Advance care planning at life milestones.

Much progress has been made in advance care planning (ACP), especially related to end of life and palliative care. These advances have moved thinking about ACP from a checklist approach to an upstream recognition that ACP is an iterative process that should begin early in adulthood and be revisited with each milestone or life-changing event. It is recognized that there are many stages and milestones in adult life that contribute to changing loci of responsibility and life goals. These changes impact how individuals view their lives, the complexity of health care, and the myriad of health conditions they may encounter. ACP discussions should routinely be started and reexamined at the time of key life events like starting a career or a marriage and not delayed until hospitalization, the occurrence of a serious accident, or the development of a catastrophic illness.

Nurse competencies for transitions of care: Implications for education and practice.

Although there are a number of transitions of care initiatives that address specific needs as patients move across healthcare settings, adverse events still occur during handoffs. Transitions of care create periods of vulnerability for populations with complex needs that include communication gaps, medication changes, and poorly coordinated treatment plans, often without involving patients and their families. This paper outlines what nurses need to know to provide for safe transitions of care across the healthcare continuum. The theoretical basis for transitions of care at the macro level, examples of nurse-led models for transitions of care, and key activities and implications for nursing education and practice are described. A holistic framework for effective transitions of care across healthcare settings can guide nursing educators in the development of specific nursing competencies for transitions of care.

A Concept Analysis of Transitions of Care for Population Health.

BACKGROUND: Compelling evidence indicates that gaps in quality, safety, and experiences occur when patients encounter transitions across the care continuum. Differences in the organization of healthcare services as well as disparities in health across the globe, may have a unique impact on processes associated with transitions of care for client populations. PURPOSE: Increased attention to the concept of transitions of care has resulted in disparate meanings and lack of clarity about its nature. Therefore, the purpose of this manuscript is to address this knowledge gap by analyzing the concept of transitions of care at the population level. METHODOLOGY: To address the knowledge gap of what constitutes transitions of care at the population level, a concept analysis was done guided by the methodology of Walker and Avant. A comprehensive search of the literature yielded a small but relevant number of publications. RESULTS: This analysis identified four defining attributes, together with antecedents and consequences of transitions of care at the macro-system level of healthcare. A synthesized definition of transitions of care was developed. IMPLICATIONS FOR PRACTICE: This analysis provides conceptual clarity for the concept of transitions of care at the macro-system level of care. It can be used to guide the development of a middle-range theory to inform clinical practice and health policy.

Hospitalized Older Adults With Established Delirium: Recognition, Documentation, and Reporting.

Delirium, a life-threatening complication for hospitalized older adults associated with adverse outcomes, is often underrecognized and underreported. The purpose of the current study was to analyze delirium documentation for hospitalized older adults. Charts of 34 patients, aged 71 and older with documented delirium and referral to a Hospital Elder Life Program, were reviewed. With the exception of International Classification of Diseases-9 coding, delirium was only mentioned in 12 (35.3%) charts, although descriptors potentially indicative of delirium were usually recorded. Of these, the most frequently recorded were confusion (94.1%), mental status change (70.6%), and disorientation (61.8%). When nurses charted delirium descriptors, only 5.9% of their notes included physician referral. Physician responses were to order diagnostic tests and medications, usually antipsychotic or benzodiazepine agents. Of 28 patients requiring transfer to another facility after discharge, delirium was mentioned in only one transfer note. Commonly used delirium descriptors can be used for the development of natural language processing tools for clinical decision support. [Journal of Gerontological Nursing, 43(3), 32-40.].

Mild, moderate, and severe pain in patients recovering from major abdominal surgery.

