Early childhood (1-5 years) obesity prevention: A systematic review of family-based multicomponent behavioral interventions

INTRODUCTION

Globally 38.9 million children under age 5 have overweight or obesity, leading to type 2 diabetes, cardiovascular complications, depression, and poor educational outcomes. Obesity is difficult to reverse and lifestyle behaviors (healthy or unhealthy) can persist from 1.5 years of age. Targeting caregivers to help address modifiable behaviors may offer a viable solution.

OBJECTIVE

Evaluate the impact of multicomponent family interventions on weight-based outcomes in early childhood and explore related secondary behavior outcomes.

METHODS

Four databases were searched (1/2017-6/2022) for randomized controlled trials (RCTs) of obesity-prevention interventions for children (1-5 years). Eligible studies included an objectively measured weight-based outcome, family interventions targeting the caregiver or family, and interventions including at least two behavioral components of nutrition, physical activity, or sleep.

RESULTS

Eleven interventions were identified consisting of four delivery modes: self-guided (n = 3), face-to-face group instruction (n = 3), face-to-face home visits (n = 2), and multiple levels of influence (n = 3). The reviewed studies reported almost no significant effects on child weight-based outcomes. Only two studies (one was an underpowered pilot study) resulted in significant positive child weight-management outcomes. Seven of the interventions significantly improved children's dietary intake.

CONCLUSION

Except for one, the reviewed studies reported that family based interventions had no significant effects on child weight-based outcomes. Future studies of this type should include measurements of age and sex-based body mass index (BMI) and trajectories, and also examine other important benefits to the children and families.

The impact of spiritual care delivered by nurses on patients' comfort: A propensity score matched cohort utilizing electronic health record data

BACKGROUND

Spiritual care has been associated with better health outcomes. Despite increasing evidence of the benefits of spiritual care for older patients coping with illness and aggressive treatment, the role of spirituality is not well understood and implemented. Nurses, as frontline holistic healthcare providers, are in a position to address patients' spiritual needs and support them in finding meaning in life. This study aimed to identify spiritual care by analyzing nursing data and to compare the psychological and physical comfort between older chronically ill patients who received spiritual care versus those who did not receive spiritual care.

MATERIAL AND METHODS

A propensity score matched cohort utilizing nursing care plan data was used to construct balanced groups based on patient characteristics at admission. 45 older patients (≥65 years) with chronic illnesses received spiritual care with measured psychological or physical comfort and 90 matched controls. To ensure the robustness of our results, two sensitivity analyses were performed. Group comparisons were performed to assess the average treatment effect of spiritual care on psychological and physical comfort outcomes.

RESULTS

The mean psychological comfort was 4.3 (SD = 0.5) for spiritual care receivers and 3.9 (SD = 0.9) for non-receivers. Regression analysis showed that spiritual care was associated with better psychological comfort (estimate = 0.479, std. error = 0.225, p = 0.041). While its effect on physical comfort was not statistically significant (estimate = -0.265, std. error = 0.234, p = 0.261). This study provides suggestive evidence of the positive impact of nurses' spiritual care in improving psychological comfort for older patients with chronic illnesses.

CONCLUSION

Using interoperable nursing data, our findings suggest that spiritual care improves psychological comfort in older patients facing illness. This finding suggests that nurses may integrate spiritual care into their usual care to support patients experiencing distress.

Standardizing nursing data extracted from electronic health records for integration into a statewide clinical data research network

BACKGROUND

Care plans documented by nurses in electronic health records (EHR) are a rich source of data to generate knowledge and measure the impact of nursing care. Unfortunately, there is a lack of integration of these data in clinical data research networks (CDRN) data trusts, due in large part to nursing care being documented with local vocabulary, resulting in non-standardized data. The absence of high-quality nursing care plan data in data trusts limits the investigation of interdisciplinary care aimed at improving patient outcomes.

OBJECTIVE

To map local nursing care plan terms for patients' problems and goals in the EHR of one large health system to the standardized nursing terminologies (SNTs), NANDA International (NANDA-I), and Nursing Outcomes Classification (NOC).

METHODS

We extracted local problems and goals used by nurses to document care plans from two hospitals. After removing duplicates, the terms were independently mapped to NANDA-I and NOC by five mappers. Four nurses who regularly use the local vocabulary validated the mapping.

RESULTS

83% of local problem terms were mapped to NANDA-I labels and 93% of local goal terms were mapped to NOC labels. The nurses agreed with 95% of the mapping. Local terms not mapped to labels were mapped to the domains or classes of the respective terminologies.

CONCLUSION

Mapping local vocabularies used by nurses in EHRs to SNTs is a foundational step to making interoperable nursing data available for research and other secondary purposes in large data trusts. This study is the first phase of a larger project building, for the first time, a pipeline to standardize, harmonize, and integrate nursing care plan data from multiple Florida hospitals into the statewide CDRN OneFlorida+ Clinical Research Network data trust.

The relationship between electronic health records user interface features and data quality of patient clinical information: an integrative review

OBJECTIVES

Electronic health records (EHRs) user interfaces (UI) designed for data entry can potentially impact the quality of patient information captured in the EHRs. This review identified and synthesized the literature evidence about the relationship of UI features in EHRs on data quality (DQ).

MATERIALS AND METHODS

We performed an integrative review of research studies by conducting a structured search in 5 databases completed on October 10, 2022. We applied Whittemore & Knafl's methodology to identify literature, extract, and synthesize information, iteratively. We adapted Kmet et al appraisal tool for the quality assessment of the evidence. The research protocol was registered with PROSPERO (CRD42020203998).

