- Email: [email protected]
Comments Regarding “Collaborative and Supervising Relationships between Attending Physicians and APNs in LTC Facilities”
OFFICIAL SECTION OF THE
Gerontological Advanced Practice Nurses Association
Comments Regarding “Collaborative and Supervising Relationships between Attending Physicians and APNs in LTC Facilities” Alice Early, MSN, ANP-BC “If you can’t describe what you are doing as a process, you don’t know what you are doing.” dW. Edwards Deming The article “Collaborative and Supervising Relationships between Attending Physicians and APNs in LTC Facilities” is an attempt to describe the process of providing team-based medical care that is appropriate, timely, and high-quality. Although a great portion of the article focuses on describing “supervision” of the advanced practice nurse (APN), its overall intent is to describe team-based medical care in long-term care, the roles and competencies of physician and APNs and the development of a collaborative relationship. It is hoped that outcomes of the article will be greater appreciation and knowledge of the APN’s role in the process of providing care and encouraging a greater understanding of how our physician colleagues can work most effectively in team-based models of care.
GAPNA Honors Outstanding Members Who Are Making a Difference in Geriatrics Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist Assistant Professor of Nursing University of Mississippi Medical Center Jackson, MS Alicia Wolf, GNP-BC was awarded Excellence in Leadership for outstanding leadership demonstrated through her commitment to geriatric care exhibited through direct care, education, and research. She has demonstrated the tenacity to advocate for geriatric education and provide care in a variety of settings, exemplifying leadership as an important element of the mission of geriatric nursing expertise. She most notably spearheaded the Ohio Geriatric Continuing Education Day and
Geriatric Nursing, Volume 32, Number 1
works to promote a self-employment model in the service of seniors in her practice. Mary Perloe, APRN-BC, GNP, received the Excellence in Research Award for her commitment to research in geriatric nursing. She demonstrated her commitment through the development and participation in research projects that emphasize and go beyond the traditional service role of the profession. Dr. Perloe has exemplified the nursing scientist by participating in a collaborative effort to develop “Care Transitions” with Dr. Joseph Ouslander and Dr. Gerri Lamb, to be used in the long-term care environment. She also serves on Medicare’s Home Health Quality Improvement Expert Panel and Care Transitions Measure Development Technical Expert Panel. Katherine Abraham, MSN, RN, NP-C, won the Excellence in Clinical Practice Award for her commitment to geriatric clinical practice. She has demonstrated outstanding geriatric care that goes beyond the traditional service role of her profession. Dr. Abraham is an excellent nurse practitioner and mentor. She teaches nurse practitioners at Emory College and has developed an information sheet, “Cardiac Pearls,” which is widely used by Evercare. Carolyn Clevenger, DNP, GNP-BC, won the Excellence in Education Award for being involved in teaching and designing gerontological nurse practitioner curriculum and course content. She has demonstrated knowledge regarding the care of older adults and has the ability to translate that knowledge to enhance students’ understanding in innovative ways. Dr. Clevenger encourages and inspires advanced practice students to develop their expertise in geriatric care. She is also a recent recipient of the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) Technology Integration Program for Nursing Education and Practice. The Chapter Excellence Award was awarded to the Georgia Chapter because they have been promoting the goals of GAPNA through their member relationships, professional activities, and promotion of advanced practice gerontological nursing locally, regionally, and throughout the state. This chapter is growing its size and is active in promoting geriatric education to nurse practitioners in Georgia.
63
2010 GAPNA Annual Conference Poster and Presentation Award Winners: Research and Practice Models Edited by Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist There were many outstanding posters and presentations shared at the GAPNA conference in September 2010. The following are the abstracts of the winning presentations and posters, as well as the Student Foundation Award.
