Nursing Theory, Terminology, and Big Data: Data-Driven Discovery of Novel Patterns in Archival Randomized Clinical Trial Data.

BACKGROUND: The growth and diversification of nursing theory, nursing terminology, and nursing data enable a convergence of theory- and data-driven discovery in the era of big data research. Existing datasets can be viewed through theoretical and terminology perspectives using visualization techniques in order to reveal new patterns and generate hypotheses. The Omaha System is a standardized terminology and metamodel that makes explicit the theoretical perspective of the nursing discipline and enables terminology-theory testing research. OBJECTIVE: The purpose of this paper is to illustrate the approach by exploring a large research dataset consisting of 95 variables (demographics, temperature measures, anthropometrics, and standardized instruments measuring quality of life and self-efficacy) from a theory-based perspective using the Omaha System. Aims were to (a) examine the Omaha System dataset to understand the sample at baseline relative to Omaha System problem terms and outcome measures, (b) examine relationships within the normalized Omaha System dataset at baseline in predicting adherence, and (c) examine relationships within the normalized Omaha System dataset at baseline in predicting incident venous ulcer. METHODS: Variables from a randomized clinical trial of a cryotherapy intervention for the prevention of venous ulcers were mapped onto Omaha System terms and measures to derive a theoretical framework for the terminology-theory testing study. The original dataset was recoded using the mapping to create an Omaha System dataset, which was then examined using visualization to generate hypotheses. The hypotheses were tested using standard inferential statistics. Logistic regression was used to predict adherence and incident venous ulcer. RESULTS: Findings revealed novel patterns in the psychosocial characteristics of the sample that were discovered to be drivers of both adherence (Mental health Behavior: OR = 1.28, 95% CI [1.02, 1.60]; AUC = .56) and incident venous ulcer (Mental health Behavior: OR = 0.65, 95% CI [0.45, 0.93]; Neuro-musculo-skeletal function Status: OR = 0.69, 95% CI [0.47, 1.00]; male: OR = 3.08, 95% CI [1.15, 8.24]; not married: OR = 2.70, 95% CI [1.00, 7.26]; AUC = .76). DISCUSSION: The Omaha System was employed as ontology, nursing theory, and terminology to bridge data and theory and may be considered a data-driven theorizing methodology. Novel findings suggest a relationship between psychosocial factors and incident venous ulcer outcomes. There is potential to employ this method in further research, which is needed to generate and test hypotheses from other datasets to extend scientific investigations from existing data.

Patient outcomes after transcatheter and surgical pulmonary valve replacement for pulmonary regurgitation in patients with repaired tetralogy of Fallot: A quasi-meta-analysis.

BACKGROUND: Individuals with repaired tetralogy of Fallot develop pulmonary regurgitation that may cause symptoms (dyspnea, chest pain, palpitations, fatigue, presyncope, and syncope), impair functional capacity, and may affect health-related quality of life. Surgical pulmonary valve replacement is the gold standard of treatment although transcatheter pulmonary valve replacement is becoming more common. Patients want to know whether less invasive options are as good. AIMS: This analysis aimed to examine the differences in surgical versus transcatheter pulmonary valve replacement effects in terms of physiological/biological variables, symptoms, functional status and health-related quality of life. METHODS: This quasi-meta-analysis included 85 surgical and 47 transcatheter pulmonary valve replacement studies published between 1995-2016. RESULTS: In terms of physiological/biological variables, both surgical and transcatheter pulmonary valve replacement improved pulmonary regurgitation and systolic and diastolic right ventricular volume indices but not heart function. In the left heart, only surgical pulmonary valve replacement improved heart function. Only transcatheter pulmonary valve replacement improved left ventricular end-diastolic indices and neither improved endsystolic indices. Only surgery has been demonstrated to decrease QRS duration but there is little evidence of arrhythmia reduction. Symptom change is poorly documented. Functional class improves but exercise capacity generally does not. Some aspects of health-related quality of life improve with surgery and in one small transcatheter pulmonary valve replacement study. CONCLUSION: Transcatheter and surgical pulmonary valve replacement compare favorably for heart remodeling. Exercise capacity does not change with either technique. Health-related quality of life improves after surgical pulmonary valve replacement. There are numerous gaps in documentation of changes in arrhythmias and symptoms.

The effectiveness of and satisfaction with high-fidelity simulation to teach cardiac surgical resuscitation skills to nurses.