RESULTS

Eleven studies met the inclusion criteria. The relationship between 1 or more UI features and 1 or more DQ indicators was examined. UI features were classified into 4 categories: 3 types of data capture aids, and other methods of DQ assessment at the UI. The Weiskopf et al measures were used to assess DQ: completeness (n = 10), correctness (n = 10), and currency (n = 3). UI features such as mandatory fields, templates, and contextual autocomplete improved completeness or correctness or both. Measures of currency were scarce.

DISCUSSION

The paucity of studies on UI features and DQ underscored the limited knowledge in this important area. The UI features examined had both positive and negative effects on DQ. Standardization of data entry and further development of automated algorithmic aids, including adaptive UIs, have great promise for improving DQ. Further research is essential to ensure data captured in our electronic systems are high quality and valid for use in clinical decision-making and other secondary analyses.

Nurses' preferences for the format of care planning clinical decision support coded with standardized nursing languages

Current electronic health records (EHRs) are often ineffective in identifying patient priorities and care needs requiring nurses to search a large volume of text to find clinically meaningful information. Our study, part of a larger randomized controlled trial testing nursing care planning clinical decision support coded in standardized nursing languages, focuses on identifying format preferences after random assignment and interaction to 1 of 3 formats (text only, text+table, text+graph). Being assigned to the text+graph significantly increased the preference for graph (P = .02) relative to other groups. Being assigned to the text only (P = .06) and text+table (P = .35) was not significantly associated with preference for their assigned formats. Additionally, the preference for graphs was not significantly associated with understanding graph content (P = .19). Further studies are needed to enhance our understanding of how format preferences influence the use and processing of displayed information.

Clinical Decision Support Systems for Palliative Care Management: A Scoping Review

CONTEXT

With the expansion of palliative care services in clinical settings, clinical decision support systems (CDSSs) have become increasingly crucial for assisting bedside nurses and other clinicians in improving the quality of care to patients with life-limiting health conditions.

OBJECTIVES

To characterize palliative care CDSSs and explore end-users' actions taken, adherence recommendations, and clinical decision time.

METHODS

The CINAHL, Embase, and PubMed databases were searched from inception to September 2022. The review was developed following the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines. Qualified studies were described in tables and assessed the level of evidence.

RESULTS

A total of 284 abstracts were screened, and 12 studies comprised the final sample. The CDSSs selected focused on identifying patients who could benefit from palliative care based on their health status, making referrals to palliative care services, and managing medications and symptom control. Despite the variability of palliative CDSSs, all studies reported that CDSSs assisted clinicians in becoming more informed about palliative care options leading to better decisions and improved patient outcomes. Seven studies explored the impact of CDSSs on end-user adherence. Three studies revealed high adherence to recommendations while four had low adherence. Lack of feature customization and trust in guideline-based in the initial stages of feasibility and usability testing were evident, limiting the usefulness for nurses and other clinicians.

CONCLUSION

This study demonstrated that implementing palliative care CDSSs can assist nurses and other clinicians in improving the quality of care for palliative patients. The studies' different methodological approaches and variations in palliative CDSSs made it challenging to compare and validate the applicability under which CDSSs are effective. Further research utilizing rigorous methods to evaluate the impact of clinical decision support features and guideline-based actions on clinicians' adherence and efficiency is recommended.

Nurses' Perceptions of Recommended Fall Prevention Strategies: A Rapid Review

BACKGROUND

Limited studies have synthesized evidence on nurses' perceptions of recommended fall prevention strategies and potential differences between those and the practiced strategies.

PURPOSE

To synthesize evidence about nurses' perceptions of recommended fall prevention strategies for hospitalized adults.

METHODS

Using PubMed, 50 records underwent abstract and full-text screening, and 10 studies were retained. Narrative synthesis was conducted to identify common themes across studies. Quality assessment was not performed.

RESULTS

Nurses are aware of effective fall prevention strategies but identified unit-level barriers and facilitators to implementing these in their practice. Unit culture and policies, educational offerings, nursing interventions, and style of communication and collaboration were seen to influence fall prevention.

CONCLUSIONS

Nurses recognize falls as a multifactorial issue suggesting that prevention efforts be tailored to the unit and involve all employees. We recommend that future research emphasize identifying and understanding the combination of factors that produce successful unit-level fall prevention strategies.

Spiritual Interventions Delivered by Nurses to Address Patients' Needs in Hospitals or Long-Term Care Facilities: A Systematic Review

Introduction: Despite increasing evidence of the benefits of spiritual care and nurses' efforts to incorporate spiritual interventions into palliative care and clinical practice, the role of spirituality is not well understood and implemented. There are divergent meanings and practices within and across countries. Understanding the delivery of spiritual interventions may lead to improved patient outcomes. Aim: We conducted a systematic review to characterize spiritual interventions delivered by nurses and targeted outcomes for patients in hospitals or assisted long-term care facilities. Methodology: The systematic review was developed following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and a quality assessment was performed. Our protocol was registered on PROSPERO (Registration No. CRD42020197325). The CINAHL, Embase, PsycINFO, and PubMed databases were searched from inception to June 2020. Results: We screened a total of 1005 abstracts and identified 16 experimental and quasi-experimental studies of spiritual interventions delivered by nurses to individuals receiving palliative care or targeted at chronic conditions, such as advanced cancer diseases. Ten studies examined existential interventions (e.g., spiritual history, spiritual pain assessment, touch, and psychospiritual interventions), two examined religious interventions (e.g., prayer), and four investigated mixed interventions (e.g., active listening, presence, and connectedness with the sacred, nature, and art). Patient outcomes associated with the delivery of spiritual interventions included spiritual well-being, anxiety, and depression. Conclusion: Spiritual interventions varied with the organizational culture of institutions, patients' beliefs, and target outcomes. Studies showed that spiritual interventions are associated with improved psychological and spiritual patient outcomes. The studies' different methodological approaches and the lack of detail made it challenging to compare, replicate, and validate the applicability and circumstances under which the interventions are effective. Further studies utilizing rigorous methods with operationalized definitions of spiritual nursing care are recommended.

