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Background There is currently no gold standard instrument for assessing pain in severely cognitively impaired adults who are unable to provide self-report. Aims To determine interrater reliability of the PACSLAC and PAINAD in assessing pain behaviors in patients with the same pain stimulus, determine the consistency of the reliable changes between and within the instruments and assess nurse preference for either instrument. Design A single-group, within-subjects repeated-measures design was implemented. Setting The study took place in a small suburban hospital. Participants/Subjects Pain levels were observed at 24, 48, and 72 hours postsurgery using two instruments: Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC) and Pain Assessment in Advanced Dementia Scale (PAINAD). These instruments were selected because they are among the most commonly recommended tools for clinical use. Interrater reliability was analyzed along with reliable changes in pain for each period, and the study concluded with the nurse raters completing a preference survey. Methods A convenience sample of 30 patients was used with a diagnosis of severe dementia rendering the patient unable to reliably express pain, 60+ years of age, recovering from hip fracture surgery. Results Greater interrater reliability was found for the PACSLAC, with reliable change potentially affected by the type and level of pain medication. The nurses’ preference for the tool was split. Conclusions The results of this study indicate that the PACSLAC may be the more reliable tool over the PAINAD; however, rater training and familiarity with the tool is critical.

An internal peer-reviewed journal was created to promote high-quality nursing practice, improve patient outcomes, and inspire nurses at an academic medical center. The goal of the journal was to increase nurses' utilization of evidence-based practice (EBP). The publication provides a platform that facilitates the dissemination of nursing research and supports the implementation of EBP across the organization.

Describe prevalence of burnout in perianesthesia nurses, explore risks, mitigating factors.Cross-sectional descriptive.Survey containing Maslach Burnout Inventory, Short Form-12, and Social Support and Personal Coping was emailed to American Society of PeriAnesthesia Nurses. Regression analysis examined relationships between burnout and health, social support, personal coping, substance use, and demographics.Of 2,837 respondents, 18% were currently and 35% were formerly burned out, with lower incidence in those40 years. Currently burned out nurses had worse health and also perceived a lack of advancement opportunities and organizational investment in the individual. Lower burnout was associated with regular participation in physical (P.001), creative (P = .004), or mindfulness hobbies (P .001) and ease in discussing work problems with spouse or partner (P = .001).Despite burnout nurses' empathy for their patients is maintained. Interests outside of work, personal and work support, healthy work environment, and regular physical activities can improve burnout.

The purpose of this study was to gather population-specific data within a pediatric hospital and contribute to understanding the intergenerational continuity of adverse childhood experiences (ACEs). This descriptive study aimed at measuring the ACE scores of parents or caretakers whose child was a suspected victim of abuse or neglect. The "Finding Your ACE Score questionnaire was used to determine participants' scores." Fifteen participants enrolled in the study (N = 15), and 86.7% had exposure to ACEs. Statistical significance was found when comparing ACE scores with reported income levels (p = .051). This study supports previous findings of ACEs being present in a variety of populations, and it presents practice implications for advance practice registered nurses (APRNs) in various practice settings. Findings support that research regarding how to assess and treat ACEs throughout family members is both necessary and difficult. Additional data regarding the intergenerational continuity of ACEs might influence how APRNs deliver family-specific assessment, treatment, and prevention of ACEs throughout generations of family members.

Objective To determine the association of caregiving task burden and patient symptom burden with psychological distress among caregivers of head and neck cancer (HNC) patients. Methods Adults with HNC and their primary caregivers were included. Patient symptom burden was assessed with the Vanderbilt Head and Neck Symptom Survey-2.0. Caregiving task burden was quantified as task number and task difficulty/distress using the HNC Caregiving Task Inventory. Psychological distress was measured with the Profile of Mood States-Short Form. Two-step clustering analysis was conducted for patient symptom burden, caregiving task burden, and psychological distress. Associations of the resultant clusters of task burden and patient symptoms with caregiver distress were tested using logistic regressions. Results Eighty-nine HNC caregivers and 84 patients were included. Among patients, two clusters of symptom burden were found (51% mod-high, 49% low). Among caregivers, two clusters of caregiving task burden (40% mod-high, 60% low) and caregiver psychological distress (40% mod-high, 60% low) were found. Caregivers with mod-high task numbers and task difficulty/distress reported higher levels of psychological distress. After controlling for caregiver number of tasks, respective difficulty/distress, and patient symptom burden, caregiver perceived task difficulty/distress had the strongest association with caregiver psychological distress (adjusted OR = 3.83; 95% CI, 1.0-14.64; P = 0.049). Conclusions Psychological distress in HNC caregivers is associated with caregiving task burden, with caregivers experiencing high task difficulty/distress at greatest risk. Further study of the caregiver and task characteristics leading to psychological distress should inform supportive interventions for HNC patients and caregivers.

OBJECTIVES: The primary purpose of this manuscript is to report feasibility results of an intervention derived from Self-Regulation theory (SRT) to promote well-being for individuals with advanced lung cancer. SAMPLE AND SETTING: 45 adults with advanced stage lung cancer, receiving chemotherapy at an ambulatory setting. METHODS: Participants were randomized to one of two conditions: 1) the intervention group received a structured symptom assessment via telephone call, weekly x8 or, 2) usual care control group. Feasibility assessment focused on recruitment, retention, design, methods, and fidelity. Outcome measures of quality of life, symptoms, and distress were collected at four time points. MAIN RESEARCH VARIABLES: symptoms, quality of life, distress RESULTS: Participation rate was 79%, retention rate was 62%. Participant loss was most often due to progressive disease and occurred early in the study. High fidelity was noted for delivery of the intervention as planned and outcome data collection by telephone. The mean number of interventions delivered was 5.5 of a planned 8. A high level of acceptability was reported for those completing the intervention. CONCLUSIONS: While it was possible to deliver the SRT derived intervention with fidelity; feasibility findings do not warrant intervention replication in this population.