Research Presentation Award Nurses’ Knowledge of Age-Related Hearing Loss and Its Treatment Margaret I. Wallhagen, PhD, GNP-BC, AGSF, FAAN, Professor Department of Physiological Nursing University of California San Francisco Purpose: To assess nurses’ knowledge of agerelated hearing loss (HL) and its treatment, including awareness of types of resources available to persons with HL. Background: Approximately 37% of persons aged $65 and 50% in those $75 have HL. HL is not benign; studies document its association with depression, isolation, lowered self-esteem, and functional decline. Close partners are also affected. Yet HL is often not assessed in primary care, and most nurses have minimal knowledge about age-related HL, its impact, and hearing aids or other assistive listening devices. Lack of proficiency in the care of older adults with HL impacts their quality of life and the safe management of chronic illnesses when specific information is not heard or is misunderstood. To develop an intervention to enhance nurses’ ability to work with older adults with HL, data are needed regarding gaps in their knowledge. Method: An Internet survey using Zoomerang was used to reach nurses from a variety of settings to assess knowledge of age-related HL and its treatment, specific demographic information that may be associated with level of knowledge, and the types of educational programs viewed as most helpful to gain this knowledge. Analyses: Descriptive, correlational analytic techniques were used. Findings: 205 nurses (RN, 11%; NP, 74%; CNS, 10%) participated. Average number of years in
64
practice was 26.5 (SD, 5 11; range, 5 1e54). Most had received education in gerontology, 84.4% at the advanced practice level, 16% through continuing education or a certificate-granting program. Almost half (46%) noted that they had worked extensively with persons with HL. Overall, most participants were aware of age-related HL and its impact on understanding. However, there were gaps in awareness and areas in which an important minority reported not knowing the information, especially as it related to adapting to hearing aids, awareness of HL, not hearing consonants, and believing that HL was like wearing earplugs. In contrast, a majority of participants did not feel proficient in dealing with problems that might arise, knowing about resources available to persons with HL, knowing about disability regulations, and knowing about various captioning services. There was a significant but moderate correlation between knowledge and perceived proficiency (r 5 .274, P 5 .000), between education in gerontology at an advanced practice level and knowledge (unstandardized beta, 2.05, P 5 .029) and between education in gerontology at an advanced practice level and perceived proficiency (unstandardized beta: 3.99, P 5 .000). However, 72% of participants did not feel they had received enough education related to agerelated HL in their educational programs. Conclusions: Knowledge of age-related HL was fairly good, but gaps in specific areas could influence how practitioners approach older adults and their families. However, the data support a need for health professional education regarding HL, hearing aids, assistive listening devices, and other resources available to older adults with HL, especially given the importance of HL to older adults and their families. Because this was a relatively small sample with a fairly significant number of advanced practice nurses, additional studies with expanded populations are needed.
Clinical Project Presentation Award Move It or Lose It: Patient Mobility Project Sonia Lee, RN, MSN, GCNS, APN, and Jill Swinning, RN, MSN, ACNS, APN Purpose: Embed patient mobility into nursing workflow by minimizing the barriers. Reinforce staff compliance through education and tracking. Background: A frequent complication of hospitalized older adults is functional decline. In
Geriatric Nursing, Volume 32, Number 1
the busy patient-care environment, nursing has forgotten the importance of maintaining patients’ function. Literature Review: Low mobility is an independent predictor of poor hospital outcomes, specifically functional decline, iatrogenic complications, nursing home placement, and death.1,2 Low mobility and bed rest are common occurrences.2,3 Wakefield’s (2007)4 study on the functional trajectory from preadmission baseline to discharge demonstrated the possibility to recover functional loss during hospitalization. Methods: A Geriatric Clinical Nurse Specialist (GCNS) and Adult Clinical Nurse Specialist (ACNS) student initiated the “Move It or Lose It” project on 4 medical-surgical units at a community-teaching hospital. A multidisciplinary task force consisting of frontline staff evaluated the barriers that prevent patients from getting out of bed. Interventions were put in place to create a work environment that enforces and monitors patient mobility. Nursing shared-governance structure will be used to disseminate this project to 3 other hospitals in the corporate system. Results: Initial increase in percentage of patients in the chair for meals and ambulating in the halls has been noted. Because of the recent implementation, full impact has not been recognized. Application to Practice: Evaluating the existing nursing work environment to minimize the barriers to mobilize patients can benefit hospitalized older adults.
References 1.
2.
3.
4.
Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc 2004;52:1263-70. Harte BD, Birkas J, Lachmann M, et al. Promoting positive outcomes for elderly persons in the hospital: prevention and risk factor modification. AACN Clinical Issues 2002;13:22-33. Callen B, Mahoney J, Wells TJ, et al. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatr Nurs 2004;25: 212-7. Wakefield B. Function trajectories associated with hospitalization in older adults. West J Nurs Res 2007;29:161-77.