Use of machine learning to transform complex standardized nursing care plan data into meaningful research variables: a palliative care exemplar

The aim of this article was to describe a novel methodology for transforming complex nursing care plan data into meaningful variables to assess the impact of nursing care. We extracted standardized care plan data for older adults from the electronic health records of 4 hospitals. We created a palliative care framework with 8 categories. A subset of the data was manually classified under the framework, which was then used to train random forest machine learning algorithms that performed automated classification. Two expert raters achieved a 78% agreement rate. Random forest classifiers trained using the expert consensus achieved accuracy (agreement with consensus) between 77% and 89%. The best classifier was utilized for the automated classification of the remaining data. Utilizing machine learning reduces the cost of transforming raw data into representative constructs that can be used in research and practice to understand the essence of nursing specialty care, such as palliative care.

Feasibility of the Web-Based Intervention Designed to Educate and Improve Adherence Through Learning to Use Continuous Glucose Monitor (IDEAL CGM) Training and Follow-Up Support Intervention: Randomized Controlled Pilot Study

Background

Proper training and follow-up for patients new to continuous glucose monitor (CGM) use are required to maintain adherence and achieve diabetes-related outcomes. However, CGM training is hampered by the lack of evidence-based standards and poor reimbursement. We hypothesized that web-based CGM training and education would be effective and could be provided with minimal burden to the health care team.

Objective

The aim of this study was to perform a pilot feasibility study testing a theory-driven, web-based intervention designed to provide extended training and follow-up support to adolescents and young adults newly implementing CGM and to describe CGM adherence, glycemic control, and CGM-specific psychosocial measures before and after the intervention.

Methods

The “Intervention Designed to Educate and improve Adherence through Learning to use CGM (IDEAL CGM)” web-based training intervention was based on supporting literature and theoretical concepts adapted from the health belief model and social cognitive theory. Patients new to CGM, who were aged 15-24 years with type 1 diabetes for more than 6 months were recruited from within a public university’s endocrinology clinic. Participants were randomized to enhanced standard care or enhanced standard care plus the IDEAL CGM intervention using a 1:3 randomization scheme. Hemoglobin A_1c levels and psychosocial measures were assessed at baseline and 3 months after start of the intervention.

Results

Ten eligible subjects were approached for recruitment and 8 were randomized. Within the IDEAL CGM group, 4 of the 6 participants received exposure to the web-based training. Half of the participants completed at least 5 of the 7 modules; however, dosage of the intervention and level of engagement varied widely among the participants. This study provided proof of concept for use of a web-based intervention to deliver follow-up CGM training and support. However, revisions to the intervention are needed in order to improve engagement and determine feasibility.

Conclusions

This pilot study underscores the importance of continued research efforts to optimize the use of web-based intervention tools for their potential to improve adherence and glycemic control and the psychosocial impact of the use of diabetes technologies without adding significant burden to the health care team. Enhancements should be made to the intervention to increase engagement, maximize responsiveness, and ensure attainment of the skills necessary to achieve consistent use and improvements in glycemic control prior to the design of a larger well-powered clinical trial to establish feasibility.

Trial Registration

ClinicalTrials.gov NCT03367351, https://clinicaltrials.gov/ct2/show/NCT03367351.

Secondary use of standardized nursing care data for advancing nursing science and practice: a systematic review

OBJECTIVE

The study sought to present the findings of a systematic review of studies involving secondary analyses of data coded with standardized nursing terminologies (SNTs) retrieved from electronic health records (EHRs).

MATERIALS AND METHODS

We identified studies that performed secondary analysis of SNT-coded nursing EHR data from PubMed, CINAHL, and Google Scholar. We screened 2570 unique records and identified 44 articles of interest. We extracted research questions, nursing terminologies, sample characteristics, variables, and statistical techniques used from these articles. An adapted STROBE (Strengthening The Reporting of OBservational Studies in Epidemiology) Statement checklist for observational studies was used for reproducibility assessment.

RESULTS

Forty-four articles were identified. Their study foci were grouped into 3 categories: (1) potential uses of SNT-coded nursing data or challenges associated with this type of data (feasibility of standardizing nursing data), (2) analysis of SNT-coded nursing data to describe the characteristics of nursing care (characterization of nursing care), and (3) analysis of SNT-coded nursing data to understand the impact or effectiveness of nursing care (impact of nursing care). The analytical techniques varied including bivariate analysis, data mining, and predictive modeling.

DISCUSSION

SNT-coded nursing data extracted from EHRs is useful in characterizing nursing practice and offers the potential for demonstrating its impact on patient outcomes.

CONCLUSIONS

Our study provides evidence of the value of SNT-coded nursing data in EHRs. Future studies are needed to identify additional useful methods of analyzing SNT-coded nursing data and to combine nursing data with other data elements in EHRs to fully characterize the patient's health care experience.

Nursing Care for Hospitalized Older Adults With and Without Cognitive Impairment

BACKGROUND

The presence of cognitive impairment (CI) among hospitalized older adults (aged 85 years and older) could interfere with the identification and treatment of other important symptoms experienced by these patients. Little is known, however, about the nursing care provided to this group. Contrasting the nursing care provided to patients with and without CI may reveal important insights about symptom treatment in the CI population.

