Search

Background Blended learning (BL), the combining of face-to-face and online learning, is gaining prominence in nursing education in response to advances in evidence-based learning using technology, the diverse and evolving needs of nursing learners, and unpredictable events impacting nursing education. Problem Blended learning requires nursing learners and educators to adapt to new modalities and educators to re-envision learning environments. However, BL lacks an educational framework to guide implementation and is not well explored in the nursing literature. Approach Universal design for learning (UDL) is applied as a framework for BL in nursing education. Conclusions Universal design for learning provides a framework for BL to enable nursing educators, learners, and educational institutions to reimagine teaching and learning in novel ways that incorporate emerging evidence and address new challenges. Blended learning, within the context of UDL, offers opportunities for diverse and inclusive learning. Research is needed to guide the implementation of BL best practices within a UDL framework.

Background Many patients with American College of Cardiology/American Heart Association Stage D (advanced) heart failure are discharged home on chronic intravenous inotropic support (CIIS) as bridge to surgical therapy or as palliative therapy. This study analyzed the clinical trajectory of patients with advanced heart failure who were on home CIIS. Methods We conducted a single-institution, retrospective cohort study of patients on CIIS between 2010 and 2016 (n = 373), stratified by indication for initiation of inotropic support. Study outcomes were time from initiation of CIIS to cessation of therapy, time to death for patients who did not receive surgical therapy and rates of involvement with palliative care. Results Overall, patients received CIIS therapy for an average of 5.9 months (standard deviation [SD] 7.3). Patients on CIIS as palliative therapy died in an average of 6.2 months (SD 6.6) from the time of initiation of CIIS, and those on CIIS as bridge therapy who did not ultimately receive surgical therapy died after an average of 8.6 months (SD 9.3). Patients who received CIIS as bridge therapy were significantly less likely to receive palliative-care consultation than those on inotropes as palliative therapy, whether or not they underwent surgery. Conclusions In this large cohort of patients with advanced HF, patients who on CIIS as palliative therapy survived for 6.2 months, on average, with wide variation among patients. Patients who were on CIIS as bridge therapy but did not ultimately receive surgical therapy received less palliative care despite the high mortality rate in this subgroup.

Caring for terminally ill patients can be emotionally burdensome. Previous research has demonstrated that caregiving is associated with anxiety and depression. Research on caregivers of terminally ill patients is limited by retrospective studies with small samples. This study aimed to (1) describe religiosity, religious coping, and depressive symptoms in caregivers of persons with amyotrophic lateral sclerosis or advanced cancer; (2) examine the relationship between religiosity and depressive symptoms in caregivers of persons with amyotrophic lateral sclerosis or advanced cancer; (3) examine the relationship between religious coping and depressive symptoms in caregivers of persons with amyotrophic lateral sclerosis or advanced cancer. A descriptive exploratory design was used to analyze data from a larger 5-year National Institutes of Health-funded multisite randomized controlled trial (the TAILORED study). Nearly half of the caregivers screened positive for depressive symptoms, and negative religious coping was associated with higher depressive symptoms (P < .001). Spouse caregivers reported higher depressive symptoms than nonspouse caregivers. Many caregivers experienced depression, which was mitigated by positive religious coping.

There is an expanding body of research on the bidirectional relationship of the human gut microbiome and cardiovascular disease, including heart failure (HF). Researchers are examining the microbiome and gut metabolites, primarily trimethylamine-N-oxide (TMAO), to understand clinically observed outcomes. This systematic review explored the current state of the science on the evaluation and testing of the gut biome in persons with HF. Using electronic search methods of Medline, Embase, CINAHL, and Web of Science, until December 2021, we identified 511 HF biome investigations between 2014 and 2021. Of the 30 studies included in the review, six were 16S rRNA and nineteen TMAO, and three both TMAO and 16S rRNA, and two bacterial cultures. A limited range of study designs were represented, the majority involving single cohorts (n = 10) and comparing individuals with HF to controls (n = 15). Patients with HF had less biodiversity in fecal samples compared to controls. TMAO is associated with age, BNP, eGFR, HF severity, and poor outcomes including hospitalizations and mortality. Inconsistent across studies was the ability of TMAO to predict HF development, the independent prognostic value of TMAO when controlling for renal indices, and the relationship of TMAO to LVEF and CRP. Gut microbiome dysbiosis is associated with HF diagnosis, disease severity, and prognostication related to hospitalizations and mortality. Gut microbiome research in patients with HF is developing. Further longitudinal and multi-centered studies are required to inform interventions to promote clinical decision-making and improved patient outcomes.

