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Documentation is a key factor in supporting consistency and quality of patient care in the hospice setting; however, variation among program provider practices, including documentation, was observed during the data collection phase of a study testing an intervention to promote Evidence-Based Practices for cancer pain management in 16 Midwestern hospices of varied size and structure. In the absence of uniformly adopted outcome measures and documentation standards, quality improvement initiatives in this important and growing healthcare sector will be difficult to manage. This article provides background on the importance of documentation, quality measures, outcomes of care, and regulatory imperatives in the hospice setting, with specific observations from our research study and suggestions for changes in documentation practices. From our observations, we posit the necessity of pertinent outcome measures supported by standardized documentation processes in hospice. Uniformity in key practice indicators and patient outcome measures in documentation systems would advance the movement to improve quality and consistency of care in hospices. Standardization of documentation systems and language would also facilitate the conduct of research in the hospice setting, a population for which advancing knowledge is essential to assure quality care at the end of life. [ABSTRACT FROM AUTHOR]

INTRODUCTION: This article examines acute pain assessment and pharmacological management in the emergency department that occurred over a period of time after the release of the new pain assessment and management compliance standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for accredited health care organizations. Data were available from that collected for a large-scale study testing a Translating Research into Practice intervention to promote use of evidence-based practices for acute pain management in older adults. METHODS: Medical records were abstracted from hospitalized older adult patients with hip fractures admitted through the emergency department (N = 1454). Records were from 12 acute care hospitals of patients receiving care in the emergency departments from 3 different periods between 2000 and 2002. Major variables examined were (1) pain assessment practices and (2) pharmacological pain treatment practices derived from an Evidence-based Guideline on Acute Pain Management in Older Adults. RESULTS: Trends over time illustrate improvements in pain assessment practices, with almost all patients having some documentation related to pain (99% in 2002), although only 54.4% had pain assessed with a numeric rating scale, 4.2% with a non-numeric rating scale (such as verbal descriptor or faces scale), and 7.4% with nonverbal pain behaviors. Thus, 34% of patients had no objective assessment of pain documented. The mean pain intensity reported remained high (6.8 to 7.2 out of 10) across the 3 periods. By the end of the study's final data collection point in 2002, only 60% of patients had any analgesic ordered, with more than half of this group (59%) having an opioid ordered. Of those administered an analgesic, more than 90% received an opioid. Practice improvements were noted over time in a decline in intramuscular opioid administration and overall meperidine administration and an increase in morphine as the opioid of choice in this setting. DISCUSSION: Pain assessment and management practices in the emergency departments showed improvements over time following the release of JCAHO standards for pain management. However, the care documented does not consistently represent best practices for all patients. [ABSTRACT FROM AUTHOR]

Models for changing clinician behavior. [ABSTRACT FROM AUTHOR]

PURPOSE. The purpose was to (a) identify frequently used nursing interventions, and (b) describe patterns of interventions used for each of the three patient groups. METHODS. This secondary data analysis used data from an academic medical center where the Nursing Interventions Classification (NIC) was used to electronically document nursing care. Descriptive statistics describe the types, frequencies, and patterns of NIC interventions delivered to three older acute care populations. FINDINGS. Four NIC treatments were frequently used in all patient groups. There were also NIC treatments and patterns of treatments that were unique to each group. CONCLUSIONS AND IMPLICATIONS. Using standardized nursing language in electronic medical records (EMRs) enables data extraction and analysis. Data extracted from EMRs provides nurse administrators with a tool to guide decisions regarding nurse staffing, education, evaluation, and resource allocation. [ABSTRACT FROM AUTHOR]

The variables that relate to cost of hospital care for a large sample of elderly patients at risk for falling are examined. The chief predictors of cost of hospitalization were medical, pharmacy, and nursing interventions. Use of nursing interventions, on average, raised the median hospital cost less than use of medical or pharmacy interventions. Using a standardized nursing language with the hospital's information system can provide nurses with information that demonstrates the cost effectiveness of their interventions. [ABSTRACT FROM AUTHOR]