Geriatric Nursing, Volume 32, Number 1
Research Poster Award Predictors of Recovery in Older Adults Following Cardiac Surgery Katherine M. Aldrich, RN, PhD, NP Nancy Stotts, RN, EdD, FAAN Virginia Carrieri-Kohlman, RN, DNS, FAAN and Mark Rollins, MD, PhD Problem: Cardiac surgery is frequently performed in older adults, but little is known about the quality of recovery (QoR) during the first postoperative month. Older adults are less likely to regain prior functional status by hospital discharge, and temporary postoperative functional loss may become permanent, adversely affecting QoR. Therefore, aims of this study were to examine relationships among pain, wound healing, surgical risk, functional status, mood, quality of life (QoL), and QoR at discharge and 30 days; estimate the effects of change over time in functional status, mood, and QoL on the change in QoR from discharge to 30 days postoperatively; describe participants’ perception of factors hindering or promoting their recovery; and the amount of recovery achieved 1 month after cardiac surgery. Methods: In this prospective cohort study, functional status, mood, and QoL were assessed preoperatively, at discharge, and at 30 days postoperatively. Functional status was operationalized as performance of basic (BADL) and intermediate (IADL) activities of daily living. Wound healing and pain were assessed for the first 5 postoperative days and at 30 days. Surgical risk was assessed preoperatively. QoR was assessed at discharge and 30 days. A 1-month interview assessed promoters and inhibitors of recovery and percentage of achieved recovery. Nonparametric correlation and multilevel negative binomial regression were used for analysis. Results: Subjects (n 5 62) were mostly men (74.2%) with a mean age of 75.9 (SD 7.01). The most frequent procedure performed was coronary artery bypass grafting (73%). Preoperative BADL/IADL was correlated with QoR at discharge (rho 5 .35, .37) and 30 days (n 5 59, rho 5 .46, .27). Preoperative mood and QoL correlated with QoR at 30 days (rho 5 e.43, .53). Multilevel models showed significant changes between BADL, IADL, and QoR over time, with the greatest predicted effect on QoR resulting from the change in IADL. Changes in mood state and QoL, although significant, did not have a significant
65
effect on the predicted change in QoR. At 30 days, family support was identified by 58% of the sample as the most important promoter of recovery. Mobility limits, particularly driving prohibitions, were identified as the greatest hindrance. In addition, 62% of the sample had perceived recovery levels of 75% 1 month after surgery. Conclusions: Functional status, particularly ability to perform IADLs, affects QoR in older cardiac surgery patients. Perception of recovery in a majority of patients is considerable, enhanced by family and social support. Future research needs to determine methods of promoting functional ability and determining effective support for those lacking social resources to improve QoR during the first postoperative month this vulnerable population.
Clinical Project Poster Award Alliance for the Ages: Geriatric Interdisciplinary Teamwork Is Central to Quality Care and Improved Outcomes for Our Hospitalized Elders Lynn Etters, MSN, NP-C, GNP-BC, and Diana LaBumbard, MSN, ACNP-BC Homeostenosis,1 a concept of aging, can impair the ability of older adults to compensate for acute physiologic illness and stress (Fig. 1). Homeostenosis refers to the principles of physiologic reserve. This reserve is the body’s ability to withstand illness stressors. As the body ages, physiologic reserve declines; older adults are able to function under normal conditions with loss of reserve but are less likely to withstand outside insults and stressors. In addition, older hospitalized adults may have complex medical, physiological, and social needs. Shaping the care of older adults is dependent on the provision of opportunities that will increase knowledge for health care workers. Lynn Etters, MSN, NP-C, GNP-BC, created a project titled “Homeostenosis” through the Geriatric Nursing Leadership Academy and the Honor Society of Nursing, Sigma Theta Tau International, that was funded by the John A. Hartford Foundation. The project uses techniques to decrease the threat to physiologic reserve that occurs with hospitalization of older adults. The program facilitates a continuum of care specific to the older adult who transitions between multiple settings by improving communication among health care providers and offering nurses 66
Figure 1. The “precipice” of homestenosis.
a specific skill set to use to assess and treat older adults. A geriatric interdisciplinary team (GIT) approach to the clinical experience permits the opportunity to build and develop geriatric education at the same time offering patient centered care. Rooted in Kristen Swanson’s theory of caring,2 the GIT at Huron Valley-Sinai Hospital assists the health care team to be prepared to meet the needs of older patients and their families. Applying evidence-based strategies decreases the functional decline that is often experienced in hospitalized older adults. The GIT is made up of the following practitioners: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Acute care nurse practitioner Nurse manager(s) General and geriatric certified RNs Geriatrician Social worker Dietitian Physical therapist Speech therapist Pharmacist Spiritual care
The GIT is provided with resources, tools, and instruction in the care of geriatric patients. In addition, various focused educational opportunities and experiences such as aging sensitivity training, dementias versus delirium instruction, and communication strategies are organized on a regular basis. Once a week, the bedside RN presents his or her SPICES assessments3 on older adult patients and begins the discussion about appropriate interventions, consults, and follow-up needs for each. This interdisciplinary approach allows for the sharing of expertise and knowledge within the whole team. Benefits of this discussion are multifaceted and include a comprehensive, integrated and patient focused plan of care for the patient and Geriatric Nursing, Volume 32, Number 1
their family. Following the discussion, the nurse presents the plan of care to the patient and family. Ultimately, this has led to competence-based education, comprehensive assessments, and evidence-based interventions. The GIT and ongoing education of health care providers at Huron Valley-Sinai Hospital has improved patient outcomes; increased patient, family, and staff satisfaction; and prevented iatrogenic problems among hospitalized elders.
