Evaluating the benefits of a live, simulation-based telebehavioral health training for a deploying army reserve unit.

Telebehavioral health (TBH) has previously been reported as underutilized in the Afghan Theater of Operations despite efforts to expand the number of operational TBH sites. A lack of training on TBH services and equipment was identified as a probable cause. The National Center for Telehealth and Technology (T2) provided members of the 1972nd Medical Detachment (Combat Stress Control [CSC]) U.S. Army Reserve with an in-person TBH training designed to provide the unit with hands-on knowledge and skills to deliver TBH services in theater. A key training component consisted of placing unit members in live, simulated clinical and technical scenarios they were likely to encounter while deployed. Evaluations suggest that the training was successful at preparing the 1972nd CSC for its TBH mission. During its deployment, the 1972nd CSC led an approximate 40% expansion of TBH services, including the direct provision of around 700 clinical encounters. Several best practice recommendations were identified including: (1) maintain the hands-on component, (2) use lessons learned to develop scenarios, (3) incorporate training into daily activities, and (4) tailor training while ensuring that all stakeholders have the same base knowledge set. To our knowledge, this is the most comprehensive process improvement evaluation of a predeployment telehealth training available.

A longitudinal analysis of nursing specialty certification by Magnet® status and patient unit type.

The objective of this study was to examine nursing specialty certification trends by Magnet® status and unit type. Research exploring organizational and unit attributes associated with higher specialty certification rates is timely given the beginning evidence that certification is associated with lower patient adverse events. The sample included 6047 units in 1249 National Database of Nursing Quality Indicators hospitals. Hierarchical linear modeling was used to predict growth in percentage of specialty-certified RNs within each unit type and Magnet status. Data (Bayesian Information Criteria = 224 583.30) demonstrated significant growth in specialty certification rates over time (P < .0001). Magnet-designated organizations had significantly different starting certification rates (P = .0002) and rates of change (P = .0002). Unit types also had significantly different starting certification rates (P < .0001) and different rates of change (P < .0001). Magnet recognition is associated with increases in specialty certification rates. Certification rates have risen faster in unit types such as pediatric critical care than in unit types such as adult step-down and adult surgical.

A multilevel confirmatory factor analysis of the Practice Environment Scale: a case study.

BACKGROUND: Practice Environment Scale (PES) data are collected from RNs in nursing units in hospitals that are members of the National Database of Nursing Quality Indicators (NDNQI). Patient and RN information are collected to aid in quality improvement and research at the nursing unit level. The data were collected from the individual RN, but items are worded so that analyses can be conducted at the individual, unit, or hospital level. There is a need to examine the validity of the PES at both the individual and the unit level. OBJECTIVE: To describe multilevel confirmatory factor analysis via a case study for investigating the validity of the PES, a measure of the nursing practice environment. APPROACH: The PES was administered to 72,889 RNs from 4,783 nursing units (16 unit types; e.g., critical care and obstetric) in 2007. The PES has 31 items in five different domains. A multilevel confirmatory factor analytic model was fit with a structure on the basis of the five domains. From this model, an estimate was sought between unit loadings and within unit loadings to investigate factorial, convergent, and discriminant validity at both the unit and the RN levels. To investigate criterion-related validity, the five PES domains were correlated with the seven job enjoyment items adapted from the National Database of Nursing Quality Indicators at the unit and RN levels (also using a multilevel model). RESULTS: The multilevel factor analysis provides evidence of factorial, convergent, discriminant, and criterion-related validity at both the unit and the RN levels. DISCUSSION: The PES is a valid instrument for use in quality improvement and research both at the unit and individual RN levels.

Predictors of exercise and effects of exercise on symptoms, function, aerobic fitness, and disease outcomes of rheumatoid arthritis.