Purpose The purpose of this study was to identify current individual practice of perianesthesia nurses regarding assessment and documentation of pain. Design Descriptive cross-sectional design using vignette technique. Methods Vignettes with questions available via electronic survey offered to attendees of the 2017 American Society of PeriAnesthesia Nurses National Conference. Findings Total of 1,680 perianesthesia nurses participated; 41.4% reported assessment of pain compared with 36.7% who reported documentation of pain assessment. The numeric (0 to 10) pain intensity score was the most commonly used assessment method. Only 16.4% assessed for and documented pain location, 14.4% assessed for and documented quality of pain. Conclusions Pain assessment should include intensity, location, quality, and functional impact. The gap between nurses' practices in assessment and documention of pain may be related to system barriers. Embedding evidence-based best practice within electronic health records may improve both. Prior literature, as well as our findings, indicate these trends (missed documentation and assessment) are more global than only perianesthesia nursing.

Objectives. This research describes the prevalence and covariates associated with opioid-induced constipation (OIC) in an observational cohort study utilizing a national veteran cohort and integrated data from the Center for Medicare and Medicaid Services (CMS). Methods. A cohort of 152,904 veterans with encounters between 1 January 2008 and 30 November 2010, an exposure to opioids of 30 days or more, and no exposure in the prior year was developed to establish existing conditions and medications at the start of the opioid exposure and determining outcomes through the end of exposure. OIC was identified through additions/changes in laxative prescriptions, all-cause constipation identification through diagnosis, or constipation related procedures in the presence of opioid exposure. The association of time to constipation with opioid use was analyzed using Cox proportional hazard regression adjusted for patient characteristics, concomitant medications, laboratory tests, and comorbidities. Results. The prevalence of OIC was 12.6%. Twelve positively associated covariates were identified with the largest associations for prior constipation and prevalent laxative (any laxative that continued into the first day of opioid exposure). Among the 17 negatively associated covariates, the largest associations were for erythromycins, androgens/anabolics, and unknown race. Conclusions. There were several novel covariates found that are seen in the all-cause chronic constipation literature but have not been reported for opioid-induced constipation. Some are modifiable covariates, particularly medication coadministration, which may assist clinicians and researchers in risk stratification efforts when initiating opioid medications. The integration of CMS data supports the robustness of the analysis and may be of interest in the elderly population warranting future examination.

Measurement of head and neck external lymphedema and fibrosis (LEF) is challenging. To address this gap, we developed the Head and Neck External Lymphedema and Fibrosis (HN-LEF) Assessment Criteria. This article aimed to report preliminary data on reliability and validity of the HN-LEF Assessment Criteria.Sixty head and neck cancer (HNC) patients who were ≥3-month post cancer therapy were recruited. Study measures included 1) demographic/medical data; 2) LEF physical examination completed independently by two staff members for interrater reliability (intrarater reliability completed by one of them); and 3) grayscale ultrasound examination of the head and neck skin. Reliability estimates used percent agreement and Kappa statistic. Validity was assessed via Spearman correlations of physical examination findings with ultrasound measurements.Fifty-one out of 60 HNC patients completed both physical examination and ultrasound assessments. Interrater reliability: 91.0% agreement (Kappa = 0.81, p 0.001) on the presence of types of LEF; 84.9% agreement regarding the grade of LEF (Kappa = 0.70, p 0.001) across all anatomic sites. Intrarater reliability: 96.1% agreement for type of LEF; and 91.4% agreement for grade across all sites. Ultrasound examination demonstrates characteristics and patterns for different types of LEF (particularly in the cheek, submental, and neck regions).The study provided initial reliability and validity data for a clinician-reported tool evaluating external LEF in the HNC population. These preliminary findings demonstrate that the tool had good reliability. Associations with the ultrasound examination results demonstrate that the tool validly captures soft tissue changes at select sites. Further validation of the tool is warranted.

The aim of this study was to explore professional and personal changes staff nurses experience during and after a 1-year evidence-based practice program. Focus groups were conducted with staff who completed an evidence-based practice fellowship program. Five themes emerged from the focus groups: support, resources, knowledge, opportunity, and empowerment. A 1-year fellowship program provides essential elements needed for organizational structural empowerment. Sense of empowerment helps to explain outcomes of fellowship programs and successes of graduates.

Background Clinical research in head and neck cancer traditionally focused on tumor control. As survival improves, it is increasingly recognized that the side-effects of multimodality treatment can be profound and enduring. Thus, clinical trials require patient-reported and functional outcomes. Methods A subcommittee of the Previously Untreated, Locally Advanced (PULA) Task Force of the Head and Neck Steering Committee of the Coordinating Centre for Clinical Trials at the National Cancer Institute (NCI) was convened to identify a set of instruments suitable for widespread application in the conduct of clinical trials for head and neck cancer. Results Based on existing literature and expert opinion, 18 main areas of concern were identified. For each, measures suitable for use in multicenter clinical trials were recommended on the basis of validity, feasibility, and clinical acceptance. Conclusion Suitable instruments exist for most head and neck cancer concerns, but gaps require further development. Future efforts should be made to harmonize measurement across trials. © 2015 Wiley Periodicals, Inc. Head Neck 37: 425–439, 2015