OBJECTIVE

The aim of this study was to examine the relationship of CI to nursing care provided and length of stay for hospitalized older adults using standardized nursing data retrieved from electronic health records.

METHODS

We conducted a comparative secondary data analysis. A data set of standardized nursing plan of care data retrieved from electronic health record data of nine units at four hospitals was analyzed. The plan of care data for this study were previously transformed into one of eight categories (family, well-being, mental comfort, physical comfort, mental, safety, functional, and physiological care). Fisher exact tests were used to compare the differences in the nursing care for hospitalized older adults with and without CI. Mixed-effects models were used to examine associations of patient's cognitive status and nursing care, and cognitive status and length of stay.

RESULTS

We identified 4,354 unique patients; 746 (17%) had CI. We observed that older adults with CI were less likely to receive physical comfort care than those without CI for seven of nine units. Older adults' cognitive status was associated with the delivery of mental comfort care. In addition, a worsening in cognitive status was associated with an increase in length of stay for older adults with CI.

DISCUSSION

Older adults with CI appeared to be undertreated for symptoms of pain when compared to those without CI across units. There is a need for further research to improve symptom recognition and management for this population. The presence of CI was associated with variation in nursing care provided and length of stay. Future studies that include the analysis of nursing data merged with elements stored in the electronic health record representing the contributions of other health professions are expected to provide additional insights into this gap.

Human Factors Associated with Continuous Glucose Monitor Use in Patients with Diabetes: A Systematic Review

Consistent continuous glucose monitor (CGM) use is associated with substantial improvements in glycemic control, yet the uptake and continued use of these technologies remains low. This systematic review aims to identify and summarize the state of science on human factors and their association with CGM use to inform training methods and best practices that support adherence to CGM use and automated insulin delivery systems. A literature search was conducted in PubMed, CINAHL, The Cochrane Library, and PsychInfo databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify studies that reported psychological human factors related to CGM or sensor-augmented pump use in patients with type 1 diabetes. In total, 389 records were identified through our database search and 26 studies published between 2010 and 2017 were included. Articles underwent quality appraisal using the Effective Public Health Practice Project Quality Assessment Tool and were categorized according to study outcomes. Identified human factors with a potential association with CGM use were treatment satisfaction, quality of life, emotional distress, and self-efficacy. Eight patient-reported barriers to CGM use were identified as a subcomponent of satisfaction. To date, studies of human factors associated with CGM use generally lack standardized measures and sufficient methodological rigor necessary to establish causation. A more robust understanding of how identified human factors influence CGM use is necessary. Future studies should test interventions that target human factors to improve consistency of use and establish best practices for enhancing patients' experience and acceptance of these technologies, especially within adolescents and young adults.

Nursing students' diagnostic accuracy using a computer-based clinical scenario simulation

BACKGROUND

Being able to make accurate clinical decisions about actual or potential health problems is crucial to provide a safe and effective care. However, nursing students generally have difficulties identifying nursing diagnoses accurately.

OBJECTIVE

To compare the diagnostic accuracy within and across the NANDA-I diagnoses domains of junior, senior, and graduate-entry students.

DESIGN

Descriptive study PARTICIPANTS AND SETTING: The sample comprised one hundred thirty nursing students from a Midwestern American university.

METHODS

The participants were divided in three groups (juniors, seniors and graduate-entry) and invited to engage in a series of diagnostic exercises presented in a software. Students were presented with 13 scenarios and asked to identify the applicable defining characteristics, related factors, and nursing diagnoses from the NANDA-I taxonomy. The number of correct answers per scenario was used to compute diagnostic accuracy. Age, gender, previous exposure to the NANDA-I taxonomy, and student level were covariates in the analysis.

RESULTS

The average percent correct answers across all groups was 64.4% and no statistical differences between the groups were found. The scenarios belonging to the Health Promotion, Self-Perception, and Growth/Development Domains were those in which students had a higher number of incorrect answers. Students also had more difficulty recognizing the correct nursing diagnoses compared with related factors and defining characteristics.

CONCLUSIONS

This study found no associations between demographic variables, exposure to the NANDA-I taxonomy, or academic program level and diagnostic accuracy. Some areas in which students had a poor performance indicate need for improvement in diagnostic reasoning skills.

Acceptability of Clinical Decision Support Interface Prototypes for a Nursing Electronic Health Record to Facilitate Supportive Care Outcomes

PURPOSE

To determine the acceptability, usefulness, and ease of use for four nursing clinical decision support interface prototypes.

METHODS

In a simulated hospital environment, 60 registered nurses (48 female; mean age = 33.7 ± 10.8; mean years of experience = 8.1 ± 9.7) participated in a randomized study with four study groups. Measures included acceptability, usefulness, and ease of use scales.

FINDINGS

Mean scores were high for acceptability, usefulness, and the ease of use for all four groups. Inexperienced participants (<1 year) reported higher perceived ease of use (p = .05) and perceived usefulness (p = .01) than those with experience of 1 year or more.

CONCLUSIONS

Participants completed the protocol and reported that all four interfaces, including the control (HANDS), were acceptable, easy to use, and useful.

IMPLICATIONS FOR NURSING KNOWLEDGE

Further study is warranted before clinical implementation within the electronic health record.

Physician nurse care: A new use of UMLS to measure professional contribution: Are we talking about the same patient a new graph matching algorithm?

