficient awareness of these guidelines by both the public and by healthcare providers. A National campaign to promote awareness of the role of folic acid in the prevention of NTDs has been initiated, and has been successful at reducing NTDs's by 19%. Nurses can be instrumental in the dissemination of information not only to women of childbearing age, but also to other nurses and physicians.