Background Use of the interprofessional Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle is recommended practice in intensive care, but its adoption remains limited. Objective To examine the relationship between intensive care unit provider attitudes regarding the ABCDE bundle and ABCDE bundle adherence. Methods A 1-time survey of 268 care providers in 10 intensive care units across the country who had worked at least 4 shifts per month to examine their attitudes toward workload burden, difficulty carrying out the bundle, perceived safety, confidence, and perceived strength of evidence. Logistic regression models were used to examine the relationship of unit-level provider attitudes with ABCDE bundle adherence in 101 patients, adjusted for patients' age, severity of illness, and comorbidity. Results For every unit increase in workload burden, adherence to the ABCDE bundle decreased 53% (odds ratio [OR], 0.47; 95% CI, 0.28-0.79; P = .004). Bundle difficulty (OR, 0.29; 95% CI, 0.08-1.07), perceived safety (OR, 0.51; 95% CI, 0.10-2.65), confidence (OR, 0.37, 95% CI, 0.10-1.35), and perceived strength of evidence (OR, 0.69; 95% CI, 0.14-3.35) were not associated with ABCDE bundle adherence. For every unit increase in perceived difficulty carrying out the bundle, adherence with early mobility was reduced 59% (OR, 0.41; 95% CI, 0.19-0.90; P = .03). In addition, ABCDE bundle adherence (ie, ventilator bundle) was less than DE bundle adherence (ie, ventilator-free bundle) (97% vs 72%, z = 5.47; P Conclusions Focusing interventions on workload burden and factors influencing bundle difficulty may facilitate ABCDE bundle adherence.

Purpose. This is a pilot study investigating the effect of healing touch (HT) on fatigue in breast cancer patients undergoing radiation therapy (RT). Methods/Design. This study presents the results of a within-subjects design randomized clinical trial where the treatment group was treated with HT, whereas the control group experienced sham therapy. The setting was a university RT clinic. The participants were breast cancer patients treated with lumpectomy or mastectomy, 21 to 75 years old with an Eastern Cooperative Oncology Group (ECOG) score of 0 to 2. The intervention was a 45-minute session of HT or sham therapy once a week during RT. Outcome measures included fatigue, quality of life (QOL), and anxiety/depression. Results. A total of 70 patients were approached, with 41 completing the study. At completion, the HT participants tended to report higher levels of fatigue, statistically significant for interference ( P = .010) and usual fatigue ( P = .024). The control group tended to report greater reductions in fatigue relative to their own means than the HT group (Cohen’s d = 0.30 to 0.49 vs 0.06 to 0.18, respectively). There were no statistically significant differences between the groups for QOL. Conclusions. Our enrollment and retention indicate that HT is feasible for women during RT. Our pilot findings do not support a beneficial effect of HT on fatigue or QOL. Future research may explore increasing dose and teasing out therapist effect.

Purpose/objectives To compare available grading and staging scales that measure external lymphedema in patients with head and neck cancer (HNC) and to assess problems and gaps related to these tools. Design Cross-sectional. Setting A comprehensive cancer center in Tennessee. Sample 103 participants post-HNC treatment. Methods Four scales were used to evaluate study participant external lymphedema status, including the Common Terminology Criteria for Adverse Events (CTCAE) Lymphedema Scale (version 3.0), American Cancer Society Lymphedema Scale, Stages of Lymphedema (Foldi's Scale), and the CTCAE Fibrosis Scale (version 3.0). Main research variables Occurrence rate, severity of lymphedema, and components and descriptors of each scale. Findings The prevalence and severity of external lymphedema differed based on the tools. Each tool had an identified limitation. Current theory postulates a continuum between lymphedema and fibrosis, but only the Foldi's Scale adequately reflected that concept. Conclusions None of the available scales clearly captured all the important characteristics of external lymphedema in patients with HNC. A need exists to develop a clearly defined and validated scale of external lymphedema in the HNC population. Implications for nursing Oncology nurses should take an active role in addressing issues related to lymphedema assessment in patients post-HNC treatment; however, new assessment tools need to be developed for clinical use. Knowledge translation Early identification and accurate documentation of head and neck lymphedema are critically important to prevent lymphedema progress. However, existing grading criteria failed to capture important characteristics of external head and neck lymphedema. More research efforts need to be made to address this under-recognized issue.

Neonatal nurse practitioner (NNP) workload is not well studied, and metrics specific to NNP practice are lacking. Factors such as changes in resident duty hours, increasing neonatal intensive care unit admissions, and a shortage of NNPs contribute to NNP workload. Increased workload has been shown to be detrimental to providers and can affect quality of care.This study quantified NNP workload using a subjective workload metric, the NASA Task Load Index, and a newly developed objective workload metric specific to NNP practice.The NNP group at a level IV academic medical center was studied. The sample included 22 NNPs and 47 workload experiences.A comparison of scores from the NASA Task Load Index and objective workload metric showed a moderate correlation (r = 0.503). Mental demand workload scores had the highest contribution to workload. Feelings of frustration also contributed to workload.The NASA Task Load Index can be utilized to measure the workload of NNPs. The objective workload metric has potential to quantify NNP workload pending further validation studies and is a simple, straightforward tool.Additional research is needed regarding NNP workload and methods to quantify workload. Larger studies are needed to validate the objective workload metric.

