Creating a Research Agenda and Setting Research Priorities for Clinical Nurse Specialists.

PURPOSE/OBJECTIVES: The purpose of this article is to describe the evolution and results of the process for establishing a research agenda and identification of research priorities for clinical nurse specialists, approved by the National Association of Clinical Nurse Specialists (NACNS) membership and sanctioned by the NACNS Board of Directors. DESCRIPTION OF THE PROJECT/PROGRAM: Development of the research agenda and identification of the priorities were an iterative process and involved a review of the literature; input from multiple stakeholders, including individuals with expertise in conducting research serving as task force members, and NACNS members; and feedback from national board members. OUTCOME: A research agenda, which is to provide an enduring research platform, was established and research priorities, which are to be applied in the immediate future, were identified as a result of this process. CONCLUSION: Development of a research agenda and identification of research priorities are a key method of fulfilling the mission and goals of NACNS. The process and outcomes are described in this article.

Family Members' and Intensive Care Unit Nurses' Response to the ECG Memento© During the Bereavement Period.

BACKGROUND: In the United States, 20% of patients die in the intensive care unit (ICU), yet little is known about bereavement strategies to aid grieving families. OBJECTIVE: The primary aim was to study the bereavement experience for families in the ICU; secondary aim was to measure nurses' perception of end-of-life care, and a third was to evaluate the impact of the ECG Memento by families and nurses. METHODS: A prospective, descriptive study design was used, with a postsurvey methodology. Fifty ICU patient families agreed to participate, although only 28 returned the Satisfaction With Bereavement Experience Questionnaire. In addition, 38 of 100 eligible nurses completed the Quality of Dying and Death in the Intensive Care Unit survey. RESULTS: The Satisfaction With Bereavement Experience Questionnaire data showed families as highly satisfied with hospital (mean, 1.5), personal (mean, 1.6), ritual (mean, 1.3), and posthospital experiences (mean, 1.9). Quality of Dying and Death in the Intensive Care Unit results indicated that ideal control of patients' symptoms was reported by only 26% of nurses surveyed. Half of the families reported that the death was unexpected. Families (86%) responded positively to the ECG Memento, and according to 98% of the nurses, the ECG Memento was very well received. DISCUSSION: Despite most families reporting high satisfaction with the bereavement experience, nurses reported a low level of patient symptom control; also, families often found the death to be unexpected. This suggests that the bereavement experience is a complex process requiring nurses to implement various interventions during this vulnerable period. Most families responded positively to this novel bereavement tool, which may aid families as they transition from anticipatory grieving to bereaved status. Further studies are needed to evaluate the ECG Memento as an innovation on a wider scale and to develop additional interventions to positively impact the grieving process for families.

Five-Layered Soft Silicone Foam Dressing to Prevent Pressure Ulcers in the Intensive Care Unit.

BACKGROUND: In critically ill patients, prevention of pressure ulcers is a challenge because of the high risk for multiple comorbid conditions, immobility, hemodynamic instability, and increased use of medical devices. OBJECTIVES: To compare the difference in incidence rates of hospital-acquired pressure ulcers (HAPUs) in critically ill patients between those treated with usual preventive care and a 5-layered soft silicone foam dressing versus a control group receiving usual care. Secondary goals were to examine risk factors for HAPUs in critically ill patients and to explicate cost savings related to prevention of pressure ulcers. METHODS: A prospective, randomized controlled trial in the intensive care units at a 569-bed, level II trauma hospital. All 366 participants received standard pressure ulcer prevention; 184 were randomized to have a 5-layered soft silicone foam dressing applied to the sacrum (intervention group) and 182 to receive usual care (control group). RESULTS: The incidence rate of HAPUs was significantly less in patients treated with the foam dressing than in the control group (0.7% vs 5.9%, P = .01). Time to injury survival analysis (Cox proportional hazard models) revealed the intervention group had 88% reduced risk of HAPU development (hazard ratio, 0.12 [95% CI, 0.02-0.98], P = .048). CONCLUSION: Use of a soft silicone foam dressing combined with preventive care yielded a statistically and clinically significant benefit in reducing the incidence rate and severity of HAPUs in intensive care patients. This novel, cost-effective method can reduce HAPU incidence in critically ill patients.

Moral distress and intention to leave: A comparison of adult and paediatric nurses by hospital setting.

OBJECTIVES: To assess moral distress intensity and frequency in adult/paediatric nurses in critical care and non-critical care units; and explore relationships of nurse characteristics and moral distress with intention to leave. METHODS/SETTING: A descriptive, correlational design was used to administer an online survey using the Moral Distress Scale to nurses across multiple settings. MAIN OUTCOME MEASURES: Intensity and frequency of moral distress and intention to leave current position. RESULTS: The survey response rate was 43% (n=426/1000). Critical care nurses had the highest levels of moral distress intensity and frequency, compared to non-critical care specialties (M=2.5±0.19, p=0.005 for intensity and M=1.6±0.11, p<0.001 for frequency). Moral distress frequency showed a positive relationship with intention to leave a position of employment. Each unit increase in moral distress frequency doubled the odds of intention to leave when adjusting for age, gender, ethnicity and specialty area (p=0.003). Hispanic nurses had significantly higher levels of moral distress intensity (p=0.01). CONCLUSION: Moral distress is a complex phenomenon requiring further study, particularly with regard to the role of ethnic and cultural differences on perceptions of moral distress.

Improving End-of-Life Care Prognostic Discussions: Role of Advanced Practice Nurses.

Research has validated the desire of patients and families for ongoing prognostic information; however, few conversations occur before patients reach the advanced stages of their disease trajectory. Physician hesitance and delay in discussing unfavorable prognoses deny patients and families optimal time to prepare for critical decision making. Advanced practice registered nurses can play a crucial, complementary role with the critical care interdisciplinary team to implement strategies to improve communication about prognosis and end of life with patients and families. Clinicians should discuss deterioration in disease-specific characteristics and changes (decline) in functional status. Functional status can serve as an accurate guide for forecasting prognosis, particularly in patients with heart failure, stroke, chronic lung disease, and end-stage renal disease. This article provides an overview of effective intensive care unit prognostic systems and discusses barriers and opportunities for nurses to use evidence-based knowledge related to disease trajectory and prognosis to improve communication and the quality of palliative and end-of-life care for patients.

Withdrawal of cardiac medications and devices.

Withdrawal of life-sustaining therapies such as cardiac medications, pacemakers, internal cardioverter defibrillators, and ventricular assist devices occurs in patients with advanced cardiac disease as goals of treatment transition from active to less aggressive. This article defines life-sustaining therapies and describes ethical and legal considerations related to withdrawal of cardiac medications and cardiac devices. Healthcare providers need to anticipate clinical situations in which implantable cardiac devices and medications are no longer desired by patients and/or are no longer medically appropriate. Discussions are important between patients, families, and healthcare providers that focus on each patient's condition, prognosis, advance directives, goals of care, and treatment options. Critical care nurses support each patient and his or her family and work with other members of the healthcare team to achieve a peaceful death.