Training of acute confusion resource nurses. Knowledge, perceived confidence, and role.

Most nurses function as generalists; however, some function in "expert" roles based on informal training as Resource Nurses. Training usually focuses on assessment and management of a specific problem, with the goal of creating a readily available "expert" for every unit. The primary activity of the Resource Nurse is to provide expert care, education, and consultation for patients, families, and staff. The Iowa-Veterans Affairs Nursing Research Consortium (IVANRC) addressed the need to manage acutely confused/delirious clients by training staff nurse volunteers (N = 129) from all units of the four Iowa Veterans Affairs facilities to act as unit-based acute confusion Resource Nurses (ACRNs). A day-long workshop included didactic content addressing etiology and presentation of acute confusion (AC), use of the IVANRC protocol to assess for AC, and basic information on treatment and management of AC. The nurses also participated in an efficacy-based experiential learning program on AC assessment that involved demonstrating assessment of AC and role enactment practice exercises in which ACRNs practiced the assessment. A test of knowledge of AC and perceived level of confidence in assessing acutely confused patients was administered before and after completion of the program. Paired t tests comparing pre- and posttest scores showed that knowledge and confidence significantly increased for the nurses as a result of their participation in the educational program. Eighteen months later, a second program was conducted to update current ACRNs and train additional RNs to enact this role. Pre- and posttest scores were obtained, with paired t tests showing a significant increase in knowledge for the participants. Twenty-four (49%) of the second program attendees had attended the first program. These participants had significantly higher scores on the second program pretest than those participants who had not attended the previous program, indicating a retention of knowledge from the first program.

Acute confusion assessment instruments: clinical versus research usability.

Acute confusion (AC), also referred to as delirium (AC/delirium), is a common problem seen by health professionals who work in a variety of care settings. This is an evaluative report on the clinical usability of instruments to assess AC/delirium as a part of nursing practice. Specifically, five instruments [the Confusion Assessment Method (CAM), Delirium Rating Scale (DRS), Delirium Symptom Inventory (DSI), Mini-Mental State Examination (MMSE), and Neelon/Champagne (NEECHAM) Confusion Scale] are discussed. The work demonstrates how the cooperation of nurses in practice, education, and research can improve both patient and staff outcomes.

Unit-based acute confusion resource nurse: an educational program to train staff nurses.

Despite the high prevalence of acute confusion among elders and the importance of its early detection, there are few reports of systematic efforts to increase staff competence. This article describes the development and evaluation of an 8-hour educational program designed to prepare staff nurses to perform in a new role, the unit-based acute confusion Resource Nurse (ACRN). Pre- and posttest scores were obtained for the 80 registered nurses who participated in the program. Paired t tests showed that knowledge and confidence significantly increased for participants as a result of their participation in the educational program. This program can serve as an effective model for geriatric staff education.

Differentiated nursing assessment of depressive symptoms in community-dwelling elders.

Because of the complexity in assessing elders for depressive symptoms, we recommend that nurses use a differentiated approach as an adjunct to clinical judgment and other assessment strategies. Based on our research and clinical experience, we advocate the joint use of the Hamilton Rating Scale for Depression and the Dementia Mood Assessment Scale, and propose a two-tiered assessment process. The first differentiation in this process is made by means of a cut-off score to determine whether or not depressive symptoms exist. If depressive symptoms are present, a second system of differentiation may be employed to identify discrete symptom factors. Application of this differentiated approach will enable the nurse to better understand and design interventions for each elder's specific presentation of depressive symptoms.

Factor structure of the Hamilton Rating Scale for Depression in a cohort of community-dwelling elderly.

We examined the factor structure of the 17-item Hamilton Rating Scale for Depression (HRS-D) in 206 community-dwelling elderly patients. Using principal components analysis and quartimax rotation, a four-factor structure involving all 17 items and accounting for 57.7% of the variance was desired. The factors represented the following dimensions of depressive symptomatology and illness: depressed affect, vegetative symptoms, anxiety, and agitation/insight. This factor structure reflects the presentation of depressive symptomatology and depressive illness in this population. Findings suggest that the HRS-D can be used for clinical assessment of depressive symptomatology along major dimensions of depressive illness in community-dwelling elderly.

Expanding the scope of continuity theory. Application to gerontological nursing.

Continuity Theory is a psychosocial theory of aging which posits that as middle-aged and elderly adults adapt to changes associated with the normal aging process, their past experiences, decisions, and behaviors will form the foundation for their present and future decisions and behaviors. Regardless of the clinical setting, nurses working with elderly individuals may find Continuity Theory helpful in viewing the experience of elders in a holistic way that incorporates a life course perspective. By applying Continuity Theory to clinical practice, nurses may be better able to provide individualized, clinically appropriate care to elders.