This study examines data collected from a survey of advanced practice providers' (APPs') perceptions of reasonable versus actual APP-to-patient ratios and other factors that affect workload burden in both inpatient and outpatient clinical settings.Advanced practice providers provide accessible, cost-effective, and quality care in a growing number of specialty practices across multiple patient care settings. They are caring for higher volumes of patients and assuming more responsibilities while continuing to navigate highly complex healthcare systems. Limited evidence or benchmark data exist that would assist in determining optimal workload and staffing models that include APPs.A group of advanced practice leaders developed and distributed a 43-question survey of workload factors to a highly diverse APP workforce.There were 1466 APPs across 37 areas of practice who responded to the survey distributed in 14 separate organizations. The perceived reasonable workload was lower than the actual workload for 22 specialty practice areas. The analysis included years of experience as an APP, work hours, on-call commitment, nonclinical responsibilities, and time spent in documentation, direct patient care, and performing procedures.There is a consensus among APPs, within their practice area, about what constitutes a reasonable patient assignment, despite the variability in APP experience, organizational culture, processes, and patient acuity.

Purpose/objectives To measure the effect of clinical decision support (CDS) on oncology nurse evidence-based practice (EBP). . Design Longitudinal cluster-randomized design. . Setting Four distinctly separate oncology clinics associated with an academic medical center. . Sample The study sample was comprised of randomly selected data elements from the nursing documentation software. The data elements were patient-reported symptoms and the associated nurse interventions. The total sample observations were 600, derived from a baseline, posteducation, and postintervention sample of 200 each (100 in the intervention group and 100 in the control group for each sample). . Methods The cluster design was used to support randomization of the study intervention at the clinic level rather than the individual participant level to reduce possible diffusion of the study intervention. An elongated data collection cycle (11 weeks) controlled for temporary increases in nurse EBP related to the education or CDS intervention. . Main research variables The dependent variable was the nurse evidence-based documentation rate, calculated from the nurse-documented interventions. The independent variable was the CDS added to the nursing documentation software. . Findings The average EBP rate at baseline for the control and intervention groups was 27%. After education, the average EBP rate increased to 37%, and then decreased to 26% in the postintervention sample. Mixed-model linear statistical analysis revealed no significant interaction of group by sample. The CDS intervention did not result in an increase in nurse EBP. . Conclusions EBP education increased nurse EBP documentation rates significantly but only temporarily. Nurses may have used evidence in practice but may not have documented their interventions. . Implications for nursing More research is needed to understand the complex relationship between CDS, nursing practice, and nursing EBP intervention documentation. CDS may have a different effect on nurse EBP, physician EBP, and other medical professional EBP.

Purpose Family caregivers provide vital support for patients with head and neck cancer (HNC), yet few studies have focused on HNC caregiving. Our objective was to develop and conduct initial validation of the HNC Caregiving Task Inventory, an instrument to characterize caregiving task burden in the HNC population. Methods This 5-phase instrument development project involved the conceptualization of caregiving task burden (Phase 1), initial instrument development (Phase 2), assessment of content validity through expert panel review (Phase 3), assessment of face validity through family caregiver review (Phase 4), and preliminary validation in a sample of 106 family caregivers (Phase 5). Results We identified 11 domains of the HNC caregiving role and caregiving tasks for each domain. In Phase 3, the experts deemed all tasks relevant to HNC family caregiving. No tasks were eliminated and 19 were added. In Phase 4, family caregiver feedback indicated that the tasks were comprehensive and relevant. Wording and formatting changes were made and one task was added. In Phase 5, we evaluated discrimination of responses to derive a final version comprised of 58 tasks in 11 domains. Kuder-Richardson values for domains with ≥3 items ranged from 0.65 to 0.94. Associations were generally high with the Caregiving Burden Scale, moderate with the Caregiver Reaction Assessment and Profile of Mood States-Short Form, and low or non-existent with the Preparedness Scale. Conclusion Convergent and divergent validity were supported. The HNC Caregiving Task Inventory can be used to evaluate caregiving task burden across the treatment trajectory and identify targets for intervention.

Background Although current national data show improved graft and patient survival following lung transplant, the effects of several modifiable preexisting comorbid conditions on health-related quality of life after transplant have not been evaluated. This study examines the effects of 3 comorbid conditions present before lung transplant (reduced bone density, diabetes mellitus, and elevated body mass index) on health-related quality of life after lung transplant. Methods The Short Form 36 Health Survey was completed by 92 adult recipients at various times after lung transplant (mean, 41 months; range, 1–127 months). Multiple linear regression models that controlled for underlying disease, chronic rejection, and time after transplant tested the independent effects of the 3 pretransplant conditions on posttransplant health-related quality of life. Results The effects of pretransplant reduced bone density and diabetes mellitus were not statistically significant in these models. However, pretransplant body mass index had a significant negative effect (β = −.29, P = .007) on posttransplant physical health–related quality of life. Additionally, overweight status and obesity exerted comparable independent negative effects ( P = .01 and P = .03, respectively) on the physical function scale of the Short-Form 36 Health Survey compared with persons who were underweight or normal weight before transplant. Conclusions Reevaluation of elevated body mass index before transplant as a risk for reduced physical quality of life after lung transplant should be considered.

This article describes an institution's efforts to help nurses integrate evidence into practice through the development of a Web-based resource. After assessing nurses' attitudes and use of evidence resources, a Web site was created to provide a central location for accessing and using evidence. Nurses who utilized the Web site had more favorable attitudes toward evidence-based practice and were more likely to access evidence resources.

