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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.

BackgroundMany patients with advanced heart failure (HF) are administered chronic intravenous inotropic support (CIIS) as bridge to surgical therapy; some ultimately never receive surgery. We aimed to describe reasons patients “crossover” from CIIS as bridge therapy to palliative therapy, and compare end-of-life outcomes to patients initiated on CIIS as palliative therapy.MethodsSingle-institution, retrospective cohort study of patients on CIIS as bridge or palliative therapy between 2010 and 2016; data obtained through review of health records and multi-disciplinary selection meeting minutes, was analyzed using descriptive and inferential statistics.ResultsOf 246 patients discharged on CIIS as bridge therapy, 37 (16%) (male n = 28, 76%; African American n = 22, 60%) ultimately never received surgery. 67 matched patients on CIIS as palliative therapy were included for analysis (male n = 47, 70%; African American n = 47, 70%). The most common reasons for “crossover” from CIIS as bridge therapy to palliative therapy were frailty (n = 10, 27%), cardiac arrest (n = 5, 13.5%), and progressive non-cardiac illnesses (n = 6, 16.2%). A similar percentage of patients in the bridge (n = 28, 76%) and palliative (n = 48, 72%) groups died outside the hospital (P=0.66); however, fewer bridge patients received hospice care compared to the palliative group (35% vs 69%, P < 0.001). Comparing patients who died in the hospital, bridge patients (n = 9; 100%) were more likely to die in the intensive care unit than palliative patients (n = 8; 42%) (P < 0.001).ConclusionPatients on CIIS as bridge therapy who do not ultimately receive surgical therapy “crossover” to palliative intention due to frailty, or development of or identification of serious illnesses. Nevertheless, these “bridge to nowhere” patients are less likely to receive palliative care or hospice and more likely to die in the intensive care unit than patients on CIIS as palliative therapy.

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.

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.

Use of continuous intravenous inotropic support (CIIS) strictly as palliative therapy for patients with ACC/AHA Stage D (end-stage) Heart Failure (HF) has increased significantly. The harms of CIIS therapy may detract from its benefits. To describe benefits (improvement in NYHA functional class) and harms (infection, hospitalization, days-spent-in-hospital) of CIIS as palliative therapy. Methods: Retrospective analysis of patients with end-stage HF initiated on CIIS as palliative therapy at an urban, academic center in the United States between 2014-2016. Clinical outcomes were extracted, and data were analyzed using descriptive statistics. Seventy-five patients, 72% male, 69% African American/Black, with a mean age 64.5 years ( SD = 14.5) met study criteria. Mean duration of CIIS was 6.5 months ( SD = 7.7). Most patients (69.3%) experienced improvement in NYHA functional class from class IV to class III. Sixty-seven patients (89.3%) were hospitalized during their time on CIIS, with a mean of 2.7 hospitalizations per patient ( SD = 3.3). One-third of patients (n = 25) required at least one intensive care unit (ICU) admission while on CIIS therapy. Eleven patients (14.7%) experienced catheter-related blood stream infection. Patients spent an average of 20.6% ( SD = 22.8), approximately 40 days, of their time on CIIS admitted to the study institution. Patients on CIIS as palliative therapy report improvement in functional class, survive 6.5 months following initiation, but spend a significant number of days in the hospital. Prospective studies quantifying the symptomatic benefit and the direct and indirect harms of CIIS as palliative therapy are warranted.

BACKGROUND Health care data are fragmenting as patients seek care from diverse sources. Consequently, patient care is negatively impacted by disparate health records. Machine learning (ML) offers a disruptive force in its ability to inform and improve patient care and outcomes. However, the differences that exist in each individual’s health records, combined with the lack of health data standards, in addition to systemic issues that render the data unreliable and that fail to create a single view of each patient, create challenges for ML. Although these problems exist throughout health care, they are especially prevalent within maternal health and exacerbate the maternal morbidity and mortality crisis in the United States. OBJECTIVE This study aims to demonstrate that patient records extracted from the electronic health records (EHRs) of a large tertiary health care system can be made actionable for the goal of effectively using ML to identify maternal cardiovascular risk before evidence of diagnosis or intervention within the patient’s record. Maternal patient records were extracted from the EHRs of a large tertiary health care system and made into patient-specific, complete data sets through a systematic method. METHODS We outline the effort that was required to define the specifications of the computational systems, the data set, and access to relevant systems, while ensuring that data security, privacy laws, and policies were met. Data acquisition included the concatenation, anonymization, and normalization of health data across multiple EHRs in preparation for their use by a proprietary risk stratification algorithm designed to establish patient-specific baselines to identify and establish cardiovascular risk based on deviations from the patient’s baselines to inform early interventions. RESULTS Patient records can be made actionable for the goal of effectively using ML, specifically to identify cardiovascular risk in pregnant patients. CONCLUSIONS Upon acquiring data, including their concatenation, anonymization, and normalization across multiple EHRs, the use of an ML-based tool can provide early identification of cardiovascular risk in pregnant patients. CLINICALTRIAL