BACKGROUND

Physician and nurses have worked together for generations; however, their language and training are vastly different; comparing and contrasting their work and their joint impact on patient outcomes is difficult in light of this difference. At the same time, the EHR only includes the physician perspective via the physician-authored discharge summary, but not nurse documentation. Prior research in this area has focused on collaboration and the usage of similar terminology.

OBJECTIVE

The objective of the study is to gain insight into interprofessional care by developing a computational metric to identify similarities, related concepts and differences in physician and nurse work.

METHODS

58 physician discharge summaries and the corresponding nurse plans of care were transformed into Unified Medical Language System (UMLS) Concept Unique Identifiers (CUIs). MedLEE, a Natural Language Processing (NLP) program, extracted "physician terms" from free-text physician summaries. The nursing plans of care were constructed using the HANDS© nursing documentation software. HANDS© utilizes structured terminologies: nursing diagnosis (NANDA-I), outcomes (NOC), and interventions (NIC) to create "nursing terms". The physician's and nurse's terms were compared using the UMLS network for relatedness, overlaying the physician and nurse terms for comparison. Our overarching goal is to provide insight into the care, by innovatively applying graph algorithms to the UMLS network. We reveal the relationships between the care provided by each professional that is specific to the patient level.

RESULTS

We found that only 26% of patients had synonyms (identical UMLS CUIs) between the two professions' documentation. On average, physicians' discharge summaries contain 27 terms and nurses' documentation, 18. Traversing the UMLS network, we found an average of 4 terms related (distance less than 2) between the professions, leaving most concepts as unrelated between nurse and physician care.

CONCLUSION

Our hypothesis that physician's and nurse's practice domains are markedly different is supported by the preliminary, quantitative evidence we found. Leveraging the UMLS network and graph traversal algorithms, allows us to compare and contrast nursing and physician care on a single patient, enabling a more complete picture of patient care. We can differentiate professional contributions to patient outcomes and related and divergent concepts by each profession.

Predicting Hospital Re-admissions from Nursing Care Data of Hospitalized Patients

Readmission rates in the hospitals are increasingly being used as a benchmark to determine the quality of healthcare delivery to hospitalized patients. Around three-fourths of all hospital re-admissions can be avoided, saving billions of dollars. Many hospitals have now deployed electronic health record (EHR) systems that can be used to study issues that trigger readmission.However, most of the EHRs are high dimensional and sparsely populated, and analyzing such data sets is a Big Data challenge. The effect of some of the well-known dimension reduction techniques is minimized due to presence of non-linear variables. We use association mining as a dimension reduction method and the results are used to develop models, using data from an existing nursing EHR system, for predicting risk of re-admission to the hospitals. These models can help in determining effective treatments for patients to minimize the possibility of re-admission, bringing down the cost and increasing the quality of care provided to the patients. Results from the models show significantly accurate predictions of patient re-admission.

A Shovel-Ready Solution to Fill the Nursing Data Gap in the Interdisciplinary Clinical Picture

PURPOSE

To critically evaluate 2014 American Academy of Nursing (AAN) call-to-action plan for generating interoperable nursing data.

DATA SOURCES

Healthcare literature.

DATA SYNTHESIS

AAN's plan will not generate the nursing data needed to participate in big data science initiatives in the short term because Logical Observation Identifiers Names and Codes and Systematized Nomenclature of Medicine - Clinical Terms are not yet ripe for generating interoperable data. Well-tested viable alternatives exist.

CONCLUSIONS

Authors present recommendations for revisions to AAN's plan and an evidence-based alternative to generating interoperable nursing data in the near term. These revisions can ultimately lead to the proposed terminology goals of the AAN's plan in the long term.

Nurses' Numeracy and Graphical Literacy: Informing Studies of Clinical Decision Support Interfaces

We present findings of a comparative study of numeracy and graph literacy in a representative group of 60 practicing nurses. This article focuses on a fundamental concern related to the effectiveness of numeric information displayed in various features in the electronic health record during clinical workflow. Our findings suggest the need to consider numeracy and graph literacy when presenting numerical information as well as the potential for tailoring numeric display types to an individual's cognitive strengths.

Nurse Continuity and Hospital-Acquired Pressure Ulcers: A Comparative Analysis Using an Electronic Health Record "Big Data" Set

BACKGROUND

Little research demonstrating the association between nurse continuity and patient outcomes exists despite an intuitive belief that continuity makes a difference in care outcomes.

OBJECTIVE

The aim of this study was to examine the association of nurse continuity with the prevention of hospital-acquired pressure ulcers (HAPU).

METHODS

A secondary use of data from the Hands on Automated Nursing Data System (HANDS) was performed for this comparative study. The HANDS is a nursing plan of care data set containing 42,403 episodes documented by 787 nurses, on nine units, in four hospitals and includes nurse staffing and patient characteristics. The HANDS data set resides in a "big data" relational database consisting of 89 tables and 747 columns of data. Via data mining, we created an analytic data set of 840 care episodes, 210 with and 630 without HAPUs, matched by nursing unit, patient age, and patient characteristics. Logistic regression analysis determined the association of nurse continuity and additional nurse-staffing variables on HAPU occurrence.

RESULTS

Poor nurse continuity (unit mean continuity index = .21-.42 [1.0 = optimal continuity]) was noted on all nine study units. Nutrition, mobility, perfusion, hydration, and skin problems on admission, as well as patient age, were associated with HAPUs (p < .001). Controlling for patient characteristics, nurse continuity, and the interactions between nurse continuity and other nurse-staffing variables were not significantly associated with HAPU development.