Mary Montie,1 Clayton Shuman,1 Jose Galinato,1 Lance Patak,2 Christine A Anderson,1 Marita G Titler1 1Department of Systems, Populations, and Leadership, School of Nursing, University of Michigan, Ann Arbor, MI, 2Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, Seattle, WA, USA Background: Call light systems remain the primary means of hospitalized patients to initiate communication with their health care providers. Although there is vast amounts of literature discussing patient communication with their health care providers, few studies have explored patients’ perceptions concerning call light use and communication. The specific aim of this study was to solicit patients’ perceptions regarding their call light use and communication with nursing staff. Methods: Patients invited to this study met the following inclusion criteria: proficient in English, been hospitalized for at least 24 hours, aged ≥21 years, and able to communicate verbally (eg, not intubated). Thirty participants provided written informed consent, were enrolled in the study, and completed interviews. Results: Using qualitative descriptive methods, five major themes emerged from patients’ perceptions (namely; establishing connectivity, participant safety concerns, no separation: health care and the call light device, issues with the current call light, and participants’ perceptions of “nurse work”). Multiple minor themes supported these major themes. Data analysis utilized the constant comparative methods of Glaser and Strauss. Discussion: Findings from this study extend the knowledge of patients’ understanding of not only why inconsistencies occur between the call light and their nurses, but also why the call light is more than merely a device to initiate communication; rather, it is a direct conduit to their health care and its delivery. Keywords: nurse–patient communication, medical technology, quality of care, qualitative research, patient safety, nurse work

The authors propose a new metric for quantifying nursing unit resource needs that is more sensitive to the rapid turnover of patients and shorter lengths of stay than the traditional hours per patient day (HPPD) metric. There was a felt need to capture intra-day census and/or demand-supply variations, skill mix variations, and other variables not adequately captured by midnight patient bed volume. Criteria for developing any new system included the following: * Simple to understand automated system, * Uses existing data and requires no additional data collection staff, * Quick to implement with ample data expansion potential, and * Amenable to detailed user data analyses with basis for comparison across units. One key difference was that the CPGR provides better disaggregate staffing need data via a series of snapshots throughout the day than the HPPD which only records midnight bed census. These data have proved indispensable in budgeting and setting cost standards, providing timely information for nurse managers, and obtaining buy-in from front-line staff members who have more confidence in the quality of staffing decisions. [ABSTRACT FROM AUTHOR]

Angela Kueny,1 Leah L Shever,2 Melissa Lehan Mackin,3 Marita G Titler4 1Luther College, Decorah, IA, 2The University of Michigan Hospital and Health Center, Ann Arbor, MI, 3University of Iowa College of Nursing, Iowa City, IA, 4University of Michigan School of Nursing, Ann Arbor, MI, USA Background/purpose: Nurse managers (NMs) play an important role promoting evidence-based practice (EBP) on clinical units within hospitals. However, there is a dearth of research focused on NM perspectives about institutional contextual factors to support the goal of EBP on the clinical unit. The purpose of this article is to identify contextual factors described by NMs to drive change and facilitate EBP at the unit level, comparing and contrasting these perspectives across nursing units. Methods: This study employed a qualitative descriptive design using interviews with nine NMs who were participating in a large effectiveness study. To stratify the sample, NMs were selected from nursing units designated as high or low performing based on implementation of EBP interventions, scores on the Meyer and Goes research use scale, and fall rates. Descriptive content analysis was used to identify themes that reflect the complex nature of infrastructure described by NMs and contextual influences that supported or hindered their promotion of EBP on the clinical unit. Results: NMs perceived workplace culture, structure, and resources as facilitators or barriers to empowering nurses under their supervision to use EBP and drive change. A workplace culture that provides clear communication of EBP goals or regulatory changes, direct contact with CEOs, and clear expectations supported NMs in their promotion of EBP on their units. High-performing unit NMs described a structure that included nursing-specific committees, allowing nurses to drive change and EBP from within the unit. NMs from high-performing units were more likely to articulate internal resources, such as quality-monitoring departments, as critical to the implementation of EBP on their units. This study contributes to a deeper understanding of institutional contextual factors that can be used to support NMs in their efforts to drive EBP changes at the unit level. Keywords: evidence-based practice, institutional context, driving forces, nurse managers

Abstract Background The objectives of this smoking cessation study among hospitalized smokers are to: 1) determine provider and patient receptivity, barriers, and facilitators to implementing the nurse-administered, inpatient Tobacco Tactics intervention versus usual care using face-to-face feedback and surveys; 2) compare the effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention versus usual care across hospitals, units, and patient characteristics using thirty-day point prevalence abstinence at thirty days and six months (primary outcome) post-recruitment; and 3) determine the cost-effectiveness of the nurse-administered, inpatient Tobacco Tactics intervention relative to usual care including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved. Methods/Design This effectiveness study will be a quasi-experimental design of six Michigan community hospitals of which three will get the nurse-administered Tobacco Tactics intervention and three will provide their usual care. In both the intervention and usual care sites, research assistants will collect data from patients on their smoking habits and related variables while in the hospital and at thirty days and six months post-recruitment. The intervention will be integrated into the experimental sites by a research nurse who will train Master Trainers at each intervention site. The Master Trainers, in turn, will teach the intervention to all staff nurses. Research nurses will also conduct formative evaluation with nurses to identify barriers and facilitators to dissemination. Descriptive statistics will be used to summarize the results of surveys administered to nurses, nurses’ participation rates, smokers’ receipt of specific cessation services, and satisfaction with services. General estimating equation analyses will be used to determine differences between intervention groups on satisfaction and quit rates, respectively, with adjustment for the clustering of patients within hospital units. Regression analyses will test the moderation of the effects of the interventions by patient characteristics. Cost-effectiveness will be assessed by constructing three ratios including cost per quitter, cost per life-year saved, and cost per quality-adjusted life-year saved. Discussion Given that nurses represent the largest group of front-line providers, this intervention, if proven effective, has the potential for having a wide reach and thus decrease smoking, morbidity and mortality among inpatient smokers. Trial registration Dissemination of Tobacco Tactics for Hospitalized Smokers NCT01309217