Pain interferes with various activities, such as coughing, deep breathing, and ambulation, designed to promote recovery and prevent complications after surgery. Determining appropriate cutpoints for mild, moderate, and severe pain is important, because specific interventions may be based on this classification. The purpose of this research was to determine optimal cutpoints for postoperative patients based on their worst and average pain during hospitalization and after discharge to home, and whether the optimal cutpoints distinguished patients with mild, moderate, or severe pain regarding patient outcomes. This secondary analysis consisted of 192 postoperative patients aged ≥60 years. Multivariate analyses of variance were used to stratify the sample into mild, moderate, and severe pain groups using eight cutpoint models for worst and average pain in the last 24 hours. One-way analyses of variance were conducted to determine whether patients experiencing mild, moderate, or severe pain were different in outcome. Optimal cutpoints were similar to those previously reported, with the boundary between mild and moderate pain ranging from 3 to 4 and the boundary between moderate and severe pain ranging from 5 to 7. Worst pain cutpoints were most useful in distinguishing patients regarding fatigue, depression, pain's interference with function, and morphine equivalent administered in the previous 24 hours. A substantial proportion of patients experienced moderate to severe pain. The results suggest a narrow boundary between mild and severe pain that interferes with function. The findings indicate that clinicians should seek to aggressively manage postoperative pain ratings greater than 3.

ANF scholars (1955-2012): stepping stones to a nursing research career.

The American Nurses Foundation (ANF) grant program has been successful in funding nurse researchers' initial research studies for nearly 60 years. (ANF, 2013). From 1955-2012, over 1,000 ANF scholars have been identified through this historical nursing research study. Over the years, obtaining an ANF grant has become increasingly competitive for scholars. The environment supportive of research is evident from the schools that are the top recipients of grants. The ANF has a proud legacy of scholars who have and continue to make contributions to the advancement of nursing science. The paths forged by the ANF scholars illustrate the significant role that small grant programs play in the evolvement of nursing research and the expansion of nursing science.

Using PDAs to detect cognitive change in the hospitalized elderly patient.

The Hospital Elder Life Program (HELP) program is designed to prevent delirium and cognitive decline in the hospitalized elderly patient. Personal digital assistants (PDAs) were trialed in collecting assessment data for the HELP program. Data for a mental status assessment (Mini-Mental Status Examination), delirium assessment (Confusion Assessment Method), and a depression screen for 352 patients enrolled over a 4-month period were collected. Participants had a slight but significant increase in cognitive function. PDAs are a useful adjunct to care enabling the staff to monitor the cognitive status of hospitalized elderly patients and track program outcomes.

A volunteer-based Hospital Elder Life Program to reduce delirium.

A community hospital with nearly 50% of its admitted patients 70 years or older adapted the well-established Hospital Elder Life Program (HELP). The primary adaptation entailed an enhanced participation of trained volunteers in HELP interventions designed to prevent and reduce delirium. Integral program elements include detailed volunteer training, required demonstration of competencies, and regular evaluation and feedback of volunteers provided by program staff. Nurse satisfaction with HELP increased from 64% to 91% in the second year of implementation, and a survey of patients and families indicated that 95% were satisfied with HELP. This innovative volunteer-assisted model of elder care support was positively embraced by patients, their families, and the nursing staff and supported by nursing administration. The use of volunteers is a cost-effective method of enhancing the nursing care of vulnerable elders during hospitalization.

Promoting evidence-based dysphagia assessment and management by nurses.

The Ottawa Model of Research Use guided the Hospital Elder Life Program nursing staff at a community hospital in promoting dysphagia assessment and management. The effect of an educational program and educational outreach on nurses' knowledge retention and nurse-initiated speech language pathology (SLP) referrals were assessed. The sample consisted of 122 nurses. Repeated measures analysis of variance demonstrated significant differences among the pretest and posttests immediately after and at 2 and 6 months later (F[3,70] = 10.126, p < 0.001). Nurses were more likely to initiate SLP referrals after the program. Improving practice requires stakeholder engagement and multiple strategies to sustain change.

Using technology to build community in professional associations.

Professional associations increasingly rely on technology to convene members in the conduct of their business. Principles of adult education can be employed to facilitate the transition to the use of innovative technology. Such innovation can facilitate an association's work in advancing policy and professional practice. Understanding generational differences can enhance the development of community and build social capital in associations.

The right to pain treatment: a reminder for nurses.

Critical care units are frequently the setting for the delivery of end-of-life care. A case study describing pain management for a terminally ill woman in an intensive care unit is used to illustrate conflicts that may be experienced by critical care nurses. The application of standards of professional organizations and regulatory bodies is described, as well as the ethical principles of autonomy, veracity, beneficence, nonmalfeasance, and double effect. Important legal and sociocultural considerations are included.