DISCUSSION

Patient characteristics including nutrition, mobility, and perfusion were associated with HAPUs, but nurse continuity was not. We demonstrated a high level of variation in the degree of continuity between patient episodes in the HANDS data, showing that it offers rich potential for future study of nurse continuity and its effect on patient outcomes.

Proposing a New Conceptual Model and an Exemplar Measure Using Health Information: Technology to Examine the Impact of Relational Nurse Continuity on Hospital-Acquired Pressure Ulcers

The influence of the staffing variable relational nurse continuity on patient outcomes has been rarely studied and with inconclusive results. Multiple definitions and an absence of systematic methods for measuring the influence of continuity have resulted in its exclusion from nurse-staffing studies and conceptual models. We present a new conceptual model and an innovative use of health information technology to measure relational nurse continuity and to demonstrate the potential for bringing the results of big data science back to the bedside. Understanding the power of big data to address critical clinical issues may foster a new direction for nursing administration theory development.

Predictive Modeling for Comfortable Death Outcome Using Electronic Health Records

Electronic health record (EHR) systems are used in healthcare industry to observe the progress of patients. With fast growth of the data, EHR data analysis has become a big data problem. Most EHRs are sparse and multi-dimensional datasets and mining them is a challenging task due to a number of reasons. In this paper, we have used a nursing EHR system to build predictive models to determine what factors impact death anxiety, a significant problem for the dying patients. Different existing modeling techniques have been used to develop coarse-grained as well as fine-grained models to predict patient outcomes. The coarse-grained models help in predicting the outcome at the end of each hospitalization, whereas fine-grained models help in predicting the outcome at the end of each shift, therefore providing a trajectory of predicted outcomes. Based on different modeling techniques, our results show significantly accurate predictions, due to relatively noise-free data. These models can help in determining effective treatments, lowering healthcare costs, and improving the quality of end-of-life (EOL) care.

Defining the key clinical indicators for ineffective breathing pattern in paediatric patients: a meta-analysis of accuracy studies

AIMS AND OBJECTIVES

The purpose of this study was to identify the key clinical indicators of ineffective breathing pattern among paediatric patients.

BACKGROUND

When nurses perform clinical reasoning, certain characteristics represent the clinical indicators necessary to confirm the presence of a particular diagnosis. Some quantitative studies have reported the prevalence of ineffective breathing pattern in different samples of patients. However, these findings should be synthesised.

DESIGN

Meta-analysis of quantitative nursing studies.

METHODS

Studies were identified via systematic searches of CINAHL, LILACS, PubMed and Scopus using the key search terms 'ineffective', 'breathing' and 'pattern'. Additional quality-related inclusion criteria were gleaned from the Cochrane Collaboration for Systematic Reviews of Diagnostic Test Accuracy, the Standards for Reporting of Diagnostic Accuracy and the Quality Assessment of Diagnostic Accuracy Studies. The pertinent results from each study were extracted and analysed via meta-analysis.

RESULTS

Six studies using paediatric populations met the inclusion criteria. Summary measures indicated that the following defining characteristics had the highest accuracy values for ineffective breathing pattern among children: bradypnoea, dyspnoea, nasal flaring, orthopnoea, tachypnoea and the use of accessory muscles to breathe.

CONCLUSION

This meta-analysis provides information regarding the accuracy of the clinical indicators of ineffective breathing pattern from studies sampling diverse paediatric populations.

RELEVANCE TO CLINICAL PRACTICE

Nurses can better use clinical indicators to infer the presence of ineffective breathing pattern when they are aware of the most relevant defining characteristics. Nursing students and professionals can also improve their critical thinking abilities and diagnostic reasoning based on these findings.

Are we talking about the same patient?

The objective of this study is to determine the degree of similarities between the clinical terms used by physicians and nurses in their documentation.

Death anxiety in hospitalized end-of-life patients as captured from a structured electronic health record: differences by patient and nurse characteristics

The nursing outcomes of hospitalized patients whose plans of care include death anxiety, which is a diagnosis among patients at the end-of-life, are obscure. The authors of the current article applied data mining techniques to nursing plan-of-care data for patients diagnosed with death anxiety, as defined by North American Nursing Diagnosis Association International, from four different hospitals to examine nursing care outcomes and associated factors. Results indicate that <50% of patients met the expected outcome of comfortable death. Gerontology unit patients were more likely to meet the expected outcome than patients from other unit types, although results were not statistically significant. Younger patients (i.e., age <65) had a lower chance of meeting the outcome compared with older patients (i.e., age ≥65) (χ(2)(1) = 9.266, p < 0.004). Longer stays improved the chances of meeting the outcome (χ(2)(2) = 6.47, p < 0.04). Results indicate that death anxiety outcomes are suboptimal and suggest the need to better educate clinicians about diagnosing and treating death anxiety among patients who face the end-of-life transition.

Evaluating a Clinical Decision Support Interface for End-of-Life Nurse Care

Clinical Decision Support Systems (CDSS) are tools that assist healthcare personnel in the decision-making process for patient care. Although CDSSs have been successfully deployed in the clinical setting to assist physicians, few CDSS have been targeted at professional nurses, the largest group of health providers. We present our experience in designing and testing a CDSS interface embedded within a nurse care planning and documentation tool. We developed four prototypes based on different CDSS feature designs, and tested them in simulated end-of-life patient handoff sessions with a group of 40 nurse clinicians. We show how our prototypes directed nurses towards an optimal care decision that was rarely performed in unassisted practice. We also discuss the effect of CDSS layout and interface navigation in a nurse's acceptance of suggested actions. These findings provide insights into effective nursing CDSS design that are generalizable to care scenarios different than end-of-life.