Abstract Background Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered. Methods The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses. Results Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area. Conclusions Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.

Abstract Background Fall prevention programs for hospitalized patients have had limited success, and the effect of programs on decreasing total falls and fall-related injuries is still inconclusive. This exploratory multi-hospital study examined the unique contribution of call light response time to predicting total fall rates and injurious fall rates in inpatient acute care settings. The conceptual model was based on Donabedian's framework of structure, process, and health-care outcomes. The covariates included the hospital, unit type, total nursing hours per patient-day (HPPDs), percentage of the total nursing HPPDs supplied by registered nurses, percentage of patients aged 65 years or older, average case mix index, percentage of patients with altered mental status, percentage of patients with hearing problems, and call light use rate per patient-day. Methods We analyzed data from 28 units from 4 Michigan hospitals, using archived data and chart reviews from January 2004 to May 2009. The patient care unit-month, defined as data aggregated by month for each patient care unit, was the unit of analysis (N = 1063). Hierarchical multiple regression analyses were used. Results Faster call light response time was associated with lower total fall and injurious fall rates. Units with a higher call light use rate had lower total fall and injurious fall rates. A higher percentage of productive nursing hours provided by registered nurses was associated with lower total fall and injurious fall rates. A higher percentage of patients with altered mental status was associated with a higher total fall rate but not a higher injurious fall rate. Units with a higher percentage of patients aged 65 years or older had lower injurious fall rates. Conclusions Faster call light response time appeared to contribute to lower total fall and injurious fall rates, after controlling for the covariates. For practical relevance, hospital and nursing executives should consider strategizing fall and injurious fall prevention efforts by aiming for a decrease in staff response time to call lights. Monitoring call light response time on a regular basis is recommended and could be incorporated into evidence-based practice guidelines for fall prevention.

Abstract Background Although most hospitalized smokers receive some form of cessation counseling during hospitalization, few receive outpatient cessation counseling and/or pharmacotherapy following discharge, which are key factors associated with long-term cessation. US Department of Veterans Affairs (VA) hospitals are challenged to find resources to implement and maintain the kind of high intensity cessation programs that have been shown to be effective in research studies. Few studies have applied the Chronic Care Model (CCM) to improve inpatient smoking cessation. Specific objectives The primary objective of this protocol is to determine the effect of a nurse-initiated intervention, which couples low-intensity inpatient counseling with sustained proactive telephone counseling, on smoking abstinence in hospitalized patients. Key secondary aims are to determine the impact of the intervention on staff nurses' attitudes toward providing smoking cessation counseling; to identify barriers and facilitators to implementation of smoking cessation guidelines in VA hospitals; and to determine the short-term cost-effectiveness of implementing the intervention. Design Pre-post study design in four VA hospitals Participants Hospitalized patients, aged 18 or older, who smoke at least one cigarette per day. Intervention The intervention will include: nurse training in delivery of bedside cessation counseling, electronic medical record tools (to streamline nursing assessment and documentation, to facilitate prescription of pharmacotherapy), computerized referral of motivated inpatients for proactive telephone counseling, and use of internal nursing facilitators to provide coaching to staff nurses practicing in non-critical care inpatient units. Outcomes The primary endpoint is seven-day point prevalence abstinence at six months following hospital admission and prolonged abstinence after a one-month grace period. To compare abstinence rates during the intervention and baseline periods, we will use random effects logistic regression models, which take the clustered nature of the data within nurses and hospitals into account. We will assess attitudes of staff nurses toward cessation counseling by questionnaire and will identify barriers and facilitators to implementation by using clinician focus groups. To determine the short-term incremental cost per quitter from the perspective of the VA health care system, we will calculate cessation-related costs incurred during the initial hospitalization and six-month follow-up period. Trial number NCT00816036