References 1.
2.
3.
Etters L. Homeostenosis. Geriatric Nursing Leadership Academy, project submission, 2008. Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991;40:161-66 Fulmer T. SPICES: an overall assessment tool for older adults. Am J Nurs 2007;107:40-8.
Student Foundation Award/Travel Award The Effects of Low-Frequency Noncontact Ultrasound on Pain Management in Patients with Chronic Pressure Ulcers, VA ECHS Medical Center Jessica Marlowe, BSN, RN, MSN/CNS Student Devon Obenauer, BSN, RN Carol Brookshire, MS, GNP-BC and Allison E. Williams, ND, PhD Background: Wound care costs the U.S. health care system an estimated $20 billion annually.1 Interventions, including low-frequency noncontact ultrasound (LFNU), have been shown to decrease the healing time of wounds. Numerous studies have shown that LFNU allows wounds to heal faster by delivering low-energy, low-intensity ultrasound through a saline solution onto the wound bed, which decreases bio-load by damaging bacteria cell walls, stimulates fibroblast activity, increases blood flow, and provides cleansing.2-4 We piloted LFNU at a 60-bed facility with a mix of long-term care, rehabilitation, and respite patients. Patients who received LFNU stated that the treatments were soothing and that LFNU provided pain relief. Purpose: The purpose of this quality assurance project was to determine: 1) whether LFNU can provide additional pain relief to Geriatric Nursing, Volume 32, Number 1
patients with chronic wounds and 2) whether LFNU can decrease the size of the wound. Methods: A retrospective analysis was done to evaluate the pain levels of male rehabilitation patients with an average age of 60 years who received LFNU from January 2009 to September 2009. Patients received LFNU 3 days per week until the wound healed or the patient was discharged. Random pretreatment pain scores from the same hospital stay, treatment day pain scores, pain scores across the duration of LFNU, and pre- and post-treatment wound measurements were collected from the patient’s medical record. Two staff nurses reviewed the data to verify accuracy. Descriptive statistics were performed to summarize pain scores from treatment days, nontreatment days, and duration of treatment. The Wilcoxon test was used to analyze change in wound size. Results: Of the 6 patients, 4 showed a decreased pain average while receiving LFNU. Three showed at least a 15% decrease in average pain score over the duration of LFNU and at least a 19% decrease in pain during the day of LFNU. Two patients showed an increase in pain during LFNU. One had a history of narcotic abuse, and the other was recovering from a neurological disorder resulting in decreased sensation, possibly explaining his increased pain levels as he regained feeling. Wound surface area decreased for all subjects who received LFNU. Pretreatment average wound size was 24 cm2, and posttreatment wound size was 17.1 cm2. This difference was significant (P \ .01). Implications for Practice: Our findings indicate that LFNU decreased average pain scores in patients with chronic wounds both immediately posttreatment and throughout the duration of their treatments. Additionally, our results suggest that LFNU contributed to wound healing. A formal research study with a larger sample in a controlled environment would provide more accurate results. Patients with a history of narcotic abuse or decreased sensation should be excluded from the research to keep from skewing the results. An alternate study should be performed to determine whether pain reduction from LFNU decreases narcotic use.
References 1.
Ablaza VJ, Gingrass MK, Perry LC, et al. Tissue temperatures during ultrasound-assisted
67
2.
3.
4.
68
lipoplasty. Plast Reconstr Surg 1998;102: 534-42. Lai J, Pittelkow M. Physiological effects of ultrasound mists on fibroblasts. Int J Dermatol 2007;46:587-93. Liedl S, Kavros D. Low frequency ultrasound therapy for wound management. Antham 2001;28:244-52. Wagner FW. Classification and treatment program for diabetic, neuropathic and dysvascular foot problems. Instructional Course Lectures 28. American Academy of Orthopadic Surgeons; 1979.
0197-4572/$ - see front matter Ó 2011 Published by Mosby, Inc. doi:10.1016/j.gerinurse.2010.12.006
Correction Geriatric Nursing, Volume 31, Number 5, September/October 2010, “Ctyochrome P450: Drug MetabolismdWhy It’s So Important to Understand.” On page 385, column 2, paragraph 3, line 14: “simvastatin (Viagra)” should read “simvastatin (Zorcor).”