The global prevalence of heart failure (HF) is increasing. Advancements in guideline-directed medical and device therapy have resulted in improved survival. Thus, there are more patients living - and living longer - with advanced HF. Only a small proportion of these patients are deemed appropriate for advanced surgical intervention (mechanical circulatory support or heart transplantation), and even if offered, some may decline such interventions if not aligned with their overall goals and values. Therefore, a growing number of patients with advanced HF receive chronic intravenous inotropic support (CIIS) for palliation of symptoms. Despite increased use, clinical evidence supporting use of palliative inotropes remains limited. However, available data suggest improvements in functional class, health-related quality of life (HRQoL) indicators, symptom burden, hemodynamic parameters, and possibly rehospitalization. While initial concerns regarding increased mortality have been assuaged in the modern era of guideline-directed medical therapy, palliative inotropes are certainly not without burden. Risks of infection and medication-related adverse effects, need for routine laboratory monitoring, frequent dressing changes, and presence of a reliable caregiver must be carefully considered prior to initiation. This review addresses pharmacology, guideline recommendations, benefits and burdens, considerations related to hospice and end-of-life care, and future directions of CIIS in advanced HF care.

Background To identify 30-day rehospitalizations in patients discharged with heart failure (HF) based on clinical indications, physiologic measures and symptoms. Methods Fifty-six patients with heart failure participated. After discharge to home, clinical indicators of dyspnea, fatigue, orthopnea, dyspnea with exertion, daily weight, edema, heart rate, blood pressure, mental condition, medication adherence, and overall well-being were reported by participants daily for up to 30 days. Results Joint modeling of longitudinal and time-to-event approach was applied to assess the association of readmission with longitudinal measurements. There was no association between demographic, physiological, or laboratory variables and re-hospitalization within 30 days post discharge. Perceptions of dyspnea (p = .012) and feeling unwell (p < .001) were associated with rehospitalization. Patients struggling to breath were 10.7 times more likely to be readmitted than those not struggling to breath. Conclusion Perceived measures, particularly dyspnea and feeling unwell were more important factors than demographic, physiological, or laboratory parameters in predicting 30-day rehospitalizations in this racially diverse cohort. The symptomatic experience of heart failure is an important indicator of rehospitalization.

Individuals with heart failure (HF) have difficulty evaluating their symptoms, understanding when to seek health care, and implementing self-care activities. The purpose of this qualitative study was to inform the development of a heart failure action plan (HFAP) for individuals living with HF. This study used a prospective, descriptive qualitative design with a content analysis approach. The HFAP included clinical indicators of self-reported symptoms, adherence to medication regimen, and physiologic changes. Patients with HF reviewed the HFAP and provided their perceptions to assist in developing the action plan. Participants had a mean age of 65 years, predominately male (78%) and African American (89%). Comorbidities included hypertension, atrial fibrillation, chronic kidney disease, ischemic heart disease, valvular heart disease, and diabetes mellitus. Five thematic categories emerged: (1) Understanding of symptoms and symptom severity, (2) management of symptoms, (3) educational opportunities, (4) changes, and (5) satisfaction. Participants suggested adding content about exercise, diet, additional symptom management, and a compact portable HFAP. Participants provided their perceptions of the HFAP. Their feedback was instrumental in modifying the action plan for use in a broader HF patient population to assist patients in self-management, including the understanding of when to seek health care.

Background Heart failure (HF) is a serious health condition, associated with high health care costs, and poor outcomes. Patient empowerment and self-care are a key component of successful HF management. The emergence of telehealth may enable providers to remotely monitor patients’ statuses, support adherence to medical guidelines, improve patient wellbeing, and promote daily awareness of overall patients’ health. Objective To assess the feasibility of a voice activated technology for monitoring of HF patients, and its impact on HF clinical outcomes and health care utilization. Methods We conducted a randomized clinical trial; ambulatory HF patients were randomized to voice activated technology or standard of care (SOC) for 90 days. The system developed for this study monitored patient symptoms using a daily survey and alerted healthcare providers of pre-determined reported symptoms of worsening HF. We used summary statistics and descriptive visualizations to study the alerts generated by the technology and to healthcare utilization outcomes. Results The average age of patients was 54 years, the majority were Black and 45% were women. Almost all participants had an annual income below $50,000. Baseline characteristics were not statistically significantly different between the two arms. The technical infrastructure was successfully set up and two thirds of the invited study participants interacted with the technology. Patients reported favorable perception and high comfort level with the use of voice activated technology. The responses from the participants varied widely and higher perceived symptom burden was not associated with hospitalization on qualitative assessment of the data visualization plot. Among patients randomized to the voice activated technology arm, there was one HF emergency department (ED) visit and 2 HF hospitalizations; there were no events in the SOC arm. Conclusions This study demonstrates the feasibility of remote symptom monitoring of HF patients using voice activated technology. The varying HF severity and the wide range of patient responses to the technology indicate that personalized technological approaches are needed to capture the full benefit of the technology. The differences in health care utilization between the two arms call for further study into the impact of remote monitoring on health care utilization and patients’ wellbeing.