Purpose: To describe policy and system-level interventions with potential to improve cancer care at six sites., Methods: In 2016, six institutions received foundation support to develop unique multi-component interventions aimed at improving cancer care for underserved populations. These organizations, located across the United States, participated in a cross-site evaluation to assess the overall initiative impact and to identify potentially promising policy and system-level solutions for dissemination and broader implementation. A health system and policy tracking tool was developed to collect data from each site and included a description of their efforts, strategies employed, and changes achieved (e.g., new policies, clinical protocols). Tracking tool data were analyzed using rapid qualitative analyses and a matrix approach. Semi-structured interviews were conducted with site leaders (N = 65) and were analyzed by thematic analysis., Results: Sites reported 20 system and policy efforts, which resulted in improvements to electronic health records and telehealth strategies, changes to hospital/health system policies, and standardized clinical protocols/guidelines, among others. Efforts were aimed at: (1) coordinating care across multiple providers, supported by patient navigators; (2) expanding psychosocial and supportive care; (3) improving patient-provider communication; and (4) addressing barriers to accessing care. Interview analyses provided insights into successful strategies, challenges, and implications of the COVID-19 pandemic on cancer care., Conclusions and Implications for Cancer Survivors: Despite advances in diagnosis and treatment, cancer care remains inequitable. System-level improvements aimed at eliminating common barriers faced by underserved populations offer opportunities to improve the delivery of equitable, effective, and efficient care., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Oral anti-cancer agents (OAAs) represent a new frontier in cancer treatment, but we do not know how well patients incorporate the strategies that they are taught for managing the side effects of OAAs into their daily lives. The purpose of this study was to understand how OAA side effects influenced patients' lives and what strategies patients used to manage them., Methods: The study used an interpretive descriptive design utilizing photo elicitation interviews (PEI). Two pharmacists employed at the study ambulatory oncology clinic assisted with recruitment. Participants took photos and subsequent interviews focused on talking to participants about each photo, eliciting participant perspectives describing side effects of OAAs and management strategies. A directed content analysis approach was used to analyze the transcribed interviews., Results: A total of nine participants were included in the study. Three themes and associated sub-themes emerged: making changes to nutritional habits due to OAA side effects (hydration and food), strategies to alleviate OAA side effects (medication and non-medication related), and methods of coping with OAA effects (intra- and interpersonal). Changing nutritional habits was an important strategy to manage OAA side effects. Medication-related strategies to alleviate OAA side effects could be nuanced and, additionally, there was wide variability in coping methods used., Conclusion: Patient education on OAAs and side effects is not always tailored to each unique patient and their circumstances. This study uncovered how participants devised their own distinct strategies to prevent or manage OAA side effects in an effort to help improve patients' experiences when taking OAAs., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Large segments of the US population do not receive quality cancer care due to pervasive and systemic inequities, which can increase morbidity and mortality. Multicomponent, multilevel interventions can address inequities and improve care, but only if they reach communities with suboptimal access. Intervention studies often underenroll individuals from historically excluded groups., Methods: The Alliance to Advance Patient-Centered Cancer Care includes 6 grantees across the United States who implemented unique multicomponent, multilevel intervention programs with common goals of reducing disparities, increasing engagement, and improving the quality of care for targeted populations. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework informed the evaluation efforts across sites. Each Alliance site identified their intended populations, which included underrepresented minorities (eg, Black and Latinx persons), individuals who prefer a language other than English, and rural residents. We evaluated the demographic characteristics of participants to determine program reach., Results: Between 2018 and 2020, a total of 2,390 of 5,309 potentially eligible participants were enrolled across the 6 sites. The proportion of enrolled individuals with selected characteristics included 38% (n=908) Black adults, 24% (n=574) Latinx adults, 19% (n=454) preferring a language other than English, and 30% (n=717) rural residents. The proportion of those enrolled who were the intended population was commensurate to the proportion with desired characteristics in those identified as potentially eligible., Conclusions: The grantees met or exceeded enrollments from their intended populations who have been underserved by quality cancer care into patient-centered intervention programs. Intentional application of recruitment/engagement strategies is needed to reach individuals from historically underserved communities.

