"I'm going to push this door open. You can close it": A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care.

BACKGROUND: Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear. AIM: To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses. DESIGN: A constructivist qualitative grounded theory study was conducted. SETTING/PARTICIPANTS: A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center. RESULTS: The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door-creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust-establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions-addressing patients' assumptions about palliative care as signifying death; and advocating with oncologists-seeding the process of referral by bringing patients' concerns forward. CONCLUSION: Oncology nurses play a central role in "brokering" the introduction of early palliative care; this process is supported by their relational proximity to patients and their location "in between" the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.

Validation par entretien cognitif de l'outil d'évaluation des plaies malignes MWAT-R.

La détresse physique et émotionnelle que peuvent causer au patient et à sa famille les plaies malignes dues à un cancer est souvent négligée. Malheureusement, nous ne disposons pas d'outils de dépistage et d'évaluation fiables et valides pouvant aider à mieux traiter ces plaies. Cette étude a cherché à valider un outil de mesure des résultats rapportés par les patients : le Malignant Wound Assessment Tool - Research (MWAT-R). Pour ce faire, huit patients ont été recrutés et interrogés selon la méthodologie de l'entretien cognitif. La compréhension et l'impression générale des patients vis-à-vis de cet outil ont été analysées. Nous avons constaté que la formulation et les choix de réponse posaient problème aux patients. En général, les participants ont néanmoins trouvé que les questions saisissaient bien les principaux enjeux relatifs aux plaies malignes et tenaient compte du point de vue du patient. Le fait d'établir la validité apparente et de contenu du MWAT-R du point de vue des patients par la technique d'entretien cognitif vient étayer la validité de cet outil.

Validation of the Malignant Wound Assessment Tool - Research (MWAT-R) using cognitive interviewing.

Malignant wounds as a result of cancer are under-recognized for the physical and emotional distress they cause patients and their families. Unfortunately, there is a lack of valid and reliable screening and assessment tools to aid in the management of malignant wounds. This study aims to validate a patient-reported outcome measurement tool, Malignant Wound Assessment Tool - Research (MWAT-R). Eight patients were recruited and interviewed using the cognitive interviewing methodology to validate this tool. Patients' understanding and overall impression of the MWAT-R were explored. Our findings showed that the wording and response options posed challenges for patients in completing the tool. Overall, participants felt that questions captured the key issues related to dealing with a malignant wound and accounted for the patients' perspective. Establishing the content and face validity of the MWAT-R from the patients' perspectives using cognitive interviews has provided further evidence to the validity of this tool.

Redesigning and implementing a Canadian oncology nursing curriculum for an international partnership.

Cancer is one of the leading causes of death and disability globally. As a result, there is a need to provide specialized nursing care to the increasing number of complex oncology patients. Numerous healthcare centres do not have specialized oncology nursing education programs, creating an environment where oncology patients may be cared for by generalist nurses. To address this gap, advanced practice nurses in Princess Margaret Cancer Centre have redesigned a local program to provide specialized oncology education to nurses caring for oncology patients. The purpose of this article is to share the experience of redesigning and delivering a Canadian Specialized Oncology Nursing Education (SONE) program in the Middle East. The article describes learnings from an international collaborative project undertaken in Qatar.

Malignant Bowel Obstruction in Advanced Gynecologic Cancers: An Updated Review from a Multidisciplinary Perspective.

Malignant bowel obstruction (MBO) is a major complication in women with advanced gynecologic cancers which imposes a significant burden on patients, caregivers, and healthcare systems. Symptoms of MBO are challenging to palliate and result in progressive decompensation of already vulnerable patients with limited therapeutic options and a short prognosis. However, there is a paucity of guidelines or innovative approaches to improve the care of women who develop MBO. MBO is a complex clinical situation that requires a multidisciplinary approach to ensure the appropriate treatment modality and interprofessional care to optimally manage these patients. This review summarizes the current literature on the different approaches targeting MBO management including surgical intervention, chemotherapy, total parenteral nutrition, and pharmacological treatment. In addition, the impact of MBO management on patients' quality of life (QOL) is examined. This article focuses on the challenges in developing evidence-based treatment guidelines for MBO and barriers in clinical trial design for MBO and proposes strategies to advance the MBO management. Collaboration is essential to design studies that may improve the overall care and quality of life for these patients. Prospective data are needed to inform clinical practice, establish a new benchmark for evidence-based MBO management, and better understand the biology of MBO.