Lymphedema may disrupt local function and affect quality of life (QOL) in patients with head and neck cancer. The purpose of this study was to examine the associations among severity of internal and external lymphedema, symptoms, functional status, and QOL in patients with head and neck cancer.The sample included 103 patients who were ≥ 3 months after head and neck cancer treatment. Variables assessed included severity of internal and external lymphedema, physical/psychological symptoms, functional status, and QOL.Severity of internal and external lymphedema was associated with physical symptoms and psychological symptoms. Patients with more severe external lymphedema were more likely to have a decrease in neck left/right rotation. The combined effects of external and internal lymphedema severity were associated with hearing impairment and decreased QOL.Lymphedema severity correlates with symptom burden, functional status, and QOL in patients after head and neck cancer treatment.

Negative patterns of thinking, termed cognitive vulnerabilities, have been identified as risk factors for the development of depressive symptoms when adolescents experience negative life events. This study evaluated the associations among three cognitive vulnerabilities (i.e., dysfunctional attitudes, negative inferential style, and ruminative response style) and negative life events with depressive symptoms in a sample of young adolescents. All three cognitive vulnerabilities were found to be significantly associated with depressive symptoms. Furthermore, ruminative response style was found to have a significant unique contribution to the number of depressive symptoms. Findings suggest that cognitive vulnerabilities, particularly rumination, may be instrumental in explaining the development of depressive symptoms in young adolescents.

Context Because surgery, radiation, and/or chemotherapy disrupt lymphatic structures, damage soft tissue leading to scar tissue formation and fibrosis, and further affect lymphatic function, patients with head and neck cancer may be at high risk for developing secondary lymphedema. Yet, no published data are available regarding the prevalence of secondary lymphedema after head and neck cancer treatment. Objectives The aim of this study was to examine prevalence of secondary lymphedema in patients with head and neck cancer. Methods The study included 81 patients with head and neck cancer who were three months or more post-treatment. External lymphedema was staged using Foldi's lymphedema scale. Internal lymphedema was identified through a flexible fiber-optic endoscopic or mirror examination. Patterson's scale was used to grade degrees of internal lymphedema. Results Of the 81 patients, 75.3% (61 of 81) had some form of late-effect lymphedema. Of those, 9.8% (6 of 61) only had external, 39.4% (24 of 61) only had internal, and 50.8% (31 of 61) had both types. Conclusion Lymphedema is a common late effect in patients with head and neck cancer, and it develops in multiple external and internal anatomical locations. During physical examination and endoscopic procedures, clinicians should assess patients with head and neck cancer for late-effect lymphedema. Referral for treatment should be considered when lymphedema is noted. Research is needed to examine risk factors of lymphedema in patients with head and neck cancer and its effects on patients' symptoms, function, and quality of life.

Background The prevalence, severity, and functional implications of adverse oral health outcomes attributed to head and neck cancer therapy are largely undefined. We report development of an oral health outcome subscale for the Vanderbilt Head and Neck Symptom Survey (VHNSS). Methods Oral health outcome questions were formulated through literature review and consultation with an expert panel. Questions were incorporated into the VHNSS resulting in a 50-item survey, scored 0 (none) to 10 (severe). The tool was administered to 70 subjects who completed radiation to assess for feasibility. Results Patient acceptance was high with a completion time

Good cancer pain control requires appropriate assessment and treatment. The purpose of this study was to examine the relationships among physician, nurse practitioner, and nurse knowledge, documentation of assessment, treatment, and pain reduction in cancer patients seen in ambulatory settings.The study method included an assessment of pain knowledge of providers (physicians, nurse practitioners, and nurses) who worked in cancer clinics and a retrospective review of patients' records treated for cancer-related pain in their clinics. Fifty-eight providers from eight cancer clinics completed the knowledge questionnaire; 56 patient records were reviewed for assessment, treatment, and outcome data. Pain relief, the outcome, was obtained from documentation at the next clinic visit.Of the 54 patient records that documented pain relief at the next clinic visit, 61.9% reported no relief. Chi square analysis revealed clinics with a higher level of pain knowledge documented a greater number of elements of an ideal pain assessment (p = 0.03) but was unrelated to treatment and pain relief reported. Assessment and treatment were unrelated to reported pain relief at the next clinic visit.These data suggest that providers' pain knowledge is related to pain assessment but not treatment or outcome. In addition, these data showed no relationship between assessment, treatment prescribed, and pain relief in these ambulatory settings.

Acoordinated physician response during a disaster is challenging in an academic medical center environment because of the size of the institution and variety of specialty services provided. As a result of internal and external drill debriefings, it became evident that there was an acute need to better organize physician response efforts at our institution. Previously, physicians were directed to respond to one physician coordination center located in the adult emergency department. This strategy led to chaos in an already congested area. We found that having the medical services coordinator role initially reporting to the operations officer led to minimizing the medical faculty’s roles and responsibilities in the event of emergency operations plan activation. In addition, our pediatric capabilities expanded to include a new freestanding children’s hospital, which, although it is in close proximity to the adult hospital, separated the adult and pediatric services. This physical separation of the facilities added new complexities to the overall emergency operations plan. As a result, Vanderbilt Medical Center (VMC) embarked on a project to develop a physician response sub-plan that coordinated the response of more than 1100 faculty members in the event of a health emergency. The goal in formulating the sub-plan was to outline responsibilities of medical faculty, house staff, and fellows in response to a health emergency. For the purpose of plan development, a mass casualty incident was defined to include health emergencies such as widespread influenza, severe weather, National Disaster Medical System activations, acts of terrorism, fires, hazardous material incidents, nuclear accidents, aircraft accidents, and earthquakes. Realizing that a coordinated approach to incident management is of utmost importance to ensure a safe and orderly response during an emergency incident, VMC adopted the Incident Command System (ICS) model for handling emergencies. The ICS system originated in Southern California in 1972 and is organized under the acronym, “FIrefighting REsources of Southern California Organized for Potential Emergencies (FIRESCOPE).” By legislative action, the FIRESCOPE Board of Directors and the Office of Emergency Services Fire and Rescue Service Advisory Committee were consolidated into a working partnership on September 10, 1986. The FIRESCOPE model was one of the first of its kind calling for the use of an established chain of command led by an incident commander. The FIRESCOPE Incident Management System was adapted and tested for hospital use in California in 1992. The hospital-adapted version of this system is called the Hospital Incident Command System (HICS). HICS is an incident management system based on the ICS that assists hospitals in improving their emergency management planning, response, and recovery capabilities for unplanned and planned events. Figure 1 shows the basic structure of the model, which is consistent with ICS and the National Incident Management System (NIMS) principles. Use of HICS strengthens hospital disaster preparedness activities in conjunction with community response agencies and allows hospitals to understand and assist in implementing the 17 elements of the hospital-based NIMS guidelines. This management structure has been used in managing a variety of incidents ranging from 9/11 to large crowd gatherings such as football games and concerts. The beauty of the system is that it allows for an appropriate Pam Hoffner is Emergency Preparedness Coordinator/Adjunct Faculty, Vanderbilt University Medical Center and Vanderbilt School of Nursing, Nashville, TN.