Background Health care data are fragmenting as patients seek care from diverse sources. Consequently, patient care is negatively impacted by disparate health records. Machine learning (ML) offers a disruptive force in its ability to inform and improve patient care and outcomes. However, the differences that exist in each individual’s health records, combined with the lack of health data standards, in addition to systemic issues that render the data unreliable and that fail to create a single view of each patient, create challenges for ML. Although these problems exist throughout health care, they are especially prevalent within maternal health and exacerbate the maternal morbidity and mortality crisis in the United States. Objective This study aims to demonstrate that patient records extracted from the electronic health records (EHRs) of a large tertiary health care system can be made actionable for the goal of effectively using ML to identify maternal cardiovascular risk before evidence of diagnosis or intervention within the patient’s record. Maternal patient records were extracted from the EHRs of a large tertiary health care system and made into patient-specific, complete data sets through a systematic method. Methods We outline the effort that was required to define the specifications of the computational systems, the data set, and access to relevant systems, while ensuring that data security, privacy laws, and policies were met. Data acquisition included the concatenation, anonymization, and normalization of health data across multiple EHRs in preparation for their use by a proprietary risk stratification algorithm designed to establish patient-specific baselines to identify and establish cardiovascular risk based on deviations from the patient’s baselines to inform early interventions. Results Patient records can be made actionable for the goal of effectively using ML, specifically to identify cardiovascular risk in pregnant patients. Conclusions Upon acquiring data, including their concatenation, anonymization, and normalization across multiple EHRs, the use of an ML-based tool can provide early identification of cardiovascular risk in pregnant patients.

BackgroundHeart failure is a troublesome condition with high healthcare utilization and cost. Most individuals with heart failure experience multiple symptoms including breathlessness, pain, depression, and anxiety.PurposeThe aim of this study was to review the literature describing the use of the Edmonton Symptom Assessment Scale to assess the burden of symptoms and the impact of symptoms on heart failure outcomes including quality of life and functional outcomes.MethodsThe search engines PubMed, Scopus, CINAHL, and Web of Science were searched from January 2001 to March 2020. A review of literature was undertaken using key terms "heart failure," "CHF," "cardiac failure," "heart decompensation," "myocardial failure," "Edmonton Symptom Assessment Scale". Hand searching of articles was also undertaken.ResultsThe search resulted in 33 relevant articles, which were imported into Rayyan, a Web-based systematic review software program. We present synthesis of results of studies (1) using the Edmonton Symptom Assessment Scale as an assessment of symptom burden and (2) evaluating the impact of symptom burden on quality of life and functional status.ConclusionThis review highlighted the Edmonton Symptom Assessment Scale as a predictive instrument to identify symptom burden, symptom clusters, and symptom changes for patients living with heart failure. The clinical use of the Edmonton Symptom Assessment Scale may identify treatment priorities, promote self-management, inform the treatment plan, and advance effective therapeutic adjustments. The symptom burden in heart failure is high, and improving the symptom experience is an important focus of future healthcare interventions. The Edmonton Symptom Assessment Scale has utility in heart failure management due to psychometric properties and ease of administration.Clinical implicationsThe Edmonton Symptom Assessment Scale may be useful in measuring patient-reported symptom burden in patients with heart failure in the clinical setting because it correlates well with other heart failure measures on quality of life and functional outcomes and provides useful information on symptom burden.

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 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. CLINICALTRIAL

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.

In response to market demand, a private, nonprofit university affiliated with an academic health center expanded its existing on-campus nurse practitioner programs to include an innovative online delivery method. This expansion aligned with the university's service mission to increase access to high-quality education to rural and underserved regions and to improve the health and well-being of communities by increasing the nurse practitioner workforce. In order to achieve these goals, the university entered into partnership with a for-profit educational technology company to develop a sustainable online program. The authors discuss the challenges and lessons learned through this venture.

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.