Health data use, stewardship, and governance: ongoing gaps and challenges: a report from AMIA's 2012 Health Policy Meeting

Large amounts of personal health data are being collected and made available through existing and emerging technological media and tools. While use of these data has significant potential to facilitate research, improve quality of care for individuals and populations, and reduce healthcare costs, many policy-related issues must be addressed before their full value can be realized. These include the need for widely agreed-on data stewardship principles and effective approaches to reduce or eliminate data silos and protect patient privacy. AMIA's 2012 Health Policy Meeting brought together healthcare academics, policy makers, and system stakeholders (including representatives of patient groups) to consider these topics and formulate recommendations. A review of a set of Proposed Principles of Health Data Use led to a set of findings and recommendations, including the assertions that the use of health data should be viewed as a public good and that achieving the broad benefits of this use will require understanding and support from patients.

Evidence for the existing American Nurses Association-recognized standardized nursing terminologies: a systematic review

OBJECTIVE

To determine the state of the science for the five standardized nursing terminology sets in terms of level of evidence and study focus.

DESIGN

Systematic review.

DATA SOURCES

Keyword search of PubMed, CINAHL, and EMBASE databases from 1960s to March 19, 2012 revealed 1257 publications.

REVIEW METHODS

From abstract review we removed duplicate articles, those not in English or with no identifiable standardized nursing terminology, and those with a low-level of evidence. From full text review of the remaining 312 articles, eight trained raters used a coding system to record standardized nursing terminology names, publication year, country, and study focus. Inter-rater reliability confirmed the level of evidence. We analyzed coded results.

RESULTS

On average there were 4 studies per year between 1985 and 1995. The yearly number increased to 14 for the decade between 1996 and 2005, 21 between 2006 and 2010, and 25 in 2011. Investigators conducted the research in 27 countries. By evidence level for the 312 studies 72.4% were descriptive, 18.9% were observational, and 8.7% were intervention studies. Of the 312 reports, 72.1% focused on North American Nursing Diagnosis-International, Nursing Interventions Classification, Nursing Outcome Classification, or some combination of those three standardized nursing terminologies; 9.6% on Omaha System; 7.1% on International Classification for Nursing Practice; 1.6% on Clinical Care Classification/Home Health Care Classification; 1.6% on Perioperative Nursing Data Set; and 8.0% on two or more standardized nursing terminology sets. There were studies in all 10 foci categories including those focused on concept analysis/classification infrastructure (n=43), the identification of the standardized nursing terminology concepts applicable to a health setting from registered nurses' documentation (n=54), mapping one terminology to another (n=58), implementation of standardized nursing terminologies into electronic health records (n=12), and secondary use of electronic health record data (n=19).

CONCLUSIONS

Findings reveal that the number of standardized nursing terminology publications increased primarily since 2000 with most focusing on North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification. The majority of the studies were descriptive, qualitative, or correlational designs that provide a strong base for understanding the validity and reliability of the concepts underlying the standardized nursing terminologies. There is evidence supporting the successful integration and use in electronic health records for two standardized nursing terminology sets: (1) the North American Nursing Diagnosis-International, Nursing Interventions Classification, and Nursing Outcome Classification set; and (2) the Omaha System set. Researchers, however, should continue to strengthen standardized nursing terminology study designs to promote continuous improvement of the standardized nursing terminologies and use in clinical practice.

Challenges and solutions for using informatics in research

Computer technology provides innovations for research but not without concomitant challenges. Herein, we present our experiences with technology challenges and solutions across 16 nursing research studies. Issues included intervention integrity, software updates and compatibility, web accessibility and implementation, hardware and equipment, computer literacy of participants, and programming. Our researchers found solutions related to best practices for computer-screen design and usability testing, especially as they relate to the target populations' computer literacy levels and use patterns; changes in software; availability and limitations of operating systems and web browsers; resources for on-site technology help for participants; and creative facilitators to access participants and implement study procedures. Researchers may find this information helpful as they consider successful ways to integrate informatics in the design and implementation of future studies with technology that maximizes research productivity.

Maintaining a consistent big picture: meaningful use of a Web-based POC EHR system

OBJECTIVE

  To test the hypothesis that Hands-on Automated Nursing Data System (HANDS) "big picture summary" can be implemented uniformly across diverse settings, and result in positive registered nurse (RN) and plan of care (POC) data outcomes across time.

DESIGN

  In a longitudinal, multisite, full test study, a representative convenience sample of eight medical-surgical units from four hospitals (one university, two large community, and one small community) in one Midwestern state implemented the HANDS intervention for 24 (four units) or 12 (four units) months.

MEASUREMENTS

  (a) RN outcomes-percentage completing training, satisfaction with standardized terminologies, perception of HANDS usefulness, POC submission compliance rate. (b) POC data outcomes-validity (rate of optional changes/episode); reliability of terms and ratings; and volume of standardized data generated.

RESULTS

  One hundred percent of the RNs who worked on the eight study units successfully completed the required standardized training; all units selected participated for the entire 12- or 24-month designated period; compliance rates for POC entry at every patient hand-off were 78-92%; reliability coefficients for use of the standardized terms and ratings were moderately strong; the pattern of optional POC changes per episode declined but remained reasonable across time; and the nurses generated a database of 40,747 episodes of care.

LIMITATIONS

  Only RNs and medical-surgical units participated.

CONCLUSION

  It is possible to effectively standardize the capture and visualization of useful "big picture" healthcare information across diverse settings. Findings offer a viable alternative to the current practice of introducing new health information layers that ultimately increase the complexity and inconsistency of information for frontline users.