Factor structure of the Dementia Mood Assessment Scale in a cohort of community-dwelling elderly.

We examined the factor structure of the 28-item Dementia Mood Assessment Scale (DMAS), an instrument to assess depressive symptoms in older adults with cognitive impairment, in a cohort of 165 community-dwelling elderly with varying degrees of cognitive impairment. Factor analysis using principal components analysis and varimax rotation was performed to explore the presence of subscales and examine construct validity. A five-factor structure involving all 28 items accounting for 63.2% of the variance in the DMAS scores was derived. Factors were named: Depressed Affect, Environmental Interaction, Diurnal Patterns, Agitation/Suspicion, and Somatic Indicators. This factor structure reflects the often differing presentations of depressive symptoms in older adults with varying degrees of cognitive function and establishes the construct validity of the DMAS in this population. We conclude that the DMAS may be used for differentiated clinical assessment of depressive symptoms along major dimensions of depressive illness in this cohort of elderly.

Care environments for patients with Alzheimer's disease.

Alzheimer's disease creates various demands in terms of community-based and institutional long-term care resources and services needed for patients, caregivers, and families. Nurses play a pivotal role in helping patients, caregivers, and families decide what resources and services are needed. The determinants involved in the decision-making process related to short-term and long-term care options are described. Next, the home, community, and institutional care environments are reviewed. Finally, policy recommendations related to care environments for Alzheimer's patients are discussed.

Reform of primary health care: effective use of advanced practice nurses.

Never before has American society undergone such dramatic and pervasive changes as those currently effecting national health care needs. New strategies to meet the health care needs created by societal changes must be identified. Consumers, employers, providers, and third-party payers are calling for more cost effective health care, better access and better quality. Simultaneously, the United States has a shortage of primary care physicians. While many people claim that one strategy necessary for health care reform is to change the primary care physician/specialty mix of providers, there are some inherent fallacies in this argument. Training for primary care medicine has historically been available; however, the majority of physicians choose specialty practice. The financial rewards are much better in specialty practice than in primary care. If the U.S. were to alter the reward structure and make primary care more attractive to physicians, the objective of controlling costs could not be met. However, there is another alternative and that is to change the provider mix. Since advanced practice nurses (APNs) have a long and successful history of taking care of primary care patients, why not make them the point of first contact? APNs working collaboratively with physicians could more cost effectively manage care for large numbers of ambulatory patients than are being adequately handled at present. APNs, defined as nurse practitioners, certified nurse midwives and clinical nurse specialists, provide high quality, cost effective, and comprehensive primary care services. Increased use of APNs in disease prevention, illness management, and health education is one way of meeting health care needs of Americans. Innovative strategies for more effectively using APNs must also be identified and implemented. Also, artificial and politically imposed barriers to effective utilization of APNs must be removed.

Outpatient psychogeriatric nursing services: an integrative model.

The complex needs of psychogeriatric patients and their families require specialized outpatient psychogeriatric services. The interaction of physical and mental health and the need for coordinated care places important responsibilities on nursing because it contributes to integrated, multidisciplinary care delivery to these patients and their families. This article presents a model of outpatient psychogeriatric nursing services focused on the community integration of patients and families. Experiences in the development of the Geriatric Neuropsychiatry Clinic at the University of Virginia, Charlottesville, are used as the point of departure from which to describe a model of outpatient psychogeriatric nursing care delivery that is multidisciplinary, clinically innovative, and epidemiologically justified.

A theoretical framework for psychiatric nursing practice.

Traditionally, specific theoretical frameworks which are congruent with psychiatric nursing practice have been poorly articulated. The purpose of this paper is to identify and discuss a philosophical base, a theoretical framework, application to psychiatric nursing, and issues related to psychiatric nursing knowledge development and practice. A philosophical framework that is likely to be congruent with psychiatric nursing, which is based on the nature of human beings, health, psychiatric nursing and reality, is identified. Aaron Antonovsky's Salutogenic Model is discussed and applied to psychiatric nursing. This model provides a helpful way for psychiatric nurses to organize their thinking processes and ultimately improve the health care services that they offer to their clients. Goal setting and nursing interventions using this model are discussed. Additionally, application of the use of Antonovsky's model is made to nursing research areas such as hardiness, uncertainty, suffering, empathy and literary works. Finally, specific issues related to psychiatric nursing are addressed.