The effect of clinical nursing instructors on student self-efficacy.

Clinical practicum experiences for nursing students provides the students an opportunity to apply concepts learned in class, practice skills learned in lab, and interact with patients, families, and other nurses. Although students look forward to these experiences, they often feel intimated and anxious about them. Clinical instructors play an important role in this experience and can either help or hinder student learning and self-efficacy. Using Bandura's Social Learning Theory as foundation, this descriptive study examined the relationship between perceived instructor effectiveness and student self-efficacy. Data were collected from a BSN school of nursing at a Midwestern USA comprehensive masters university. The instruments used were the Nursing Clinical Teacher Effectiveness Inventory (NCTEI) and the student self-efficacy (SSE) questionnaire. Participants (n = 236) were from a traditional nursing program with 86% female and 14% male. Data was analyzed using Pearson's correlation and MANCOVA. Results indicated: Out of the five areas of attributes, one area showed significant (p < .01) difference between the lower and higher self-efficacy groups and with specific teacher behaviors within the Evaluation category. Students with high self-efficacy reported faculty who suggested ways to improve, identified strengths and weaknesses, observed frequently, communicated expectations, gives positive reinforcement ad corrects without belittling. This can help faculty develop behaviors that increases student learning and student self-efficacy.

Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experience.

OBJECTIVE: To analyze postoperative outcomes, morbidity, and mortality following enterocutaneous fistula (ECF) takedown. DESIGN, SETTING, AND PATIENTS: Retrospective review of the complete medical records of patients who presented to a single tertiary care referral center from December 24, 1987, to June 18, 2010, and subsequently underwent definitive surgical treatment for ECF originating from the stomach, small bowel, colon, or rectum. MAIN OUTCOME MEASURES: Postoperative fistula recurrence and mortality. RESULTS: A total of 153 patients received operative intervention for ECF. Most ECFs were referred to us from outside institutions (75.2%), high output (52.3%), originating from the small bowel (88.2%), and iatrogenic in cause (66.7%). Successful ECF closure was ultimately achieved in 128 patients (83.7%). Six patients (3.9%) died within 30 days of surgery, and overall 1-year mortality was 15.0%. Postoperative complications occurred in 134 patients, for an overall morbidity rate of 87.6%. Significant risk factors for fistula recurrence were numerous, but postoperative ventilation for longer than 48 hours, organ space surgical site infection, and blood transfusion within 72 hours of surgery carried the most considerable impact (relative risks, 4.87, 4.07, and 3.91, respectively; P < .05). Risk of 1-year mortality was also associated with multiple risk factors, the most substantial of which were postoperative pulmonary and infectious complications. Closure of abdominal fascia was protective against both recurrent ECF and mortality (relative risks, 0.47 and 0.38, respectively; P < .05). CONCLUSIONS: Understanding risk factors both associated with and protective against ECF recurrence and postoperative morbidity and mortality is imperative for appropriate ECF management. Closure of abdominal fascia is of utmost importance, and preventing postoperative complications must be prioritized to optimize patient outcomes.

Impact of operative duration on postoperative pulmonary complications in laparoscopic versus open colectomy.

BACKGROUND: Prolonged operative duration is associated with increased postoperative morbidity and mortality. Although laparoscopic colectomy (LC) is associated with longer operative duration compared with open colectomy (OC), research shows paradoxically decreased morbidity following LC versus OC. The direct impact of operative duration on postoperative pulmonary complications (PPC) following LC versus OC has not been analyzed. METHODS: We queried the ACS/NSQIP 2009-2010 Public Use File for patients who underwent elective LC and OC. The associations between operative duration and a PPC (pneumonia, intubation >48 h, and unplanned intubation) were evaluated. Multivariable regression models were created to determine the independent effect of operative time on the development of PPC controlling for LC versus OC. RESULTS: A total of 25,419 colectomies (13,741 laparoscopic and 11,678 open) were reviewed; 765 (3 %) patients experienced at least one PPC. Regression modeling demonstrated that for both LC and OC each 60-min increase in operative time up to 480 min was associated with 13 % increased odds of PPC [odds ratio (OR) 1.13; 95 % confidence interval (CI) 1.07-1.19]. Beyond 480 min, each additional 60-min interval was associated with 33 % increased risk of PPC (OR 1.33; 95 % CI 1.12-1.58). Overall, PPCs occurred half as often following LC [270 (2 %) laparoscopic vs. 497 (4.3 %) open; OR 0.45; 95 % CI 0.39-0.53]. CONCLUSIONS: Operative duration is independently associated with increased risk of PPC in patients undergoing LC and OC. However, a laparoscopic approach carries half the absolute risk of PPC and, when safe, should be preferentially utilized despite a potential for prolonged operative duration.