BACKGROUND: There are few reports of the effectiveness or satisfaction with simulation to learn cardiac surgical resuscitation skills. OBJECTIVES: To test the effect of simulation on the self-confidence of nurses to perform cardiac surgical resuscitation simulation and nurses' satisfaction with the simulation experience. METHODS: A convenience sample of sixty nurses rated their self-confidence to perform cardiac surgical resuscitation skills before and after two simulations. Simulation performance was assessed. Subjects completed the Satisfaction with Simulation Experience scale and demographics. RESULTS: Self-confidence scores to perform all cardiac surgical skills as measured by paired t-tests were significantly increased after the simulation (d=-0.50 to 1.78). Self-confidence and cardiac surgical work experience were not correlated with time to performance. Total satisfaction scores were high (mean 80.2, SD 1.06) indicating satisfaction with the simulation. There was no correlation of the satisfaction scores with cardiac surgical work experience (τ=-0.05, ns). CONCLUSION: Self-confidence scores to perform cardiac surgical resuscitation procedures were higher after the simulation. Nurses were highly satisfied with the simulation experience.

Team-Based Learning Improves Staff Nurses' Knowledge of Open- and Closed-Chest Cardiac Surgical Resuscitation.

BACKGROUND: There are few reports of the use of 1-session team-based learning (TBL) in hospital settings and none to teach cardiac surgical resuscitation (CSR). OBJECTIVE: The aim of this study was to investigate whether 1-session TBL is an effective method to increase nursing knowledge of CSR. METHODS: The participating subjects viewed a PowerPoint presentation about CSR prior to the learning session. Participants completed a 16-item individual readiness assessment test. Immediately after, participants in groups of 3 completed the same 16-item test as a team using the Immediate Feedback Assessment Technique form. Participants were asked open-ended questions about their concerns with CSR, which were analyzed with a grounded theory approach. RESULTS: The sample consisted of 60 subjects (54 completing all phases). Team-based learning significantly increased scores from 36.93 (SD, 8.49) to 50.89 (SD, 5.29), t53 = -13.05, P < .001. There was a significant increase in scores (t46 = 2.13, P = .04) among the noncohesive groups from baseline (52.88 [SD, 3.29]) versus the cohesive groups (50.38 [SD, 4.73]). The qualitative data indicated that the subjects had worries/concerns and lack of self-confidence around CSR. DISCUSSION: Team-based learning is a feasible method to use for single-session education where team building is also required. Noncohesive groups may benefit from TBL, from discussing divergent viewpoints to reach a consensus. Additional studies are needed to compare preferences for TBL with other teaching methods.

Transcatheter Closure of Patent Ductus Arteriosus in Extremely Premature Newborns: Early Results and Midterm Follow-Up.

OBJECTIVES: The goal of this study was to describe early and midterm outcomes of extremely premature newborns (EPNs) who underwent transcatheter echocardiographically guided patent ductus arteriosus (PDA) closure. BACKGROUND: Surgical ligation of PDA in EPNs confers significant risk for procedural morbidity and adverse long-term outcomes. METHODS: The Amplatzer Vascular Plug II was used in all cases. Post-ligation syndrome was defined using previously published parameters. Patients were followed at pre-specified intervals, and prospectively collected data were reviewed. RESULTS: Transcatheter closure was attempted in 24 EPNs (mean procedural age 30 days [range 5 to 80 days], mean procedural weight 1,249 g [range 755 to 2,380 g]) and was successful in 88%. The 3 procedural failures were related to the development of left pulmonary artery (LPA) stenosis caused by the device, and all devices were removed uneventfully. Complications included 2 instances of device malposition, resolved with device repositioning, and 1 instance of LPA stenosis, requiring an LPA stent. There were no procedural deaths, cases of post-ligation syndrome, residual PDA, or device embolization. Survival to discharge was 96% (23 of 24), with a single late death unrelated to the procedure. After a median follow-up period of 11.1 months, all patients were alive and well, with no residual PDA or evidence of LPA or aortic coarctation. CONCLUSIONS: This newly described technique can be performed safely with a high success rate and minimal procedural morbidity in EPNs. Early and midterm follow-up is encouraging. Future efforts should be directed toward developing specific devices for this unique application.

Your Patient Has Congenital Heart Disease--What Questions Should You Ask to Provide High-Quality Care?