Many barriers inhibit nurses from using evidence to guide their practice. The authors describe the development of a Nursing Research Internship Program designed to overcome barriers to evidence-based practice and provide staff nurses with an opportunity for professional growth. Evaluation of the program indicates it has increased staff nurses' use of the literature to identify and solve clinical problems, fostered positive attitudes about research, and led to increased professional development activities.

Authors from the USA sought to establish the relationship between tumour volume, pathological stage and outcomes after radical prostatectomy. In a large series of patients they found that tumour volume was correlated directly with pathological stage, and that it was independently correlated with PSA recurrence. The authors suggested that tumour volume had a potential use for prognostication in patients undergoing radical prostatectomy. Two papers, one from the USA and one from Germany, advise a re-staging TUR in patients with superficial bladder cancer who are at high risk of early tumour progression. In a large series of patients they found that residual tumour after initial resection was commoner than might be expected, and that the second resection indicated the way to earlier radical treatment and a better prognosis. OBJECTIVE To establish the relationship between tumour volume (TV), pathological stage and outcome after radical prostatectomy (RP), as TV is theoretically an important variable in prostate cancer pathology, but to date it has not been routinely reported and its independent prognostic significance is not well defined. PATIENTS AND METHODS The study included 431 consecutive patients undergoing RP for clinically localized cancer, from January 2000 to January 2002, who had a pathological examination of totally submitted whole-mount processed RP specimens. In addition to Gleason grade, tumour stage and margin assessment by standard techniques, TV was determined by digital planimetry. The total TV or index TV, for cases with obvious discrete separate tumours, were correlated with pathological stage and prostate-specific antigen (PSA) recurrence. RESULTS The mean (range) follow-up was 25.4 (6–51) months, and the mean TV for all patients was 3.28 (0.4–38.8) mL. There was a direct correlation between TV and pathological stage (P

The impact of treatment on the health related quality of life (HRQOL) of patients is being recognized with increasing importance, particularly in those with urological malignancies. However, a validated disease and treatment specific instrument to assess HRQOL following radical cystectomy (RC) and urinary diversion (UD) is currently lacking. We report the results of a new questionnaire designed specifically to measure HRQOL in these patients.A 45-item questionnaire consisting of the Functional Assessment of Cancer Therapy (FACT)-General and 17 additional items designed to measure disease and treatment specific health outcomes were combined to form the Vanderbilt Cystectomy Index (FACT-VCI). FACT-VCI and the generic RAND 36-Item Health Survey (SF-36) were administered to 50 patients from our institution RC data base who were more than 1 year from the time of surgery. Each patient was asked to complete the survey at 1 and 4 weeks. The results of the SF-36 and FACT-VCI were correlated along with the first and second administration of the FACT-VCI.Overall FACT-VCI was found to have adequate internal consistency (Cronbach's alpha0.70). Furthermore, intraclass correlation for the first and second administration of the VCI was 0.79. In addition, there was good correlation between the validated SF-36 and FACT-VCI (r = 0.81). The result was initial validation of a questionnaire for the assessment of HRQOL in patients following RC and UD.Instruments designed to measure accurately HRQOL following RC and UD are in early development. We have now constructed and validated a disease and treatment specific questionnaire that can objectively assess HRQOL following RC and UD. A prospective longitudinal study of FACT-VCI is currently ongoing.

Professional practice programs are designed to attract, retain, and reward nurses. This three-part series will describe Vanderbilt's performance-based career advancement system, the Vanderbilt Professional Nursing Practice Program (VPNPP). Part 1 outlines the overall program's foundation, philosophical background, and basic structure. The VPNPP is built upon Benner's work, distinguishing among four levels of practice: novice, competent, proficient, and expert. Work by many in the organization identified the expected behaviors for nurses at each level, which were then used to develop clear process evaluation criteria. Part 2 will examine the performance measurement and evaluation system created to support the program. The process of advancing within the program will be described in part 3.