Routine intraoperative frozen section analysis of bronchial margins is of limited utility in lung cancer resection.

BACKGROUND: Residual disease at the bronchial margin after resection of non-small cell lung cancer (NSCLC) adversely affects survival. To ensure an R0 resection, thoracic surgeons commonly use intraoperative frozen section analysis of the bronchial margin. We hypothesize that frozen section of the bronchial margin is rarely positive and seldom changes intraoperative management. METHODS: Our institutional Society of Thoracic Surgery database was queried for all patients undergoing planned lobectomy for NSCLC from 2009 to 2011. Clinical variables, intraoperative data, and postoperative outcomes were reviewed. Specifically, intraoperative frozen section and final pathology results of all bronchial margins were examined. The frequency that frozen section results affected intraoperative decision making was evaluated. RESULTS: A total of 287 lobectomies for NSCLC were performed. Frozen section of the bronchial margin was performed in 270 patients (94.1%). There were 6 (2.2%) true-positive bronchial margins and 1 (0.4%) false-negative margin. In no cases did a positive frozen section lead to a change in operative management; reasons included unable to tolerate further resection (n = 5) and advanced-stage disease (n = 1). Positive margins were more frequent with open techniques (7%) than in video-assisted thoracoscopic operations (0.05%; p < 0.01). Tumors with positive margins were closer to the bronchial margin (1.0 vs 2.5 cm; p = 0.04). Frozen section was not used in 17 patients (5.9%), and none had positive margins on final pathology. CONCLUSIONS: Frozen section analysis of the bronchial margin rarely yields a positive result and infrequently changes intraoperative management in patients undergoing NSCLC resection. These data support selective use of intraoperative frozen section of bronchial margins during lobectomy for NSCLC.

Pneumonectomy for benign disease: analysis of the early and late outcomes.

OBJECTIVES: To analyse the indications, operative techniques, postoperative morbidity, mortality and long-term outcomes of patients who underwent pneumonectomy for benign lung disease. METHODS: We retrospectively reviewed our institutional database for patients who underwent a pneumonectomy for benign lung disease from January 1991 to June 2010. The data were queried for the indications for surgery, details of operative technique, development of perioperative complications, mortality and long-term survival. RESULTS: There were 32 patients, 19 men (59%) and 13 women, with a mean age of 48 years (17-78). Indications for pneumonectomy included pulmonary tuberculosis in 10 patients (31%), chronic septic lung disease in seven (22%), invasive opportunistic infections in five (16%), fibrosing mediastinitis in four (12%) and other in six (19%). Pneumonectomies were left-sided in 17 (53%) and right-sided in 15 patients; nine (28%) were completion pneumonectomies. Intraoperatively, intrapericardial isolation was performed in 21 (66%) patients and extrapleural dissection in seven (22%); bronchial reinforcement was performed in 25 (78%). Operative mortality occurred in two (6%) patients. Major complications occurred in 12 (38%) patients; no patient developed bronchopleural fistula or postpneumonectomy empyema requiring intervention. Overall 5-year survival was 75% (95% CI 56.2-87.9), with a mean follow-up of 99 months. CONCLUSIONS: Pneumonectomy for benign disease is a high-risk procedure performed for a variety of indications. A detailed operative technique is of the utmost importance to minimize postoperative morbidity and mortality. Despite an increased perioperative risk, the long-term outcomes can be especially satisfactory. Pneumonectomy for benign disease should continue to be a treatment option for carefully selected patients.