Background: Optimization of health care delivery in different settings with the goal of improving quality of life and reduction of heart failure (HF) morbidity continues to be an unmet need. Digital engagement between patients and providers is becoming more prevalent for care coordination and management of heart failure.Aims: To design and test a customized and interactive heart failure disease specific functionality with activated technology (Amazon's Echo Dot or an Avatar) as a tool for management of HF patients at home. To identify the effect of a voice activated technology in the reduction of heart failure hospitalizations, improvement of medication adherence, improvement in health-related quality of life and increase in comfort with voice activated technologies. Methods We compared two types of conversational agent technologies to standard of care, using speech recognition, to evaluate patient engagement in HF patients. The first technologyutilized the Amazon Echo Dot Alexa technology and only communicated with the patient through audio and the second was an application on a tablet using an Avatar, combining audio and visual. The conversational agent asks the HF patients a series of 11 questions, divided into three components: compliance (questions 1-3), mild HF symptoms (questions 4-6) and moderate/severe HF symptoms (questions 7-11). Participants completed questions regarding their use and comfort with technology. Inclusion criteria: admitted or treated for HF;18 or older; and resides with access to wifi. Exclusion criteria: heart transplant or ventricular assist device recipients. Participants were monitored for three months.Results: Thirty patients were enrolled in each intervention arm of the two studies with the Alexa or Avatar. Mean age was 54 years in the Alexa group and 56 years in the Avatar group. There were predominately males 61% and 63%, Alexa and Avatar, respectively. In the Alexa and Avatar groups race was predominately black, 64% and 63% followed by white 21% and 30%. The Alexa group was statistically more likely to complete the three compliance factors of weight checking (p=.030), salt monitoring (p=0.016) and medication adherence (p=0.005). Initial results suggest that older people and individuals using the smart phone answer the questionnaire at higher rates, and individuals taking an increased number of medications to treat HF had lower participation.Conclusion: Voice enabled, internet connected devices are poised to have profound impacts on the quality of life for in-home, independent, and assisted-living patients by vastly increasing the connectivity to healthcare providers.

Nell Hodgson Woodruff School of Nursing, Emory University, 1520 Clifton Rd, NE #366, Atlanta, GA 30322, USA b School of Nursing & Health Studies, Georgetown University, USA Medstar, Georgetown University Hospital, USA Advanced Heart Failure Center, University of Cincinnati, USA Northeast Georgia Medical Center, Gainesville, GA, USA College of Nursing, University of Kentucky, USA Vanderbilt University Medical Center, USA Memorial Medical Center, Springfield, IL, USA

Family nurse practitioner (FNP) graduates must be prepared to care for individuals and families and to demonstrate a commitment to family-centered care. FNP educators are challenged to translate theoretical frameworks into meaningful clinical engagement through novel teaching strategies that promote family-centered care in a health care environment that focuses primarily on the individual. The Living Family Tree (LFT) is a video-enhanced active learning strategy that features a multigenerational family through which students view reality-based family health care scenarios. This creative educational innovation serves to bridge the gap between knowledge and practice by actively engaging learners using technology and multimedia.

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.

Introduction Individuals with heart failure have difficulty evaluating their symptoms and understanding when to seek health care or to implement self-care activities. The purpose of this qualitative study is to inform the development of a Heart Failure Action Plan by individuals living with heart failure. Methods The proposed study used a prospective qualitative design using a grounded theory approach to understand the process of HF symptom management and the development of an action plan. Specifically, patients were interviewed regarding clinical indicators of self-reported symptoms, adherence to medication regimen, and physiologic changes to develop an individualized heart failure action plan. Demographic data of participants was collected including age, ethnicity, gender, medications, vital signs, heart failure history, and heart failure etiology. Results Participants reported that the color zones (red, yellow, green) of the action plan were helpful to “give you an idea of what you are supposed to do” with “weight, swelling, symptoms” and to evaluate “⋯target weight, keep tracking of medicine helps figure out symptom”. Participants suggested adding content for “more exercise, talk about what you eat, cough, chest tightness, dizziness, with swelling” and “more specifics, on a healthy diet, and encouragement, for, some form of activity, if only just walking” and “bigger letters, understandable,⋯contact someone to help you” and “I would like it to be small to be placed in a wallet.” Conclusions Participants provided their perceptions of the HF action plan and their feedback is instrumental in modifying the action plan for use in a broader HF patient population to assist patients in self-management of their condition, including the understanding of when to seek health 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.