Background/Objective: Below-level central neuropathic pain, a diffuse pain characterized by generalized burning, is commonly experienced by individuals with spinal cord injury (SCI) . The objective of this study was to investigate the effects of an electroacupuncture protocol for the treatment of below-level central neuropathic pain developed at the Toronto Rehabilitation Institute, Lyndhurst Center, Toronto, Ontario, Canada.Method: Retrospective chart review.Results: Thirty-six individuals with traumatic and nontraumatic SCI met the inclusion criteria. Of these, 24 showed improvement after treatment with the electroacupuncture protocol. Type of injury, level of injury, and duration of below-level central neuropathic pain was not correlated with improvement. However, individuals whose pain was described as bilateral (vs unilateral; P = 0 .01 4) or symmetric (vs non symmetric; P = 0.02 6) were more likely to improve after acupuncture treatment. Overall, patients whose burning pain was bilateral, sy...

Purpose: Radical cystectomy is gold standard treatment for muscle invasive bladder cancer and is an option for many patients with nonmuscle invasive disease at high risk for disease progression. We assessed the early complications of radical cystectomy among patients with nonmuscle invasive compared to those with muscle invasive disease.Materials and Methods: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We evaluated complications that occurred within 30 days of the procedure. Cases were stratified into nonmuscle invasive (PO, Pa, P1 and PIS, N0) or muscle invasive (P2–4, N0–3) tumors based on final specimen pathology. The 2 groups were then compared with respect to age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, estimated blood loss, operative time and length of stay, and major and minor complications.Results: Of the 293 available patients 105 (36.8%) had nonmuscle invasive specimen ...

Purpose: The low rate of pelvic node metastasis in most contemporary series of patients undergoing radical prostatectomy for carcinoma of the prostate has been attributed to earlier and better patient selection than historical series. Alternatively, it has been suggested that the limited dissection commonly performed misses nodal metastasis in a substantial number of patients. To assess the value of an extended node dissection in detecting nodal metastasis, we performed a randomized prospective study.Materials and Methods: A total of 123 patients undergoing radical prostatectomy were randomized to an extended node dissection on the right versus the left side of the pelvis with the other side being a limited dissection. The extended dissection included removal of all external iliac nodes to a point above the bifurcation of the common iliac artery, the obturator nodes and the presacral nodes. The limited dissection included only the nodes along the external iliac vein and obturator nerve.Results: Me...

Directed medical play is used to reduce children's pain and distress during medical treatment. In this pilot study, young children who attended the burn clinic received either directed medical play provided by a child life specialist or standard preparation from the burn clinic nurse to prepare for their first dressing change. Data were collected using validated instruments. Children who participated in medical play experienced less distress during their dressing change (M = 0.5, n = 12) than did those receiving standard preparation (M = 2.0, n = 9). Children who received standard care reported a 2-point increase in pain during the procedure, whereas children who participated in medical play reported a 1-point increase. Change in parental anxiety was similar for both groups. Parent satisfaction was higher for caregivers who observed medical play than standard preparation. Although all findings were in the hypothesized direction, none was statically significant, most likely because of the small sample size.

Purpose: Surgical techniques that provide adequate urinary and fecal continence in children with neurogenic bladder and bowel dysfunction are becoming increasingly used. We reviewed our experience and discuss factors that influence outcome.Materials and Methods: Between 1994 and 2000, 65 stomal procedures were performed in 47 patients. For the urinary continent catheterizable channel we used appendix in 60% of cases, a continent bladder tube in 20%, a Yang-Monti tube in 16% and ureter in 4%. For the antegrade continence enema continent catheterizable channel we used appendix in 85% of cases, a Yang-Monti tube in 5% and a cecal tube in 10%. In the 19 patients who underwent simultaneous Mitrofanoff and antegrade continence enema procedures the urinary continent catheterizable channel was appendix in 21%, a Yang-Monti tube in 32% and continent vesicostomy in 47%. Patients were divided into 2 groups based on compliance status. In addition, percentile body weight for age was evaluated.Results: Stomal c...

Purpose: We examined our recent series of patients who underwent radical cystectomy to determine and analyze the early perioperative morbidity of the procedure in a contemporary series treated with the guidance of a clinical pathway.Materials and Methods: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. We specifically evaluated complications that developed within 30 days of the procedure. Potential variables predictive of early morbidity were analyzed, including patient age, gender, race, American Society of Anesthesiologists score, type of urinary diversion, smoking history, estimated blood loss, transfusion requirement, pathological stage and operative time.Results: The overall minor complication rate was 30.9% (94 of 304 patients). Postoperative ileus was the most common minor complication, affecting 54 patients (18%). Increased blood loss and major complications predicted a significantly higher likelihood of ileus on multivariate an...

The purpose of this randomized placebo-controlled crossover pilot study was to evaluate the effectiveness and acceptability of magnetic therapy for hot flashes among breast cancer survivors. Participants completed a 24-hour baseline hot-flash monitoring session, wore the magnetic devices or placebo for 3 days, completed an after-treatment hot-flash monitoring session, experienced a 10-day washout period, and then crossed over to the opposite study arm. Magnetic devices and placebos were placed on 6 acupressure sites corresponding to hot-flash relief. Complete data were available from 11 survivors of breast cancer. Results indicated magnetic therapy was no more effective than placebo in decreasing hot-flash severity, and contrary to expectations, placebo was significantly more effective than magnets in decreasing hot-flash frequency, bother, interference with daily activities, and overall quality of life. Implications for clinical practice and future research include the need to explore alternative interventions aimed at alleviating hot flashes in this population.