Geriatric Nursing, Volume 32, Number 1
Gerontological Advanced Practice Nurses Association
Comments Regarding “Collaborative and Supervising Relationships between Attending Physicians and APNs in LTC Facilities” Alice Early, MSN, ANP-BC “If you can’t describe what you are doing as a process, you don’t know what you are doing.” dW. Edwards Deming The article “Collaborative and Supervising Relationships between Attending Physicians and APNs in LTC Facilities” is an attempt to describe the process of providing team-based medical care that is appropriate, timely, and high-quality. Although a great portion of the article focuses on describing “supervision” of the advanced practice nurse (APN), its overall intent is to describe team-based medical care in long-term care, the roles and competencies of physician and APNs and the development of a collaborative relationship. It is hoped that outcomes of the article will be greater appreciation and knowledge of the APN’s role in the process of providing care and encouraging a greater understanding of how our physician colleagues can work most effectively in team-based models of care.
GAPNA Honors Outstanding Members Who Are Making a Difference in Geriatrics Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist Assistant Professor of Nursing University of Mississippi Medical Center Jackson, MS Alicia Wolf, GNP-BC was awarded Excellence in Leadership for outstanding leadership demonstrated through her commitment to geriatric care exhibited through direct care, education, and research. She has demonstrated the tenacity to advocate for geriatric education and provide care in a variety of settings, exemplifying leadership as an important element of the mission of geriatric nursing expertise. She most notably spearheaded the Ohio Geriatric Continuing Education Day and
Geriatric Nursing, Volume 32, Number 1
works to promote a self-employment model in the service of seniors in her practice. Mary Perloe, APRN-BC, GNP, received the Excellence in Research Award for her commitment to research in geriatric nursing. She demonstrated her commitment through the development and participation in research projects that emphasize and go beyond the traditional service role of the profession. Dr. Perloe has exemplified the nursing scientist by participating in a collaborative effort to develop “Care Transitions” with Dr. Joseph Ouslander and Dr. Gerri Lamb, to be used in the long-term care environment. She also serves on Medicare’s Home Health Quality Improvement Expert Panel and Care Transitions Measure Development Technical Expert Panel. Katherine Abraham, MSN, RN, NP-C, won the Excellence in Clinical Practice Award for her commitment to geriatric clinical practice. She has demonstrated outstanding geriatric care that goes beyond the traditional service role of her profession. Dr. Abraham is an excellent nurse practitioner and mentor. She teaches nurse practitioners at Emory College and has developed an information sheet, “Cardiac Pearls,” which is widely used by Evercare. Carolyn Clevenger, DNP, GNP-BC, won the Excellence in Education Award for being involved in teaching and designing gerontological nurse practitioner curriculum and course content. She has demonstrated knowledge regarding the care of older adults and has the ability to translate that knowledge to enhance students’ understanding in innovative ways. Dr. Clevenger encourages and inspires advanced practice students to develop their expertise in geriatric care. She is also a recent recipient of the U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) Technology Integration Program for Nursing Education and Practice. The Chapter Excellence Award was awarded to the Georgia Chapter because they have been promoting the goals of GAPNA through their member relationships, professional activities, and promotion of advanced practice gerontological nursing locally, regionally, and throughout the state. This chapter is growing its size and is active in promoting geriatric education to nurse practitioners in Georgia.
63
2010 GAPNA Annual Conference Poster and Presentation Award Winners: Research and Practice Models Edited by Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist There were many outstanding posters and presentations shared at the GAPNA conference in September 2010. The following are the abstracts of the winning presentations and posters, as well as the Student Foundation Award.
