The Postpandemic Nursing Workforce: Increasing Fill Rates and Reducing Workload Through a Generational Design of Workforce Layers.

Inequities between nursing workforce supply and demand continue to challenge nurse executives in creating the vision for a postpandemic nursing workforce. Health system's workforce redesign strategies must prioritize the changing needs of the multigenerational workforce to maximize the available supply of nurses willing to remain in the workforce. A test of a newly designed flexible workforce framework, aimed to meet the needs of the multigenerational workforce, resulted in increased fill rates and decreased costs of labor.

Leveraging academic initiatives to advance implementation practice: a scoping review of capacity building interventions.

BACKGROUND: Academic institutions building capacity for implementation scholarship are also well positioned to build capacity in real world health and human service settings. How practitioners and policy makers are included and trained in implementation capacity-building initiatives, and their impact on building implementation practice capacity is unclear. This scoping review identified and examined features of interventions that build implementation practice capacity across researchers and practitioners or practitioners-in-training. METHODS: Five bibliographic databases were searched. Eligible studies (a) described an implementation capacity building intervention with a connection to an academic institution, (b) targeted researchers and practitioners (including practitioners-in-training, students, or educators), and (c) reported intervention or participant outcomes. Articles that only described capacity building interventions without reporting outcomes were excluded. Consistent with Arksey and O'Malley's framework, key study characteristics were extracted (target participants, core components, and outcomes) and analyzed using open coding and numerical analysis. RESULTS: Of 1349 studies identified, 64 met eligibility for full-text review, and 14 were included in the final analysis. Half of the studies described implementation capacity building interventions that targeted health or behavioral health researchers, practitioners, and practitioners-in-training together, and half targeted practitioners or practitioners-in-training only. The most common components included structured didactic activities offered in person or online, mentorship and expert consultation to support implementation, and practical application activities (e.g., field placements, case studies). Knowledge sharing activities and technical assistance were less common. All studies reported favorable outcomes related to knowledge attainment, increased ability to implement evidence, productivity, and satisfaction. CONCLUSIONS: Building implementation capacity among practitioners is critical for integrating insights from implementation science into the field and preventing the "secondary" implementation research-to-practice gap. This scoping review identified several promising implementation practice capacity building interventions that tend to build practitioner capacity via expert led activities which may be relevant for academic institutions seeking to build implementation practice capacity. To avoid widening the implementation research-to-practice gap, implementation capacity building interventions are needed that target policy makers, expand beyond multiple practice settings, and leverage university/community partnerships or on-site academic medical centers. Future studies will also be needed to test the impact on service quality and public health outcomes.

Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness.

Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.

A National Trial on Differences in Cerebral Perfusion Pressure Values by Measurement Location.

BACKGROUND: Cerebral perfusion pressure (CPP) is a key parameter in management of brain injury with suspected impaired cerebral autoregulation. CPP is calculated by subtracting intracranial pressure (ICP) from mean arterial pressure (MAP). Despite consensus on importance of CPP monitoring, substantial variations exist on anatomical reference points used to measure arterial MAP when calculating CPP. This study aimed to identify differences in CPP values based on measurement location when using phlebostatic axis (PA) or tragus (Tg) as anatomical reference points. The secondary study aim was to determine impact of differences on patient outcomes at discharge. METHODS: This was a prospective, repeated measures, multi-site national trial. Adult ICU patients with neurological injury necessitating ICP and CPP monitoring were consecutively enrolled from seven sites. Daily MAP/ICP/CPP values were gathered with the arterial transducer at the PA, followed by the Tg as anatomical reference points. RESULTS: A total of 136 subjects were enrolled, resulting in 324 paired observations. There were significant differences for CPP when comparing values obtained at PA and Tg reference points (p < 0.000). Differences remained significant in repeated measures model when controlling for clinical factors (mean CPP-PA = 80.77, mean CPP-Tg = 70.61, p < 0.000). When categorizing CPP as binary endpoint, 18.8% of values were identified as adequate with PA values, yet inadequate with CPP values measured at the Tg. CONCLUSION: Findings identify numerical differences for CPP based on anatomical reference location and highlight importance of a standard reference point for both clinical practice and future trials to limit practice variations and heterogeneity of findings.