Background Faculty in Doctor of Nursing Practice (DNP) programs identify challenges of increased enrollment and variances in previous student educational preparation and professional experiences that require innovative approaches to curriculum transformation. Purpose This article informs nurse educators about the vibrant and inclusive approach of universal design for instruction (UDI), a framework to conceptualize and implement learning strategies in the DNP curriculum. Approach UDI is guided by 9 instructional principles that anticipate diverse learners and is intentionally inclusive of multiple ways of learning. Principles of UDI were synergized into several DNP didactic courses and the scholarly project process. Conclusion Integration of UDI into the DNP curriculum included precourse assessments, multiple modalities of content delivery, options to present acquired knowledge, and supporting the adult learner through the iterative work of the scholarly project.

Background: Educating Doctor of Nursing Practice (DNP) students for an increasingly complex health care environment requires novel applications of learning concepts and technology. A deliberate and thoughtful process is required to integrate concepts of the DNP program into practice paradigm changes to subsequently improve students' abilities to innovate solutions to complex practice problems. Method: The authors constructed or participated in electronic portfolio development inspired by theories of metacognition and integrated learning. The objective was to develop DNP student's reflection, integration of concepts, and technological capabilities to foster the deliberative competencies related to the DNP Essentials and the foundations of the DNP program. Results: The pedagogical process demonstrates how e-portfolios adapted into the doctoral-level curriculum for DNP students can address the Essentials and foster the development of metacognitive capabilities, which translates into practice changes. Conclusion: The authors suggest that this pedagogical approach has the potential to optimize reflective and deliberative competencies among DNP students. [ J Nurs Educ. 2017;56(8):497–500.]

Coronary artery bypass graft (CABG) surgery is a lifesaving procedure for patients with coronary artery disease but ranks highest (13.5%) for preventable hospital readmissions and second highest in average Medicare payment ($8,136) per readmission. Care transitions after hospital discharge warrant exploration to improve outcomes. The purpose of this brief report was to compare the effect of remote patient monitoring (RPM) on 30-day outcomes in Medicare beneficiaries after isolated CABG surgery. Results demonstrated no statistically significant difference in 30-day readmission (p = .568) or emergency department encounters (p = .785) between groups. However, time to achieve a cardiology follow-up appointment decreased from 19.8 to 13.7 days (p = .062) in the RPM group. Although the findings were not statistically significant, this study demonstrated a reduction in CABG readmissions and timely provider follow-up with RPM. In addition, study findings contribute to the body of nursing knowledge and support the need for further studies to identify high-risk CABG patients who may benefit from RPM after hospital discharge.

Background Heart failure (HF) is associated with high mortality rates and high costs, and self-care is crucial in the management of the condition. Telehealth can promote patients’ self-care while providing frequent feedback to their health care providers about the patient’s compliance and symptoms. A number of technologies have been considered in the literature to facilitate telehealth in patients with HF. An important factor in the adoption of these technologies is their ease of use. Conversational agent technologies using a voice interface can be a good option because they use speech recognition to communicate with patients. Objective The aim of this paper is to study the engagement of patients with HF with voice interface technology. In particular, we investigate which patient characteristics are linked to increased technology use. Methods We used data from two separate HF patient groups that used different telehealth technologies over a 90-day period. Each group used a different type of voice interface; however, the scripts followed by the two technologies were identical. One technology was based on Amazon’s Alexa (Alexa+), and in the other technology, patients used a tablet to interact with a visually animated and voice-enabled avatar (Avatar). Patient engagement was measured as the number of days on which the patients used the technology during the study period. We used multiple linear regression to model engagement with the technology based on patients’ demographic and clinical characteristics and past technology use. Results In both populations, the patients were predominantly male and Black, had an average age of 55 years, and had HF for an average of 7 years. The only patient characteristic that was statistically different (P=.008) between the two populations was the number of medications they took to manage HF, with a mean of 8.7 (SD 4.0) for Alexa+ and 5.8 (SD 3.4) for Avatar patients. The regression model on the combined population shows that older patients used the technology more frequently (an additional 1.19 days of use for each additional year of age; P=.004). The number of medications to manage HF was negatively associated with use (−5.49; P=.005), and Black patients used the technology less frequently than other patients with similar characteristics (−15.96; P=.08). Conclusions Older patients’ higher engagement with telehealth is consistent with findings from previous studies, confirming the acceptability of technology in this subset of patients with HF. However, we also found that a higher number of HF medications, which may be correlated with a higher disease burden, is negatively associated with telehealth use. Finally, the lower engagement of Black patients highlights the need for further study to identify the reasons behind this lower engagement, including the possible role of social determinants of health, and potentially create technologies that are better tailored for this population.