Data mining nursing care plans of end-of-life patients: a study to improve healthcare decision making

PURPOSE

To reveal hidden patterns and knowledge present in nursing care information documented with standardized nursing terminologies on end-of-life (EOL) hospitalized patients.

METHOD

596 episodes of care that included pain as a problem on a patient's care plan were examined using statistical and data mining tools. The data were extracted from the Hands-On Automated Nursing Data System database of nursing care plan episodes (n = 40,747) coded with NANDA-I, Nursing Outcomes Classification, and Nursing Intervention Classification (NNN) terminologies. System episode data (episode = care plans updated at every hand-off on a patient while staying on a hospital unit) had been previously gathered in eight units located in four different healthcare facilities (total episodes = 40,747; EOL episodes = 1,425) over 2 years and anonymized prior to this analyses.

RESULTS

Results show multiple discoveries, including EOL patients with hospital stays (<72 hr) are less likely (p < .005) to meet the pain relief goals compared with EOL patients with longer hospital stays.

CONCLUSIONS

  The study demonstrates some major benefits of systematically integrating NNN into electronic health records.

Model for the First NIH-funded Center of Excellence in End-of-Life Research

Centers of excellence are widely acknowledged as a mechanism to promote scientific advances in a particular field of science, but until recently there have been no end-of-life or palliative care research centers funded by the National Institutes of Health (NIH). The purpose of this article is to describe aims, framework, and organizational structure of the first NIH-funded Center of Excellence on end-of-life research, the Center for End-of-Life Transition Research (CEoLTR), and the advances in end-of-life research that the CEoLTR will facilitate. The teams of researchers involved in the CEoLTR have grown impressively since it was funded in 2007. Collectively, the teams are on target to accomplish all of the original goals for this five year award.

Top EHR challenges in light of the stimulus. Enabling effective interdisciplinary, intradisciplinary and cross-setting communication

US healthcare is undergoing a transformation. The economic stimulus plan is intended to transform healthcare through health IT. The government has defined "meaningful use" of health IT. Healthcare is a team activity, and as such presents a challenge to the concept of meaningful use. While encoding clinical data into a computer is a positive step, it is not enough. A continuity-of-care record is needed to document and measure care; support clinical care; and coordinate care with public health agencies. This paper examines current research to assist decisionmakers moving forward. To realize the promise, integration across all clinical disciplines is critical. There are many challenges. These include: the threat of information overload, both at the transitions of care and between disciplines; the need to provide for data-sharing between clinical and public health agencies, an important component in both local community and national health issues; how to use health IT to improve the delivery of healthcare, especially with unintended outcomes of any change in healthcare and paper persistence; and addressing different views of "meaningful" for different uses and users of health IT. All of these challenges need to be considered for wise installation of health IT. In addition, attention must be paid to weaknesses in the current healthcare system to prevent codifying them in health IT.

The HANDS project: studying and refining the automated collection of a cross-setting clinical data set

The consistent availability of a core set of clinical nursing data is essential to promote quality patient care. Although important work to improve terminology and enhance comparability of data is underway, the efforts do not address the immediate need for useful nursing data sets and valid methods of collection at the point of data entry. The Hands-on Automated Nursing Data System (HANDS) project is dedicated to refining a feasible methodology for gathering, storing, and retrieving a standardized nursing data set. To date the project team has developed and tested a prototype research tool that is automated and contains the structured terminologies (North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification) to represent nursing diagnoses, outcomes, and interventions, respectively. The Phase I project development activities are reported in this article, along with Phase II and III plans for testing and refining the methodology under actual clinical conditions. Results and lessons learned during Phase I are reported.

Norms and nurse management of conflicts: keys to understanding nurse-physician collaboration

In this cross-sectional study, registered nurses from 36 emergency rooms completed an abridged version of the Organizational Culture Inventory (Cooke & Lafferty, 1989) and responded to nine hypothetical conflict vignettes. Stepwise regressions were performed with nurse conflict style intentions as dependent variables and 10 independent variable (three sets of norms, five measures of conflict styles expected to be used by the physician, gender, and education). Nurses' expectations for physicians to collaborate and strong constructive and aggressive norms were found to explain a moderate amount of variance (32%) in nurses' intentions to collaborate in conflicts conducive to nurse-physician collaboration. The findings of this study provide support for the proposed theoretical framework and can be used to design interventions that promote nurse-physician collaboration.

Extradural diamorphine with adrenaline in labour: comparison with diamorphine and bupivacaine

In a randomized double-blind study of 51 primigravida, we have examined the relative efficacies of bupivacaine, diamorphine or diamorphine with adrenaline given by the extradural route for relief of pain during labour. Group 1 (n = 18) received diamorphine 5 mg in 0.9% sodium chloride 8 ml; group 2 (n = 19) received diamorphine 5 mg in 0.9% sodium chloride 8 ml with 1:200,000 adrenaline; group 3 (n = 14) received 0.375% bupivacaine 8 ml. All patients received 0.375% bupivacaine 8 ml as a supplement after the initial analgesia had subsided. Patients in all groups had satisfactory and comparable analgesia 20 min after the initial injection. However, after 60 min and up to 8 h, analgesia was superior in group 2 as assessed by linear analogue pain scores, with statistical significance at 4, 6 and 8 h. Groups 1 and 2 required bupivacaine supplements less frequently than group 3 (P less than 0.001). There were no serious adverse effects in any group, but pruritus was a feature in the diamorphine groups. Diamorphine 5 mg may be used as an alternative to bupivacaine 0.375% 8 ml in the first stage of labour and provides a longer duration of action. The addition of adrenaline 1:200,000 appears to augment both the quality and duration of analgesia.