Purpose: Patients undergoing radical cystectomy have historically required intensive care monitoring in the perioperative period. We examined the postoperative care of these patients since the institution of a clinical care pathway with special attention to the need for intensive care unit admission.Materials and Methods: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from December 1995 to July 2000. Variables examined were the location and nature of postoperative care, American Society of Anesthesiologists score, estimated blood loss, transfusion requirement, hospital stay, perioperative minor complications, major complications, the mortality rate and urinary diversion type.Results: Of the 304 patients 20 (6.5%) required intensive care unit monitoring during postoperative recovery and 18 were admitted directly to the intensive care unit postoperatively. Compared with the total population those admitted to the intensive care unit had increased hospital stay (p = 0.002...

Purpose: Our institution targets postoperative days 6 to 8 for discharge home after radical cystectomy. We examined this population to determine the causes of increased hospital stay and risk factors that may predict prolonged hospitalization.Materials and Methods: We reviewed the records of 304 consecutive patients who underwent radical cystectomy from October 1995 to July 2000. The variables examined included age, gender, race, American Society of Anesthesiologists score, urinary diversion type, smoking history, estimated blood loss, transfusion requirement, operative time, hospital stay, perioperative minor and major complications, and the mortality rate.Results: Of the 304 patients 144 (47.4%) underwent ileal conduit diversion and 145 (47.7%) underwent orthotopic bladder substitution. Median hospital stay was 7 days (range 4 to 48). Of 302 patients 225 (74%) were discharged home by postoperative day 8, while 52 of the remaining 77 (67.5%) with increased hospital stay were discharged home by day 12. Po...

e21568 Background: There are no validated tools assessing FQOL in the cancer population. We developed a 32-item cancer specific tool (CFQOL) comprised of general and cancer specific subscales directed towards the patient and caregiver. Domains included family interactions, roles, communication, and emotional support. Methods: 150 patient-caregiver dyads in a general oncology population completed the CFQOL, SF36, FACT, BC-FQOL, and FACE IV tools. Exploratory factor analysis was used to identify the underlying structure. We compared the CFQOL with validated measures using Spearman's Rho. Results: Characteristics: Patients - median age 59, 57% male, 96% Caucasian, and 65% in treatment. Caregivers - median age 56, 67% spouses/partners and 86% primary caregiver. The analysis revealed a single underlying structure for both the general and cancer-specific domains (Cronbach's α 0.96 and 0.94 respectively). Median scores for patients on both measures were 4.5 out of 5 (IQR: 4-5); caretaker scores were lower (median: 4.2, IQR: 3.5-4.2, p < .05). As expected, convergent validity was supported with those tools focusing on similar themes to those in the CFQOL, and items involving physical aspects demonstrated divergent validity but were not statistically significant (table 1). Conclusions: The CFQOL is a brief, valid tool for assessing multiple constructs relevant to FQOL in the cancer patient population. Patterns of correlations were similar for general and cancer subscales questioning the need for both sub-scales. Further validation and exploration of sensitivity to change is indicated. [Table: see text]

Purpose: Radical cystectomy has been associated with significant blood loss and/or transfusion requirement. We defined and characterized blood loss and transfusion parameters in this population.Materials and Methods: We reviewed the records of 304 consecutive patients who underwent radical cystectomy and urinary diversion between October 1995 and July 2000. Charts were examined, and univariate and multivariate logistic regression analysis was performed to evaluate estimated blood loss and the transfusion requirement.Results: Complete blood loss data were available in 297 cases. Overall 45% of patients had anemia preoperatively. Median estimated blood loss was 600 ml. (range 100 to 3,000). On univariate analysis increased estimated blood loss was related to patient age, American Society of Anesthesiologists score, longer operative time and paralytic ileus. Overall transfusion was done in 88 of 297 cases (30%) with a median requirement of 2 units (range 1 to 10). The transfusion rate in male and female pati...

The grant writing process can be daunting to a novice investigator. This article focuses on three inter-related activities that lead to a completed grant application. The first activity involves developing the research team. Selection of colleagues who will strengthen and support the research ideas is an early first step to developing a competitive grant application. It is important to communicate clearly the roles and responsibilities of each team member. The second activity is development of the scientific plan-the research proposal-from specific aims to plans for data analysis. Strategies used to review the literature, synthesize existing knowledge, develop the argument for the research proposal, and select the most appropriate method are discussed. The third activity involves developing a business plan-the budget-that demonstrates clearly the investigator's ability to complete the proposed research. These three activities are set within a timeline to guide investigators in successful completion of a grant application.

Among the reasons that cancer pain is not controlled adequately are patient-related barriers. Patient beliefs that may contribute to poor outcome have been measured in previous research with the Barriers Questionnaire (BQ). The purpose of this study was to examine the internal consistency of a shortened version of the BQ. A sample of 217 outpatients with cancer completed a 17-item version of the scale. Factor analysis suggested two subscales, one reflecting beliefs about communication about pain and the other reflecting beliefs about the use of analgesics. Both subscales demonstrated adequate internal consistency. Beliefs did not differ between patients who had and those who had not experienced pain within the previous two weeks. Findings suggest the shortened BQ provides an internally consistent measure of two broad patient barriers to pain management.

Quality of life can be substantially affected by pain. While many pain control options are available, analgesics are the most common, and usually most effective, method used to manage moderate to severe pain. There are, however, potential adverse effects of these drugs that may reduce patients' willingness to take their analgesics as prescribed. Both pain and the modalities used to manage it can impact patients' quality of life. Quality of life measurements can be used to evaluate the effectiveness of pain treatment, and guide the selection of pharmacologic and non-pharmacologic therapies. A variety of instruments, developed from two different measurement approaches (psychometric and decision-making or economic) is available to measure quality of life. This article discusses the applications, dimensions, and benefits of psychometric and decision-making models and potential uses in evaluating pain therapies.