Risk Factors for Falls Among Hospitalized Acute Post-Ischemic Stroke Patients.

BACKGROUND: Falls remain an important benchmarking indicator for hospitals. Research identifies factors associated with falls among hospitalized patients in general. Similarly, the stroke literature outlines fall risk factors in the inpatient rehabilitation and community setting. PURPOSE: The aim of this study was to identify prevalence and risk factors for falls among acute, hospitalized AIS patients within an urban public healthcare system. Secondary aims were to identify activities present at the time of the fall and outcomes associated with falling. METHODS: This is a retrospective case-control study. Data were abstracted and merged from hospital stroke and fall registries and matched with medical records from 2013 to 2015 among all adult patients admitted for AIS. RESULTS: The study included 856 patients with AIS, with 2.3% experiencing a fall during the acute care hospitalization period. Falls among patients with AIS accounted for 1.4% of all hospitalized adult falls. Bivariate analysis indicate that a higher proportion of falls occurred among male patients when compared with female patients (75% male; χ = 3.964, P < .05) and among patients with a history of previous myocardial infarction or renal insufficiency (χ = 5.260, P < .05; χ = 11.116, P < .001, respectively). Multivariate analyses identify previous myocardial infarction (OR, 2.5; 95% confidence interval, 1.0-6.3; P = .04) and renal insufficiency (odds ratio, 4.2; 95% confidence interval, 1.5-12.2; P = .008) as strongest predictors of falls. The occurrence of a fall resulted in increased hospital length of stay (7.1 vs 4.0 days, P < .000) and slightly decreased functional outcome at discharge. Most falls occurred during the day shift while toileting, despite implementation and adherence to fall prevention programs. CONCLUSIONS: Fall rates among hospitalized patients with AIS are low, which may be reflective of increased vigilance among providers and widespread integration of fall prevention strategies. Consistent with the fall literature among other populations, the occurrence of a fall in the inpatient setting can substantially increase length of stay.

Challenges of Cerebral Perfusion Pressure Measurement.

Monitoring cerebral perfusion pressure (CPP) is recommended by a number of clinical practice guidelines and is a routine function performed by critical care neuroscience nurses. However, several studies highlight theoretical and practice variations in the measurement of CPP regarding the location of the arterial pressure transducer during measurement. Agreement on the technique and process for obtaining valid measurements is lacking. This article identifies the challenges associated with CPP measurement and highlights opportunities for standardizing CPP measurement to improve consistency in care and findings reported in the research literature. The challenges associated with practice variations impact multiple nursing domains, including the environment, patient treatment, and team communication; all ultimately impacting nursing workflow. The practice variation and impact on nursing workflow have significant implications for further research, electronic health record development, and refining monitoring technology.

A Comparative Study of Glasgow Coma Scale and Full Outline of Unresponsiveness Scores for Predicting Long-Term Outcome After Brain Injury.

PURPOSE: The aim of this study was to compare predictive ability of hospital Glasgow Coma Scale (GCS) scores and scores obtained using a novel coma scoring tool (the Full Outline of Unresponsiveness [FOUR] scale) on long-term outcomes among patients with traumatic brain injury. Preliminary research of the FOUR scale suggests that it is comparable with GCS for predicting mortality and functional outcome at hospital discharge. No research has investigated relationships between coma scores and outcome 12 months postinjury. METHODS: This is a prospective cohort study. Data were gathered on adult patients with traumatic brain injury admitted to urban level I trauma center. GCS and FOUR scores were assigned at 24 and 72 hours and at hospital discharge. Glasgow Outcome Scale scores were assigned at 6 and 12 months. RESULTS: The sample size was n = 107. Mean age was 53.5 (SD = ±21, range = 18-91) years. Spearman correlations were comparable and strongest among discharge GCS and FOUR scores and 12-month outcome (r = .73, p < .000; r = .72, p < .000). Multivariate regression models indicate that age and discharge GCS were the strongest predictors of outcome. Areas under the curve were similar for GCS and FOUR scores, with discharge scores occupying the largest areas. CONCLUSION: GCS and FOUR scores were comparable in bivariate associations with long-term outcome. Discharge coma scores performed best for both tools, with GCS discharge scores predictive in multivariate models.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care.