To provide advanced practice nurses (APNs) with practice recommendations for noninvasive cardiac stress testing (NCST) to enhance diagnostic test selection and to improve the interpretation of the test results.A review and synthesis of current scientific literature on noninvasive cardiac stress tests was conducted including a review of pertinent guidelines, indications, contraindications, procedures and findings of exercise, pharmacological, echocardiographic, and myocardial perfusion imaging studies.Noninvasive cardiac stress testing is an integral component in the care of men and women for the diagnosis, prognosis, and management of individuals at risk for cardiovascular conditions or with known histories of cardiovascular disorders.Cardiovascular disorders are common in our society. APNs care for a variety of individuals in the inpatient and outpatient settings that may require noninvasive cardiac stress tests for the evaluation of significant health histories and clinical presentations. An enhanced understanding of NCST improves test selection, preparation and education of patients, interpretation of test results, and implications for future patient care.

Advanced practice nurses have increased in number and public acceptance. Students preparing for these roles require quality clinical education so they are prepared to assume collaborative roles in healthcare settings. Although graduate clinical preceptors have a vitally important role in the clinical education and professional socialization of advanced practice students, there is a paucity of evidence about factors that influence their role commitment. In this article, the authors review the literature related to graduate-level, clinical-preceptor experiences; describe their study of 91 graduate clinical preceptors that identified factors influencing graduate clinical preceptors’ role commitment; report and discuss their findings; as well as the limitations of this study. They conclude that the graduate clinical preceptor role needs to be more visible and better integrated into schools of nursing and healthcare organizational structures, and identify the need for intra-professional collaboration among nursing faculty, administrators, and clinicians to facilitate the recruitment, cultivation, and retention of graduate clinical preceptors

The concept of radiant thinking, which led to the concept of mind mapping, promotes all aspects of the brain working in synergy, with thought beginning from a central point. The mind map, which is a graphical technique to improve creative thinking and knowledge attainment, utilizes colors, images, codes, and dimensions to amplify and enhance key ideas. This technique augments the visualization of relationships and links between concepts, which aids in information acquisition, data retention, and overall comprehension. Faculty can promote students’ use of the technique for brainstorming, organizing ideas, taking notes, learning collaboratively, presenting, and studying. These applications can be used in problem-based learning, developing plans of care, health promotion activities, synthesizing disease processes, and forming differential diagnoses. Mind mapping is a creative way for students to engage in a unique method of learning that can expand memory recall and help create a new environment for processing information. [ J Nurs Educ . 2013;52(5):291–293.]

Purpose: To review current issues in the diagnosis, prognosis, and management of heart failure (HF), focusing on the clinical use of brain natriuretic peptide (BNP) as a diagnostic marker. Data sources: Selective review of scientific literature and clinical practice guidelines. Conclusions: BNP is a useful clinical tool for the diagnosis, prognosis, and management of HF patients. Studies have consistently demonstrated high sensitivity, specificity, and negative predictive value of BNP levels in diagnostic situations. BNP cannot differentiate between systolic and diastolic HF. Implications for practice: BNP can be used to assist in diagnosing HF in emergency and outpatient situations, particularly when the presenting symptom is dyspnea; determining HF prognosis, including predicting death and cardiac events; and potentially managing individuals with HF by determining safe discharge levels from acute care to avoid readmissions. BNP levels can vary depending on multiple confounders; therefore, clinical interpretation can be difficult.