Objectives: To share a concept analysis of social movement aimed at advancing its application to evidence uptake and sustainability in health-care., Methods: We applied Walker and Avant method to clarify the concept of social movement in the context of knowledge uptake and sustainability. Peer-reviewed and grey literature databases were systematically searched for relevant reports that described how social movement action led to evidence-based practice changes in health and community settings. Titles, abstracts and full texts were reviewed independently and in duplicate, resulting in 38 included articles., Results: Social movement action for knowledge uptake and sustainability can be defined as individuals, groups, or organizations that, as voluntary and intrinsically motivated change agents, mobilize around a common cause to improve outcomes through knowledge uptake and sustainability. The 10 defining attributes, three antecedents and three consequences that we identified are dynamic and interrelated, often mutually reinforcing each other to fortify various aspects of the social movement. Examples of defining attributes include an urgent need for action, collective action and collective identity. The concept analysis resulted in the development of the Social Movement Action Framework., Conclusions: Social movement action can provide a lens through which we view implementation science. Collective action and collective identity - concepts less frequently canvassed in implementation science literature - can lend insight into grassroots approaches to uptake and sustainability. Findings can also inform providers and change leaders on the practicalities of harnessing social movement action for real-world change initiatives. By mobilizing individuals, groups, or organizations through social movement approaches, they can engage as powered change agents and teams that impact the individual, organizational and health systems levels to facilitate knowledge uptake and sustainability., Competing Interests: Doris Grinspun has declared a conflict of interest in the following categories: Support for attending meetings and/or travel; patents, planned, issued, or pending; Participation on a Data Safety Monitoring Board or Advisory board; Leadership or fiduciary role in other board, society, committee, or advocacy group paid or unpaid; and Receipt of equipment, materials, drugs, medical writing, gifts or other services. None of the other co-authors declared having a conflict of interest that may have influenced the work reported in this article., (© 2022 The Authors.)

Introduction: Novel approaches to address the most vexing problems facing patients and vulnerable populations are needed. The purpose of this project was to establish an innovative research Center based on the principles of transformational organizations., Methods: A new Center formed included faculty members with expertise in cancer, serious illness, and population health. Applying Sinek's "why, how, and what" framework, members developed and refined a purpose statement and strategic objectives. The Center now includes members representing diverse disciplines. Year 1 accomplishments included a refined mission and vision statement, two funded research proposals, one submitted training grant, one administrative hire, and active recruitment of two-research faculty to support Center activities., Conclusions: The newly-formed Center for Improving Patient and Population Health has enabled scholars within a research-intensive school of nursing to forge new partnerships to compete successfully for larger, complicated grant proposals on shorter deadlines. Opportunities exist to integrate students and research staff more fully into Center operations., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

The goal of the NEC-Zero project is to reduce the burden of necrotizing enterocolitis (NEC) by increasing access to evidence-based tools to help clinicians and parents integrate evidence into daily care. It involves (a) human milk feeding with prioritized mother's own milk; (b) use of a unit-adopted standardized feeding protocol; (c) a unit-adopted strategy for timely recognition that integrates risk awareness and a structured communication tool when symptoms develop; and (d) stewardship of empiric antibiotics and avoidance of antacids. A toolkit for caregivers and parents was developed to make implementation consistent. For clinicians the toolkit includes: the GutCheck NEC risk score, a structured communication tool, the "Avoiding NEC" checklist, and the NEC-Zero website. For parents, NEC-Zero tools include the website, three educational brochures in English and Spanish, and a collaborative care video produced with the NEC Society. This article describes the toolkit and how it has been accessed and used., (© Copyright 2020 Springer Publishing Company, LLC.)

Background: Memory loss is an independent predictor of mortality among heart failure patients. Twenty-three percent to 50% of heart failure patients have comorbid memory loss, but few interventions are available to treat the memory loss. The aims of this 3-arm randomized controlled trial were to (1) evaluate efficacy of computerized cognitive training intervention using BrainHQ to improve primary outcomes of memory and serum brain-derived neurotrophic factor levels and secondary outcomes of working memory, instrumental activities of daily living, and health-related quality of life among heart failure patients; (2) evaluate incremental cost-effectiveness of BrainHQ; and (3) examine depressive symptoms and genomic moderators of BrainHQ effect., Methods: A sample of 264 heart failure patients within 4 equal-sized blocks (normal/low baseline cognitive function and gender) will be randomly assigned to (1) BrainHQ, (2) active control computer-based crossword puzzles, and (3) usual care control groups. BrainHQ is an 8-week, 40-hour program individualized to each patient's performance. Data collection will be completed at baseline and at 10 weeks and 4 and 8 months. Descriptive statistics, mixed model analyses, and cost-utility analysis using intent-to-treat approach will be computed., Conclusions: This research will provide new knowledge about the efficacy of BrainHQ to improve memory and increase serum brain-derived neurotrophic factor levels in heart failure. If efficacious, the intervention will provide a new therapeutic approach that is easy to disseminate to treat a serious comorbid condition of heart failure.