Research Presentation Award Nurses’ Knowledge of Age-Related Hearing Loss and Its Treatment Margaret I. Wallhagen, PhD, GNP-BC, AGSF, FAAN, Professor Department of Physiological Nursing University of California San Francisco Purpose: To assess nurses’ knowledge of agerelated hearing loss (HL) and its treatment, including awareness of types of resources available to persons with HL. Background: Approximately 37% of persons aged $65 and 50% in those $75 have HL. HL is not benign; studies document its association with depression, isolation, lowered self-esteem, and functional decline. Close partners are also affected. Yet HL is often not assessed in primary care, and most nurses have minimal knowledge about age-related HL, its impact, and hearing aids or other assistive listening devices. Lack of proficiency in the care of older adults with HL impacts their quality of life and the safe management of chronic illnesses when specific information is not heard or is misunderstood. To develop an intervention to enhance nurses’ ability to work with older adults with HL, data are needed regarding gaps in their knowledge. Method: An Internet survey using Zoomerang was used to reach nurses from a variety of settings to assess knowledge of age-related HL and its treatment, specific demographic information that may be associated with level of knowledge, and the types of educational programs viewed as most helpful to gain this knowledge. Analyses: Descriptive, correlational analytic techniques were used. Findings: 205 nurses (RN, 11%; NP, 74%; CNS, 10%) participated. Average number of years in
64
practice was 26.5 (SD, 5 11; range, 5 1e54). Most had received education in gerontology, 84.4% at the advanced practice level, 16% through continuing education or a certificate-granting program. Almost half (46%) noted that they had worked extensively with persons with HL. Overall, most participants were aware of age-related HL and its impact on understanding. However, there were gaps in awareness and areas in which an important minority reported not knowing the information, especially as it related to adapting to hearing aids, awareness of HL, not hearing consonants, and believing that HL was like wearing earplugs. In contrast, a majority of participants did not feel proficient in dealing with problems that might arise, knowing about resources available to persons with HL, knowing about disability regulations, and knowing about various captioning services. There was a significant but moderate correlation between knowledge and perceived proficiency (r 5 .274, P 5 .000), between education in gerontology at an advanced practice level and knowledge (unstandardized beta, 2.05, P 5 .029) and between education in gerontology at an advanced practice level and perceived proficiency (unstandardized beta: 3.99, P 5 .000). However, 72% of participants did not feel they had received enough education related to agerelated HL in their educational programs. Conclusions: Knowledge of age-related HL was fairly good, but gaps in specific areas could influence how practitioners approach older adults and their families. However, the data support a need for health professional education regarding HL, hearing aids, assistive listening devices, and other resources available to older adults with HL, especially given the importance of HL to older adults and their families. Because this was a relatively small sample with a fairly significant number of advanced practice nurses, additional studies with expanded populations are needed.
Clinical Project Presentation Award Move It or Lose It: Patient Mobility Project Sonia Lee, RN, MSN, GCNS, APN, and Jill Swinning, RN, MSN, ACNS, APN Purpose: Embed patient mobility into nursing workflow by minimizing the barriers. Reinforce staff compliance through education and tracking. Background: A frequent complication of hospitalized older adults is functional decline. In
Geriatric Nursing, Volume 32, Number 1
the busy patient-care environment, nursing has forgotten the importance of maintaining patients’ function. Literature Review: Low mobility is an independent predictor of poor hospital outcomes, specifically functional decline, iatrogenic complications, nursing home placement, and death.1,2 Low mobility and bed rest are common occurrences.2,3 Wakefield’s (2007)4 study on the functional trajectory from preadmission baseline to discharge demonstrated the possibility to recover functional loss during hospitalization. Methods: A Geriatric Clinical Nurse Specialist (GCNS) and Adult Clinical Nurse Specialist (ACNS) student initiated the “Move It or Lose It” project on 4 medical-surgical units at a community-teaching hospital. A multidisciplinary task force consisting of frontline staff evaluated the barriers that prevent patients from getting out of bed. Interventions were put in place to create a work environment that enforces and monitors patient mobility. Nursing shared-governance structure will be used to disseminate this project to 3 other hospitals in the corporate system. Results: Initial increase in percentage of patients in the chair for meals and ambulating in the halls has been noted. Because of the recent implementation, full impact has not been recognized. Application to Practice: Evaluating the existing nursing work environment to minimize the barriers to mobilize patients can benefit hospitalized older adults.
References 1.
2.
3.
4.
Brown CJ, Friedkin RJ, Inouye SK. Prevalence and outcomes of low mobility in hospitalized older patients. J Am Geriatr Soc 2004;52:1263-70. Harte BD, Birkas J, Lachmann M, et al. Promoting positive outcomes for elderly persons in the hospital: prevention and risk factor modification. AACN Clinical Issues 2002;13:22-33. Callen B, Mahoney J, Wells TJ, et al. Frequency of hallway ambulation by hospitalized older adults on medical units of an academic hospital. Geriatr Nurs 2004;25: 212-7. Wakefield B. Function trajectories associated with hospitalization in older adults. West J Nurs Res 2007;29:161-77.