Congenital heart disease (CHD) is the most common birth defect. About two-thirds of those individuals living with CHD are now adults. If you do not have in-depth knowledge of CHD, knowing what questions to ask and what resources to use can improve patient outcomes and satisfaction with care.

CE: Long-term outcomes after repair of congenital heart defects: part 2.

OVERVIEW: Many congenital heart defects can be repaired, but long-term monitoring is often required to forestall possible complications. This two-part article reviews 10 common congenital heart defects, their repairs, and their common long-term outcomes, along with the implications for nurses in cardiac and noncardiac settings alike. Here, in part 2, the author reviews four defects: tetralogy of Fallot, transposition of the great arteries, congenitally corrected transposition of the great arteries, and single-ventricle defects.

CE: Long-term outcomes after repair of congenital heart defects: part 1.

Many congenital heart defects can be repaired, but long-term monitoring is often required to forestall possible complications. This two-part article reviews 10 common congenital heart defects, their repairs, and their common long-term outcomes, along with the implications for nurses in both cardiac and noncardiac settings. Here, in part 1, the author reviews six defects: bicuspid aortic valve, atrial septal defect, ventricular septal defect, atrioventricular septal defect, coarctation of the aorta, and pulmonic stenosis.

Long-term issues after the Fontan procedure.

The Fontan procedure is used to treat various serious congenital heart defects. Although many people who have had the procedure live productively into adulthood, as they age, they face several health issues due to the physiology of the Fontan circulation. This article reviews the 4 types of Fontan procedures and the changes caused by the surgery, including single-ventricle physiology, nonpulsatile pulmonary perfusion, systemic venous hypertension, and intracardiac scarring, as well as their sequelae. Key nursing assessment items and possible treatment strategies are reviewed. Additional topics, including pregnancy in patients who have undergone the procedure, infective endocarditis prophylaxis, and health-related quality of life, are briefly discussed. Options for Fontan failure, including Fontan conversion or transplantation, are presented. Potential future solutions are outlined.

Transcatheter aortic valve implantation outcomes: implications for practice.

Aortic stenosis is a common valvular pathological finding in older adults. Currently, aortic valve replacement is the gold-standard treatment for severe symptomatic aortic stenosis. However, patients with advanced age and multiple comorbidities carry a significant operative risk. Transcatheter aortic valve implantation (TAVI) was developed with the goal of offering a less invasive alternative to symptomatic high-risk patients with aortic stenosis. Since the first successful TAVI procedure in 2002, TAVI has been used as a treatment option for patients at very high or prohibitive surgical risk in clinical feasibility trials, registries, and in ongoing randomized controlled trials. There are 2 transcatheter valves in widespread clinical application, with several others in different stages of development. This article provides an overview of TAVI outcomes including insertion options, procedural outcomes, morbidity, valve durability, short- to medium-term survival, and quality of life to guide nursing care interventions. Enhancing nurses' knowledge of the risks, benefits, and potential complications of TAVI will empower nurses in their role as patient advocates and educators and improve patient outcomes. Gaps in the current TAVI research literature are identified.

Using audience response technology in hospital education programs.

An audience response system (ARS) is an interactive teaching tool that permits an instructor to poll an audience, either anonymously or in a tracked manner, in response to questions. The instructor can then display the responses to the audience. An ARS can be used in hospital-based education programs to assess group learning. The instructor receives immediate feedback that allows review of concepts that were not grasped by the majority of students. This article reviews systems currently on the market and offers tips for choosing an ARS for hospital-based use. Survey data of nurses attending in-service education sessions show that participants overwhelmingly favor the use of an ARS and the nonthreatening learning environment that these systems create. Instructor survey data show positive responses regarding the benefits of ARS use in hospital-based education programs.

Cardiac surgical nurses' use of atrial electrograms to improve diagnosis of arrhythmia.