Impact of surgical care improvement project inf-9 on postoperative urinary tract infections: do exemptions interfere with quality patient care?

BACKGROUND: The Surgical Care Improvement Project (SCIP) Inf-9 guideline promotes removal of indwelling urinary catheters (IUCs) within 48 hours of surgery. OBJECTIVES: To determine whether a correlation exists between SCIP Inf-9 compliance and postoperative urinary tract infection (UTI) rates and whether an association exists between UTI rates and SCIP Inf-9 exemption status. DESIGN Retrospective case control study. SETTING: Southeastern academic medical center. PATIENTS: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and SCIP Inf-9 compliance data were collected prospectively on randomly selected general and vascular surgery inpatients. Monthly UTI rates and SCIP Inf-9 compliance scores were tested for correlation. Complete NSQIP data for all the inpatients with postoperative UTIs were compared with a group of 100 random controls to determine whether an association exists between UTI rates and SCIP Inf-9 exemption status. MAIN OUTCOME MEASURE: Postoperative UTI. RESULTS: In 2459 patients reviewed, SCIP Inf-9 compliance increased over time, but this was not correlated with improved monthly UTI rates. Sixty-one of the 69 UTIs (88.4%) were compliant with SCIP Inf-9; however, 49 (71.0%) of these were considered exempt from the guideline and, therefore, the IUC was not removed within 48 hours of surgery. Retrospective review of 100 random controls showed a similar compliance rate (84.0%, P = .43) but a lower rate of exemption (23.5%, P < .001). The odds of developing a postoperative UTI were 8 times higher in patients deemed exempt from SCIP Inf-9 (odds ratio [OR], 7.99; 95% CI, 3.85-16.61). After controlling for differences between the 2 groups, the adjusted ORs slightly increased (OR, 8.34; 95% CI, 3.70-18.76). CONCLUSIONS: Most UTIs occurred in patients deemed exempt from SCIP Inf-9. Although compliance rates remain high, practices are not actually improving. Surgical Care Improvement Project Inf-9 guidelines should be modified with fewer exemptions to facilitate earlier removal of IUCs.

Risk factors for 30-day hospital readmission among general surgery patients.

BACKGROUND: Hospital readmission within 30 days of an index hospitalization is receiving increased scrutiny as a marker of poor-quality patient care. This study identifies factors associated with 30-day readmission after general surgery procedures. STUDY DESIGN: Using standard National Surgical Quality Improvement Project protocol, preoperative, intraoperative, and postoperative outcomes were collected on patients undergoing inpatient general surgery procedures at a single academic center between 2009 and 2011. Data were merged with our institutional clinical data warehouse to identify unplanned 30-day readmissions. Demographics, comorbidities, type of procedure, postoperative complications, and ICD-9 coding data were reviewed for patients who were readmitted. Univariate and multivariate analysis was used to identify risk factors associated with 30-day readmission. RESULTS: One thousand four hundred and forty-two general surgery patients were reviewed. One hundred and sixty-three (11.3%) were readmitted within 30 days of discharge. The most common reasons for readmission were gastrointestinal problem/complication (27.6%), surgical infection (22.1%), and failure to thrive/malnutrition (10.4%). Comorbidities associated with risk of readmission included disseminated cancer, dyspnea, and preoperative open wound (p < 0.05 for all variables). Surgical procedures associated with higher rates of readmission included pancreatectomy, colectomy, and liver resection. Postoperative occurrences leading to increased risk of readmission were blood transfusion, postoperative pulmonary complication, wound complication, sepsis/shock, urinary tract infection, and vascular complications. Multivariable analysis demonstrates that the most significant independent risk factor for readmission is the occurrence of any postoperative complication (odds ratio = 4.20; 95% CI, 2.89-6.13). CONCLUSIONS: Risk factors for readmission after general surgery procedures are multifactorial, however, postoperative complications appear to drive readmissions in surgical patients. Taking appropriate steps to minimize postoperative complications will decrease postoperative readmissions.