Piloting an integrated education pathway as a strategy to prepare for and encourage oncology specialty certification.

Although continuing nursing education is crucial to improve professional and patient outcomes, programs in oncology nursing remain scarce, piecemeal, and focused on one modality of treatment, which limits the effectiveness of education interventions. The objectives of this paper are to describe the development and implementation of a longitudinal specialized oncology nursing education pathway program, and the evaluation results of a year-long pilot of the first stage of the program at a large university-affiliated cancer centre. Preliminary findings indicated that participants' perceived competence in health assessment and symptom management was improved after one year of enrolment in the education pathway. Next steps following this pilot, including implications for participants with regards to attaining oncology certification are also discussed.

Mitigating errors caused by interruptions during medication verification and administration: interventions in a simulated ambulatory chemotherapy setting.

BACKGROUND: Nurses are frequently interrupted during medication verification and administration; however, few interventions exist to mitigate resulting errors, and the impact of these interventions on medication safety is poorly understood. OBJECTIVE: The study objectives were to (A) assess the effects of interruptions on medication verification and administration errors, and (B) design and test the effectiveness of targeted interventions at reducing these errors. METHODS: The study focused on medication verification and administration in an ambulatory chemotherapy setting. A simulation laboratory experiment was conducted to determine interruption-related error rates during specific medication verification and administration tasks. Interventions to reduce these errors were developed through a participatory design process, and their error reduction effectiveness was assessed through a postintervention experiment. RESULTS: Significantly more nurses committed medication errors when interrupted than when uninterrupted. With use of interventions when interrupted, significantly fewer nurses made errors in verifying medication volumes contained in syringes (16/18; 89% preintervention error rate vs 11/19; 58% postintervention error rate; p=0.038; Fisher's exact test) and programmed in ambulatory pumps (17/18; 94% preintervention vs 11/19; 58% postintervention; p=0.012). The rate of error commission significantly decreased with use of interventions when interrupted during intravenous push (16/18; 89% preintervention vs 6/19; 32% postintervention; p=0.017) and pump programming (7/18; 39% preintervention vs 1/19; 5% postintervention; p=0.017). No statistically significant differences were observed for other medication verification tasks. CONCLUSIONS: Interruptions can lead to medication verification and administration errors. Interventions were highly effective at reducing unanticipated errors of commission in medication administration tasks, but showed mixed effectiveness at reducing predictable errors of detection in medication verification tasks. These findings can be generalised and adapted to mitigate interruption-related errors in other settings where medication verification and administration are required.

Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model.

OBJECTIVE: To determine what components of a checklist contribute to effective detection of medication errors at the bedside. DESIGN: High-fidelity simulation study of outpatient chemotherapy administration. SETTING: Usability laboratory. PARTICIPANTS: Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors. MAIN OUTCOME MEASURES: Rates of specified types of errors related to medication administration. RESULTS: As few as 0% and as many as 90% of each type of error were detected. Error detection varied as a function of error type and checklist used. Specific step-by-step instructions were more effective than abstract general reminders in helping nurses to detect errors. Adding a specific instruction to check the patient's identification improved error detection in this category by 65 percentage points. Matching the sequence of items on the checklist with nurses' workflow had a positive impact on the ease of use and efficiency of the checklist. CONCLUSIONS: Checklists designed with explicit step-by-step instructions are useful for detecting specific errors when a care provider is required to perform a long series of mechanistic tasks under a high cognitive load. Further research is needed to determine how best to assist clinicians in switching between mechanistic tasks and abstract clinical problem solving.

Interruptions during the delivery of high-risk medications.

OBJECTIVE: The goal of this study was to assess the nature and frequency of interruptions during medication administration and the interruptions' effects on task efficiency to guide healthcare managers/executives in improving patient safety and staff productivity. BACKGROUND: Interruptions have been identified as causal factors in medication administration errors. Research, however, is needed to assess the nature and frequency of interruptions throughout specific stages of the medication administration process and to develop mitigation interventions. METHOD: A direct observation study was conducted to document the nature, frequency, and timing of interruptions during specific stages of medication administration in a chemotherapy daycare unit. RESULTS: Nurses were interrupted, on average, 22% of their time and were frequently interrupted while performing safety-critical tasks. Task completion times were greater for interrupted tasks than for uninterrupted tasks. CONCLUSION: Nurses are frequently interrupted during safety-critical stages of medication administration, which decreases task efficiency and could lead to adverse events.

Implementing a wound care resource nurse program.