OBJECTIVE: To determine the effects of participation in a low-impact aerobic exercise program on fatigue, pain, and depression; to examine whether intervention groups compared with a control group differed on functional (grip strength and walk time) and disease activity (total joint count, erythrocyte sedimentation rate, and C-reactive protein) measures and aerobic fitness at the end of the intervention; and to test which factors predicted exercise participation. METHODS: A convenience sample of 220 adults with rheumatoid arthritis (RA), ages 40-70, was randomized to 1 of 3 groups: class exercise, home exercise using a videotape, and control group. Measures were obtained at baseline (T1), after 6 weeks of exercise (T2), and after 12 weeks of exercise (T3). RESULTS: Using structural equation modeling, overall symptoms (latent variable for pain, fatigue, and depression) decreased significantly at T3 (P < 0.04) for the class exercise group compared with the control group. There were significant interaction effects of time and group for the functional measures of walk time and grip strength: the treatment groups improved more than the control group (P

Unit type differences in RN workgroup job satisfaction.

Using cross-sectional data from the 2004 National Database of Nursing Quality Indicators (NDNQI) RN Satisfaction Survey, differences in RN workgroup job satisfaction were examined among 10 unit types--medical-surgical, step-down, critical care, pediatric, maternal-newborn, psychiatric, emergency department, rehabilitation, surgical services, and outpatient clinics and labs. The national sample included RN workgroups in 2,900 patient care units (55,516 RNs; 206 hospitals in 44 states). Workgroup satisfaction across all unit types was moderate. RN workgroups in pediatric units were the most satisfied, whereas those in surgical services and emergency department unit types were least satisfied. A consistent finding across all unit types was high satisfaction with the specific domains of nurse-to-nurse interaction, professional status, and professional development versus much lower satisfaction with task, decision making, and pay. Findings can be used to inform and develop investigations that examine specific aspects of the work environment for RN workgroups in various unit types.

Communication and end-of-life care in the intensive care unit: patient, family, and clinician outcomes.

Even though good communication among clinicians, patients, and family members is identified as the most important factor in end-of-life care in ICUs, it is the least accomplished. According to accumulated evidence, communication about end-of-life decisions in ICUs is difficult and flawed. Poor communication leaves clinicians and family members stressed and dissatisfied, as well as patients' wishes neglected. Conflict and anger both among clinicians and between clinicians and family members also result. Physicians and nurses lack communication skills, an essential element to achieve better outcomes at end of life. There is an emerging evidence base that proactive, multidisciplinary strategies such as formal and informal family meetings, daily team consensus procedures, palliative care team case finding, and ethics consultation improve communication about end-of-life decisions. Evidence suggests that improving end-of-life communication in ICUs can improve the quality of care by resulting in earlier transition to palliative care for patients who ultimately do not survive and by increasing family and clinician satisfaction. Both larger, randomized controlled trials and mixed methods designs are needed in future work. In addition, research to improve clinician communication skills and to assess the effects of organizational and unit context and culture on end-of-life outcomes is essential.

Correlates of falls and fear of falling among adults with rheumatoid arthritis.

OBJECTIVE: To identify correlates of falling and fear of falling, and to examine how fear of falling affects activities among adults with rheumatoid arthritis (RA). METHODS: Adults (mean age 54.2 years; SD 9.1) with RA (n = 128) responded to questions related to falls, fear of falling, and activities modified. Other measures included the Profile of Mood States Short Form, the McGill Pain Questionnaire Short Form, walk time, grip strength, predicted maximum oxygen uptake, and joint count. RESULTS: Thirty-five percent of participants fell during the previous year. Subjects who fell had more comorbid conditions than subjects who did not fall. Almost 60% were fearful of falling. Compared with subjects who denied fear of falling, fearful subjects had longer walk times, more comorbid conditions, and more intense pain. Activities affected most by fear of falling involved heavy work and climbing. CONCLUSIONS: The number of comorbid conditions plays an important role in falling and fear of falling in adults with RA. Knowledge of this and other factors, such as pain intensity and functional status, can facilitate appropriate interventions.