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

Effects of nursing interventions on intracranial pressure.

BACKGROUND: Intracranial pressure is a frequent target for goal-directed therapy to prevent secondary brain injury. In critical care settings, nurses deliver many interventions to patients having intracranial pressure monitored, yet few data documenting the immediate effect of these interventions on intracranial pressure are available. OBJECTIVE: To examine the relationship between intracranial pressure and specific nursing interventions observed during routine care. METHODS: Secondary analysis of prospectively collected observational data. RESULTS: During 3118 minutes of observation, 11 specific nursing interventions were observed for 28 nurse-patient dyads from 16 hospitals. Family members talking in the room, administering sedatives, and repositioning the patient were associated with a significantly lower intracranial pressure. However, intracranial pressure was sometimes higher, lower, or unchanged after each intervention observed. CONCLUSION: Response of intracranial pressure to nursing interventions is inconsistent. Most interventions were associated with inconsistent changes in intracranial pressure at 1 or 5 minutes after the intervention.

Significant practice pattern variations associated with intracranial pressure monitoring.

PURPOSE: The purpose of this study was to describe nursing practice in the care of patients with intracranial pressure monitoring. Although standards for care of such patients have been established, there continue to be variations in the nursing practice. METHODS: This was an observational study in which data were collected from 28 nurse-patient dyads at 16 different hospitals across the United States. Each dyad was observed for 2 hours; nursing actions and patient responses including intracranial pressure readings were documented. RESULTS: Differences in the care of patients with intracranial pressure monitoring were prevalent. Variations in practice were prompted by healthcare provider prescriptions as well as nursing decisions. Prescriptions and interventions were often not supported by the available scientific evidence. VIDEO ABSTRACT: For more insights from the authors, see Supplemental Digital Content 1, at http://links.lww.com/JNN/A7.

Nursing interventions for critically ill traumatic brain injury patients.

Neuroscience intensive care unit (ICU) nurses deliver a number of interventions when caring for critically ill traumatic brain injury (TBI) patients. Yet, there is little research evidence documenting specific nursing interventions performed. As part of a larger study investigating ICU nurse judgments about secondary brain injury, ICU nurses were asked to identify interventions routinely performed when caring for TBI patients. Quantitative and qualitative analyses indicate that all nurses routinely monitored hemodynamic parameters such as oxygen saturation, blood pressure, and temperature. Nurses were responsible for monitoring intracranial pressure and cerebral perfusion pressure approximately 50% of the time. Qualitative analyses revealed that additional nursing interventions could be categorized as neurophysiological interventions, psychosocial interventions, injury prevention interventions, and interventions to maintain a therapeutic milieu. Findings from this study provide evidence of the multifaceted role of the neuroscience ICU nurse caring for TBI patients and can be used in future research investigating the impact of nursing interventions on patient outcomes.

The PhD-prepared nurse in the clinical setting.

BACKGROUND: The emergence of new doctoral programs within the nursing discipline has stimulated dialogue regarding the role of the doctorally prepared nurse in the clinical setting. National nursing organizations have cited the need for additional research that would provide information regarding the current practice of doctorally prepared nurses. A review of the literature reveals little published information about the role of PhD nurses in the clinical setting. PURPOSE: The purpose of this descriptive qualitative study was to investigate how PhD-prepared nurses describe and define their role within the clinical setting. METHODS: Interviews were conducted with 5 PhD nurses who were all employed full time in the clinical setting. Interview notes were recorded, transcribed, and analyzed using qualitative data analysis. Recurrent themes that emerged from the interviews were identified. RESULTS: The 2 themes that emerged from the interviews were bridging the research/practice gap and serving as a healthcare leader. All participants spoke to their role in leading, encouraging, or participating in clinical nursing research within their healthcare institutions. Phrases regarding leadership emerged throughout each interview and reflected a number of leadership responsibilities that each participant had within the healthcare environment. CONCLUSIONS: The findings from this qualitative study provide insight into the current role of the PhD-prepared nurse in the clinical setting. This information can be used to guide additional research that might influence the development of future doctoral programs in nursing.