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The study purposes were to (a) describe interaction behaviors and factors that may effect communication and (b) explore associations between interaction behaviors and nursing care quality indicators among 38 mechanically ventilated patients (age ≥60 years) and their intensive care unit nurses (n = 24). Behaviors were measured by rating videorecorded observations from the Study of Patient-Nurse Effectiveness with Communication Strategies (SPEACS). Characteristics and quality indicators were obtained from the SPEACS dataset and medical chart abstraction. All positive behaviors occurred at least once. Significant (p < 0.05) associations were observed between (a) positive nurse and positive patient behaviors, (b) patient unaided augmentative and alternative communication (AAC) strategies and positive nurse behaviors, (c) individual patient unaided AAC strategies and individual nurse positive behaviors, (d) positive nurse behaviors and pain management, and (e) positive patient behaviors and sedation level. Findings provide evidence that nurse and patient behaviors effect communication and may be associated with nursing care quality., (Copyright 2014, SLACK Incorporated.)

Background: Valid and reliable instruments are needed to measure communication interaction behaviors between nurses and mechanically ventilated intensive care unit patients who are without oral speech., Objectives: The aim of this study was to refine and evaluate preliminary validity and reliability of a Communication Interaction Behavior Instrument (CIBI) adapted for use with mechanically ventilated, nonvocal patients in the intensive care unit., Methods: Raters observed nurse-patient communication interactions using a checklist of nurse and patient behaviors, categorized as positive and negative behaviors. Three-minute video-recorded observations of five mechanically ventilated adults (<60 years old) in the intensive care unit and their nurses were used to establish preliminary interrater reliability and confirm appropriateness of definitions (four observations per dyad, n = 20). On the basis of expert input and reliability results, the behaviors and item definitions on the CIBI were revised. The revised tool was then tested in a larger sample of 38 mechanically ventilated intensive care patients (> 60 years old) and their nurses (four observations per dyad, n = 152) to determine interrater reliability., Results: For preliminary testing, percent agreement for individual items ranged from 60% to 100% for nurse behaviors and 20% to 100% for patient behaviors across the five pilot cases. On the basis of these results, 11 definitions were modified and four items were dropped. Using the revised 29-item instrument, percent agreement improved for nurse behaviors (73%-100%) and patient behaviors (68%-100%). Kappa coefficients ranged from 0.13 to 1.00, with lower coefficients for patient behaviors., Conclusion: Preliminary results suggest that the revised CIBI has good face validity and shows good interrater reliability for many of the behaviors, but further refinement is needed. The use of dual raters with adjudication of discrepancies is the recommended method of administration for the revised CIBI.

Objective: The purpose of this study was to describe clinicians' evaluation and management of co-existing mental health, substance abuse (MHSA), and chronic pain (CP) conditions in patients with prolonged critical illness. Little is known about the evaluation and management of these conditions in the intensive care unit, and practice guidelines do not address management in the context of critical illness, optimal sedation/analgesia, or ventilator weaning., Design: Longitudinal qualitative description., Setting: Intensive care unit of an urban academic medical center., Patients: Total of 12 patients with co-existing MHSA or CP conditions who were weaning from mechanical ventilation., Interventions: Intensive care unit clinicians, patients, and family members were formally interviewed and directly observed in the critical care setting for 56 consecutive weeks., Measurements and Main Results: Transcribed interviews, field notes, and clinical records, representing >400 documents, were reviewed and coded using constant comparative analysis to identify the facilitators, barriers, contextual factors, and consequences associated with the evaluation and management of MHSA and CP conditions. Numeric clinical data supplemented and clarified thematic findings. Facilitators of MHSA and CP evaluation and management included family as history keepers, the use of subspecialty consultations, and anticipated alcohol withdrawal. Barriers included limited history taking and assessment of MHSA and CP conditions and the use of cognitive shortcuts. Consequences included nonintegration of MHSA and CP medications and diagnoses, episodic pharmacologic responses to psychobehavioral symptoms, and clinician-patient interpersonal tension. Contextual factors involved ambiguous psychobehavioral symptomatology, patients' critical illness and inability to speak, and competing clinical goals., Conclusions: The explicit evaluation and management of MHSA and CP conditions was highly variable and inconsistent across cases. Findings suggest that MHSA and CP conditions require monitoring and management similar to that required for other chronic conditions. Multidisciplinary, individual-level, and system-level responses are warranted to address the complex interplay of barriers, consequences, and context.

This article describes one step in the process that was undertaken to prepare for the introduction of evidence-based practice (EBP) into the curriculum across the Bachelor of Science in Nursing, Master of Science in Nursing, and Doctor of Philosophy programs, as well as the programs that were under development, Clinical Nurse Leader and Doctor of Nursing Practice, at the University of Pittsburgh School of Nursing. Expected research competencies were identified for each level or academic year within each program. Based on these competencies, recommendations on how to modify the curriculum into one that would support students' acquisition and development of the skills necessary to be successful in matriculating through an EBP curriculum were developed. Evaluation mechanisms for the achievement of these competencies vary across the academic programs and will include performance on capstone projects, comprehensive examinations, and program milestones for doctoral students. The establishment of evidence-based competencies provided a foundation for the development of new teaching approaches and the curricular revisions across the three academic programs. Thus, the University of Pittsburgh model of educating for EBP is based on a sequential layering of research competencies throughout the curriculum.