Geriatric Nursing, Volume 32, Number 1
Research Poster Award Predictors of Recovery in Older Adults Following Cardiac Surgery Katherine M. Aldrich, RN, PhD, NP Nancy Stotts, RN, EdD, FAAN Virginia Carrieri-Kohlman, RN, DNS, FAAN and Mark Rollins, MD, PhD Problem: Cardiac surgery is frequently performed in older adults, but little is known about the quality of recovery (QoR) during the first postoperative month. Older adults are less likely to regain prior functional status by hospital discharge, and temporary postoperative functional loss may become permanent, adversely affecting QoR. Therefore, aims of this study were to examine relationships among pain, wound healing, surgical risk, functional status, mood, quality of life (QoL), and QoR at discharge and 30 days; estimate the effects of change over time in functional status, mood, and QoL on the change in QoR from discharge to 30 days postoperatively; describe participants’ perception of factors hindering or promoting their recovery; and the amount of recovery achieved 1 month after cardiac surgery. Methods: In this prospective cohort study, functional status, mood, and QoL were assessed preoperatively, at discharge, and at 30 days postoperatively. Functional status was operationalized as performance of basic (BADL) and intermediate (IADL) activities of daily living. Wound healing and pain were assessed for the first 5 postoperative days and at 30 days. Surgical risk was assessed preoperatively. QoR was assessed at discharge and 30 days. A 1-month interview assessed promoters and inhibitors of recovery and percentage of achieved recovery. Nonparametric correlation and multilevel negative binomial regression were used for analysis. Results: Subjects (n 5 62) were mostly men (74.2%) with a mean age of 75.9 (SD 7.01). The most frequent procedure performed was coronary artery bypass grafting (73%). Preoperative BADL/IADL was correlated with QoR at discharge (rho 5 .35, .37) and 30 days (n 5 59, rho 5 .46, .27). Preoperative mood and QoL correlated with QoR at 30 days (rho 5 e.43, .53). Multilevel models showed significant changes between BADL, IADL, and QoR over time, with the greatest predicted effect on QoR resulting from the change in IADL. Changes in mood state and QoL, although significant, did not have a significant
65
effect on the predicted change in QoR. At 30 days, family support was identified by 58% of the sample as the most important promoter of recovery. Mobility limits, particularly driving prohibitions, were identified as the greatest hindrance. In addition, 62% of the sample had perceived recovery levels of 75% 1 month after surgery. Conclusions: Functional status, particularly ability to perform IADLs, affects QoR in older cardiac surgery patients. Perception of recovery in a majority of patients is considerable, enhanced by family and social support. Future research needs to determine methods of promoting functional ability and determining effective support for those lacking social resources to improve QoR during the first postoperative month this vulnerable population.
Clinical Project Poster Award Alliance for the Ages: Geriatric Interdisciplinary Teamwork Is Central to Quality Care and Improved Outcomes for Our Hospitalized Elders Lynn Etters, MSN, NP-C, GNP-BC, and Diana LaBumbard, MSN, ACNP-BC Homeostenosis,1 a concept of aging, can impair the ability of older adults to compensate for acute physiologic illness and stress (Fig. 1). Homeostenosis refers to the principles of physiologic reserve. This reserve is the body’s ability to withstand illness stressors. As the body ages, physiologic reserve declines; older adults are able to function under normal conditions with loss of reserve but are less likely to withstand outside insults and stressors. In addition, older hospitalized adults may have complex medical, physiological, and social needs. Shaping the care of older adults is dependent on the provision of opportunities that will increase knowledge for health care workers. Lynn Etters, MSN, NP-C, GNP-BC, created a project titled “Homeostenosis” through the Geriatric Nursing Leadership Academy and the Honor Society of Nursing, Sigma Theta Tau International, that was funded by the John A. Hartford Foundation. The project uses techniques to decrease the threat to physiologic reserve that occurs with hospitalization of older adults. The program facilitates a continuum of care specific to the older adult who transitions between multiple settings by improving communication among health care providers and offering nurses 66
Figure 1. The “precipice” of homestenosis.
a specific skill set to use to assess and treat older adults. A geriatric interdisciplinary team (GIT) approach to the clinical experience permits the opportunity to build and develop geriatric education at the same time offering patient centered care. Rooted in Kristen Swanson’s theory of caring,2 the GIT at Huron Valley-Sinai Hospital assists the health care team to be prepared to meet the needs of older patients and their families. Applying evidence-based strategies decreases the functional decline that is often experienced in hospitalized older adults. The GIT is made up of the following practitioners: ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖ ❖
Acute care nurse practitioner Nurse manager(s) General and geriatric certified RNs Geriatrician Social worker Dietitian Physical therapist Speech therapist Pharmacist Spiritual care
The GIT is provided with resources, tools, and instruction in the care of geriatric patients. In addition, various focused educational opportunities and experiences such as aging sensitivity training, dementias versus delirium instruction, and communication strategies are organized on a regular basis. Once a week, the bedside RN presents his or her SPICES assessments3 on older adult patients and begins the discussion about appropriate interventions, consults, and follow-up needs for each. This interdisciplinary approach allows for the sharing of expertise and knowledge within the whole team. Benefits of this discussion are multifaceted and include a comprehensive, integrated and patient focused plan of care for the patient and Geriatric Nursing, Volume 32, Number 1
their family. Following the discussion, the nurse presents the plan of care to the patient and family. Ultimately, this has led to competence-based education, comprehensive assessments, and evidence-based interventions. The GIT and ongoing education of health care providers at Huron Valley-Sinai Hospital has improved patient outcomes; increased patient, family, and staff satisfaction; and prevented iatrogenic problems among hospitalized elders.