Nurses are leaders in implementing innovations that can create positive outcomes in the prevention and management of pressure ulcers in patients admitted to acute care hospitals. Believing that nurses knowledgeable in best practices could impact prevalence, incidence, and care of pressure ulcers, an educational program was developed in a Canadian healthcare system to inform and empower nurses providing skin and wound care. The program afforded participants the opportunity to acquire the knowledge and skill to recognize patients at risk for developing pressure ulcers and to independently treat Stage I and Stage II pressure ulcers and skin breakdown related to moisture, friction, and shear. The program includes evidence-based practice recommendations and highlights the Best Practice Guidelines developed by the Registered Nurses Association of Ontario, a provincial body taking an active role in the development, implementation, and evaluation of published guidelines derived from global research literature synthesis. Pre- and post participation assessment of 65 nurse participants from three hospitals deemed the program successful in terms of knowledge and fulfillment of their educational expectations. Organizational support to implement the skin and wound care resource nurse role was encouraging and medical directives for Stage I and Stage II pressure ulcers by nurses were implemented. Evaluation and monitoring of program outcomes, including pressure ulcer incidence rates, continue.

Interaction of enterohemorrhagic Escherichia coli (EHEC) with mammalian cells: cell adhesion, type III secretion, and actin pedestal formation.

Infection by the food-borne pathogen enterohemorragic Escherichia coli (EHEC) can lead to diarrhea, hemorrhagic colitis, and, in the most serious cases, renal failure. A critical step in colonization is the unusual interaction between EHEC and the intestinal epithelium. EHEC is able to adhere to mammalian cells, and then, by injecting bacterial proteins, or "effectors," into the host cell via a type III secretion system, induces the formation of attaching and effacing (AE) lesions characterized by the accumulation of filamentous actin directly beneath bound bacteria. This unit describes methods to evaluate the ability of EHEC to adhere to cultured mammalian cells, to secrete type III effectors, and to promote the formation of actin "pedestals." These methods can not only be used to evaluate the contribution of specific EHEC gene products to adherence, type III secretion, and mammalian cell signaling, but also facilitate the analysis of the eukaryotic pathways controlling fundamental cellular processes such as actin assembly.

Rapid allelic exchange in enterohemorrhagic Escherichia coli (EHEC) and other E. coli using lambda red recombination.

This unit describes an allelic exchange system for enterohemorrhagic E. coli (EHEC), and similar pathogenic species of bacteria. The phage lambda Red recombination system is expressed from a plasmid, inducing a hyper-recombinogenic state where electroporated PCR-generated substrates recombine with the bacterial chromosome at high efficiency. The technique can be used to substitute a drug marker for the gene of interest, or used to generate a clean in-frame deletion of the target gene. Single gene knockouts in EHEC, or deletions of whole pathogenicity islands, can be constructed. A procedure for the preparation of hyper-recombinogenic electrocompetent cells is also described. Besides E. coli K-12 and EHEC, this method has also been used for the construction of gene knockouts in enteropathogenic E. coli (EPEC), enteroaggregative E. coli, and uropathogenic E. coli, as well as Shigella flexneri and Salmonella enterica.

Point mutants of EHEC intimin that diminish Tir recognition and actin pedestal formation highlight a putative Tir binding pocket.

Attachment to host cells by enterohaemorrhagic Escherichia coli (EHEC) is associated with the formation of a highly organized cytoskeletal structure containing filamentous actin, termed an attaching and effacing (AE) lesion. Intimin, an outer membrane protein of EHEC, is required for the formation of AE lesions, as is Tir, a bacterial protein that is translocated into the host cell to function as a receptor for intimin. We established a yeast two-hybrid assay for intimin-Tir interaction and, after random mutagenesis, isolated 24 point mutants in intimin, which disrupted Tir recognition in this system. Analysis of 11 point mutants revealed a correlation between recognition of recombinant Tir and the ability to trigger AE lesions. Many of the mutations fell within a 50-residue region near the C-terminus of intimin. Alanine-scanning mutagenesis of this region revealed four residues (Ser890, Thr909, Asn916 and Asn927) that are critical for Tir recognition. Mapping the sequences of EHEC intimin and Tir onto the crystal structure of the intimin-Tir complex of enteropathogenic E. coli predicts that each of these four intimin residues lies at the intimin-Tir interface and contributes to a pocket that interacts with Ile298 of EHEC Tir. Thus, this genetic approach to intimin function both identified residues critical for Tir binding and demonstrated a correlation between the ability to bind Tir and the ability to trigger actin focusing.