BACKGROUND: The practice standard for electrocardiographic monitoring in hospitals recommends use of atrial electrograms after cardiac surgery to help diagnose cardiac arrhythmias. OBJECTIVES: To determine whether use of atrial electrograms significantly improves nurses' ability to diagnose cardiac arrhythmias and to assess nurses' perceptions of the ease of obtaining and interpreting electrograms, the frequency of use of atrial electrograms, and the correlation between nurses' experience with the technique and arrhythmia scores. METHODS: In total, 282 nurses completed a test consisting of 5 electrocardiographic rhythms for which use of atrial electrograms might improve interpretation. A standardized educational session on obtaining and interpreting atrial electrograms was given to 165 nurses who had not previously received such education. In a second test, the same rhythms were provided along with atrial electrograms to 261 nurses. Overall changes in total test scores and individual changes in interpreting rhythms were analyzed. Demographic information, perceptions of the ease of obtaining and interpreting atrial electrograms, and the frequency of use were collected. Correlation between scores on the second test and nurses' years of experience in interpreting atrial electrograms was determined. RESULTS: Use of atrial electrograms significantly increased overall arrhythmia interpretation scores. Nurses rated obtaining atrial electrograms as easy and interpreting the findings as moderately easy. Despite this reported ease, 57.1% of nurses obtained atrial electrograms less than monthly and only 3.4% obtained them daily. Correlation between experience with atrial electrograms and arrhythmia test scores was not significant. CONCLUSIONS: Nurses' use of atrial electrograms improves diagnoses of cardiac arrhythmias.

Delirium in older cardiac surgery patients: directions for practice.

Delirium affects approximately 20% to 25% of patients undergoing cardiac surgery and is particularly common in older adults. This article reviews the etiology and risk factors for delirium associated with cardiac surgery in older adults. Delirium screening, prevention, and treatment strategies, including both pharmacological and nonpharmacological therapies, are presented. Interventions appropriate in both the intensive care unit and

Cardiac support devices.

Heart failure is an increasingly common condition in the United States and is associated with high mortality and burden to health care. It is a chronic condition that is characterized by progressive left ventricular enlargement. While medical therapy can slow the progression of left ventricular remodeling, surgical approaches to treatment have been developed to improve the survival and quality of life of heart failure patients. This article reviews the surgical procedures for left ventricular dysfunction and focuses on cardiac support devices as a new therapy for heart failure patients. The nursing care of patients with cardiac support devices will be presented and a case study will highlight practical points to help guide patient care.

Transcatheter and transapical aortic valve replacement.

Minimally invasive valve replacement is limited to bioprosthetic aortic and pulmonary valves for use in very specific populations of patients. Replacement via trans-catheter and transapical techniques should be used only in patients in whom traditional surgical replacement is deemed an unacceptable risk. Nursing management will focus heavily on care for comorbid conditions because of the high-risk nature of the patients in whom these valves will initially be implanted.

ECG monitoring after cardiac surgery: postoperative atrial fibrillation and the atrial electrogram.

Atrial fibrillation is one of the most common complications after cardiac surgery and is associated with adverse outcomes such as increased mortality, neurological problems, longer hospitalizations, and increased cost of care. Major risk factors for the development of postoperative atrial fibrillation include older age and a history of atrial fibrillation. beta-Blockers are the most effective preventive therapy, although sotalol and amiodarone can also be used for prophylaxis. In the postoperative period, the nurse plays an important role in the early detection of atrial fibrillation by the recording of an atrial electrogram, which is easily obtained from the bedside monitor. Because an atrial electrogram records larger atrial activity than ventricular activity, it can be invaluable in establishing the diagnosis of postoperative atrial fibrillation. Once atrial fibrillation begins, treatment can be started with either rhythm conversion or rate-controlling medications.

Myectomy for hypertrophic obstructive cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden cardiovascular death in young people. Myectomy is the gold standard treatment for hypertrophic obstructive cardiomyopathy (HOCM). This article briefly reviews the pathophysiology and medical management of HOCM. The physiologic rationale for myectomy and associated cardiac surgical procedures such as unroofing of coronary artery muscle bridges and the MAZE procedure are presented. Outcomes after myectomy, as well as alternative therapies such as percutaneous septal ethanol ablation and pacing are compared. Nursing management of patients after myectomy is discussed.

Repaired tetralogy of Fallot in the adult.

The majority of persons living with tetralogy of Fallot are now adults and may face a number of long-term cardiac problems that necessitate reoperation. These problems include pulmonary regurgitation, tricuspid regurgitation, ventricular tachycardia, atrial flutter and/or fibrillation, pulmonary artery branch stenoses, right ventricular aneurysms, right ventricular outflow tract obstruction, residual ventricular septal defects, and coronary artery disease. Management approaches to these potential problems are discussed. Issues related to genetics, pregnancy, infective endocarditis, insurability, and employment are also reviewed with specific reference to the individual with repaired tetralogy of Fallot.