References 1.
2.
3.
Etters L. Homeostenosis. Geriatric Nursing Leadership Academy, project submission, 2008. Swanson KM. Empirical development of a middle range theory of caring. Nurs Res 1991;40:161-66 Fulmer T. SPICES: an overall assessment tool for older adults. Am J Nurs 2007;107:40-8.
Student Foundation Award/Travel Award The Effects of Low-Frequency Noncontact Ultrasound on Pain Management in Patients with Chronic Pressure Ulcers, VA ECHS Medical Center Jessica Marlowe, BSN, RN, MSN/CNS Student Devon Obenauer, BSN, RN Carol Brookshire, MS, GNP-BC and Allison E. Williams, ND, PhD Background: Wound care costs the U.S. health care system an estimated $20 billion annually.1 Interventions, including low-frequency noncontact ultrasound (LFNU), have been shown to decrease the healing time of wounds. Numerous studies have shown that LFNU allows wounds to heal faster by delivering low-energy, low-intensity ultrasound through a saline solution onto the wound bed, which decreases bio-load by damaging bacteria cell walls, stimulates fibroblast activity, increases blood flow, and provides cleansing.2-4 We piloted LFNU at a 60-bed facility with a mix of long-term care, rehabilitation, and respite patients. Patients who received LFNU stated that the treatments were soothing and that LFNU provided pain relief. Purpose: The purpose of this quality assurance project was to determine: 1) whether LFNU can provide additional pain relief to Geriatric Nursing, Volume 32, Number 1
patients with chronic wounds and 2) whether LFNU can decrease the size of the wound. Methods: A retrospective analysis was done to evaluate the pain levels of male rehabilitation patients with an average age of 60 years who received LFNU from January 2009 to September 2009. Patients received LFNU 3 days per week until the wound healed or the patient was discharged. Random pretreatment pain scores from the same hospital stay, treatment day pain scores, pain scores across the duration of LFNU, and pre- and post-treatment wound measurements were collected from the patient’s medical record. Two staff nurses reviewed the data to verify accuracy. Descriptive statistics were performed to summarize pain scores from treatment days, nontreatment days, and duration of treatment. The Wilcoxon test was used to analyze change in wound size. Results: Of the 6 patients, 4 showed a decreased pain average while receiving LFNU. Three showed at least a 15% decrease in average pain score over the duration of LFNU and at least a 19% decrease in pain during the day of LFNU. Two patients showed an increase in pain during LFNU. One had a history of narcotic abuse, and the other was recovering from a neurological disorder resulting in decreased sensation, possibly explaining his increased pain levels as he regained feeling. Wound surface area decreased for all subjects who received LFNU. Pretreatment average wound size was 24 cm2, and posttreatment wound size was 17.1 cm2. This difference was significant (P \ .01). Implications for Practice: Our findings indicate that LFNU decreased average pain scores in patients with chronic wounds both immediately posttreatment and throughout the duration of their treatments. Additionally, our results suggest that LFNU contributed to wound healing. A formal research study with a larger sample in a controlled environment would provide more accurate results. Patients with a history of narcotic abuse or decreased sensation should be excluded from the research to keep from skewing the results. An alternate study should be performed to determine whether pain reduction from LFNU decreases narcotic use.
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lipoplasty. Plast Reconstr Surg 1998;102: 534-42. Lai J, Pittelkow M. Physiological effects of ultrasound mists on fibroblasts. Int J Dermatol 2007;46:587-93. Liedl S, Kavros D. Low frequency ultrasound therapy for wound management. Antham 2001;28:244-52. Wagner FW. Classification and treatment program for diabetic, neuropathic and dysvascular foot problems. Instructional Course Lectures 28. American Academy of Orthopadic Surgeons; 1979.
0197-4572/$ - see front matter Ó 2011 Published by Mosby, Inc. doi:10.1016/j.gerinurse.2010.12.006
Correction Geriatric Nursing, Volume 31, Number 5, September/October 2010, “Ctyochrome P450: Drug MetabolismdWhy It’s So Important to Understand.” On page 385, column 2, paragraph 3, line 14: “simvastatin (Viagra)” should read “simvastatin (Zorcor).”
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