Background: Information about the contributions of acute care nurse practitioners to medical management teams in critical care settings is limited., Objective: To examine contributions of acute care nurse practitioners to medical management of critically ill patients from the perspectives of 3 disciplines: medicine, respiratory care, and nursing., Methods: Attending physicians, respiratory therapists, and nurses in 2 intensive care units were asked to list 3 advantages and 3 disadvantages of collaborative care provided by acute care nurse practitioners. Qualitative methods (coding/constant comparative analysis) were used to identify common themes and subthemes. Overall response rate was 35% (from 69% for attending physicians to 26% for nurses)., Results: Responses were grouped into 4 main themes: accessibility, competence/knowledge, care coordination/communication, and system issues. Acute care nurse practitioners were valued for their accessibility, expertise in routine daily management of patients, and ability to meet patient/family needs, especially for "long-stay" patients. Also, they were respected for their commitment to providing quality care and for their communication skills, exemplified through teaching of nursing staff, patient/family involvement, and fluency in weaning protocols. Physicians valued acute care nurse practitioners' continuity of care, patient/family focus, and commitment. Nurses valued their accessibility, commitment, and patient/family focus. Respiratory therapists valued their accessibility, commitment, and consistency in implementing weaning protocols., Conclusion: Responses reflected unique advantages of acute care nurse practitioners as members of medical management teams in critical care settings. Despite perceptions of the acute care nurse practitioner's role as medically oriented, the themes reflect a clear nursing focus.

Background: The inability to speak during mechanical ventilation is recognized as a terrifying and isolating experience that is related to feelings of panic, insecurity, anger, worry, fear, sleep disturbances, and stress among critically ill patients. Alternative methods of communicating with temporarily nonspeaking patients in the intensive care unit (ICU) have received little study. Although electronic voice output communication aids (VOCAs) are available for disabled children and adults, the effectiveness of VOCA systems with adult medical ICU patients who may have multisystem illness, prolonged intubation, and longer ICU stays has not been explored., Objectives: The purpose of this pilot study was to describe (1) the characteristics of intubated MICU patients who use VOCAs, (2) the usage patterns (message categories, frequency, assistance required), (3) communication quality (ease, user satisfaction), and (4) barriers to communication with VOCAs., Methods: This pilot study used participant observation, semi-structured interviews, questionnaires, and clinical record review in a complementary design to obtain data on communication events and VOCA use with 11 critically ill adults., Results: Study participants, 45.5 +/- 16.0 years of age with 13 +/- 1.9 years of education and moderately severe illness (APACHE III=27.5 +/- 16.1), used the VOCA for 5.7 +/- 4.6 days. Ease of Communication Scale measurements showed significantly less difficulty with communication after device use (t>2.62; P=.047). Almost half (n=5) of the participants demonstrated some independent use of the device. VOCAS were used in one quarter of observed communication events. Patients used VOCAs most often to communicate with family visitors and initiated communication interactions more often when VOCAs were used than when communicating by other nonvocal methods. Poor device positioning, deterioration in patient condition, staff time constraints, staff unfamiliarity with device, and complex message screens were primary barriers to VOCA use., Conclusions: This study showed that use of VOCAs is possible with selected critically ill adults and may contribute to greater ease of communication during respiratory tract intubation particularly with family members. Further clinical research using control or comparison groups is needed.

Objectives: To examine the state of knowledge of treatment interference, the self-removal of technological devices, in acutely or critically ill adults and to propose a multidisciplinary research agenda to further understanding of this clinical problem., Method: A combined computerized and hand search of the nursing and medical literature (MEDLINE, 1966 to June 1996; Cumulative Index to Nursing and Allied Health Literature, 1985 to June 1996; and holdings at the Center for the Study of Nursing History at the University of Pennsylvania) was conducted. Literature on specific technological devices and articles that contained the terms self-removal, withdrawal, devices, self-extubation, unplanned extubation, and involuntary treatment were searched., Results: Literature on treatment interference was found in four main topic areas: (1) maintaining treatment, (2) unplanned extubation, (3) disruption or manipulation of a medical device, and (4) involuntary treatment., Conclusions: The results clearly establish the clinical importance of treatment interference and underscore the multidisciplinary and multifactorial nature of this perplexing, life-threatening clinical problem. Future research on treatment interference should emphasize systematically building an understanding of the processes involved, including patients' attributes, behavioral cues, and consequences, to develop appropriate multidisciplinary strategies to prevent patients' self-removal of technological devices.