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Objectives: (1) Estimate the proportion of mechanically ventilated (MV) intensive care unit (ICU) patients meeting basic communication criteria who could potentially be served by assistive communication tools and speech-language consultation. (2) Compare characteristics of patients who met communication criteria with those who did not., Design: Observational cohort study in which computerized billing and medical records were screened over a 2-year period., Setting: Six specialty ICUs across two hospitals in an academic health system., Participants: Eligible patients were awake, alert, and responsive to verbal communication from clinicians for at least one 12-h nursing shift while receiving MV ≥ 2 consecutive days., Main Results: Of the 2671 MV patients screened, 1440 (53.9%) met basic communication criteria. The Neurological ICU had the lowest proportion of MV patients meeting communication criteria (40.82%); Trauma ICU had the highest proportion (69.97%). MV patients who did not meet basic communication criteria (n = 1231) were younger, had shorter lengths of stay and lower costs, and were more likely to die during the hospitalization., Conclusions: We estimate that half of MV patients in the ICU could potentially be served by assistive communication tools and speech-language consultation., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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.)

Objective: To test the impact of two levels of intervention on communication frequency, quality, success, and ease between nurses and intubated intensive care unit (ICU) patients., Design: Quasi-experimental, 3-phase sequential cohort study: (1) usual care, (2) basic communication skills training (BCST) for nurses, (3) additional training in augmentative and alternative communication devices and speech language pathologist consultation (AAC + SLP). Trained observers rated four 3-min video-recordings for each nurse-patient dyad for communication frequency, quality and success. Patients self-rated communication ease., Setting: Two ICUs in a university-affiliated medical center., Participants: 89 intubated patients awake, responsive and unable to speak and 30 ICU nurses., Main Results: Communication frequency (mean number of communication acts within a communication exchange) and positive nurse communication behaviors increased significantly in one ICU only. Percentage of successful communication exchanges about pain were greater for the two intervention groups than the usual care/control group across both ICUs (p = .03) with more successful sessions about pain and other symptoms in the AAC + SLP group (p = .07). Patients in the AAC + SLP intervention group used significantly more AAC methods (p = .002) and rated communication at high difficulty less often (p < .01)., Conclusions: This study provides support for the feasibility, utility and efficacy of a multi-level communication skills training, materials and SLP consultation intervention in the ICU., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Oral epidermal growth factor receptor inhibitors (EGFRIs) improve survival for non-small cell lung cancer (NSCLC) patients; however, medication-taking implications are unknown. We used grounded theory to explore the process of medication-taking for NSCLC patients receiving oral EGFRIs. Thirty-two interviews were conducted for 13 participants purposively selected for gender, race/ethnicity, age, time in therapy, dose reductions, and therapy discontinuation and theoretically sampled for age and health insurance carrier. The study produced a grounded theory, Surviving with Lung Cancer, in which participants framed EGFRI therapy within recognition of NSCLC as a life-limiting illness without cure. Medication-taking was a "window" into participants' process of surviving with metastatic cancer that included deciding and preparing to take EGFRIs and treating lung cancer as a chronic condition. Our results contribute to understanding how NSCLC patients view themselves in the context of a life-limiting illness and support development of a theoretically-based intervention to improve medication-taking with EGFRIs., (Copyright © 2014 Mosby, Inc. All rights reserved.)

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.

Background: Despite recognized benefits, many children with cystic fibrosis (CF) do not consistently participate in physical activities. There is little empirical literature regarding the feelings and attitudes of children with CF toward exercise programs, parental roles in exercise, or factors influencing exercise experiences during research participation., Objectives: The aim of this study is to describe the exercise experiences of children with CF and their parents during participation in a 6-month program of self-regulated, home-based exercise., Methods: This qualitative descriptive study was nested within a randomized controlled trial of a self-regulated, home-based exercise program and used serial semistructured interviews conducted individually at 2 and 6 months with 11 purposively selected children with CF and their parent(s)., Results: Six boys and five girls, ages 10-16 years, and parents(nine mothers, four fathers) participated in a total of 44 interviews. Five major thematic categories describing child and parent perceptions and experience of the bicycle exercise program were identified in the transcripts: (a) motivators, (b) barriers, (c) effort/work, (d) exercise routine, and (e) sustaining exercise. Research participation, parent-family participation, health benefits, and the child's personality traits were the primary motivators. Competing activities, priorities, and responsibilities were the major barriers in implementing the exercise program as prescribed. Motivation waned, and the novelty wore off for several (approximately half) parent-child dyads, who planned to decrease or stop the exercise program after the study ended., Discussion: We identified motivators and barriers to a self-regulated, home-based exercise program for children with CF that can be addressed in planning future exercise interventions to maximize the health benefits for children with CF and the feasibility and acceptability to the children and their families.

Symptom communication is integral to quality patient care. Communication between patients and nurses in the intensive care unit (ICU) is complicated by oral or endotracheal intubation and fluctuating neurocognitive status or delirium. We report the (a) prevalence of delirium and its subtypes in non-vocal, mechanically ventilated, critically ill patients; (b) impact of age on delirium; and (c) influence of delirium and age on symptom communication. Videorecorded interactions between patients (N = 89) and nurses (N = 30) were analyzed for evidence of patient symptom communication at four time points across 2 consecutive days. Delirium was measured at enrollment and following sessions. Delirium prevalence was 23.6% at enrollment and 28.7% across sessions. Participants age >60 were more likely to be delirious on enrollment and during observational sessions. Delirium was associated with self-report of pain, drowsiness, and feeling cold. Patients were significantly less likely to initiate symptom communication when delirious. Symptom identification should be carefully undertaken in older adults with or without delirium., (Copyright 2013, SLACK Incorporated.)

Increasingly, family members are assisting with the complex task of medication management when patients are experiencing cognitive decline. To date, limited published research addresses caregiver-mediated medication management of patients with impaired cognition. Thus, the purpose of this study was to describe the characteristics and correlates of caregiver-mediated medication management in community-dwelling patients with memory loss. We used baseline data from the 91 patient-caregiver dyads participating in a randomized controlled trial designed to assist caregivers of patients with memory loss with medication management. The patient's level of cognitive impairment was not related to medication errors; however, the number of medications that patients were prescribed and taking was related to medication errors. Important factors to consider when discussing medication management with caregivers of patients with memory loss include the caregiver's age, cognitive ability, and depressive symptoms, as well as the caregiver's perception of the impact of the patient's behavioral problems., (Copyright 2013, SLACK Incorporated.)

Background: Communication interactions between nurses and mechanically ventilated patients in the intensive care unit (ICU) are typically brief. Factors associated with length of nurses' communication have not been explored., Objective: To examine the association between nurse and patient characteristics and duration of nurse talk., Methods: In this secondary analysis, we calculated duration of nurse talk in the first 3-min of video-recorded communication observation sessions for each nurse-patient dyad (n = 89) in the SPEACS study (4 observation sessions/dyad, n = 356). In addition, we explored the association between nurses' characteristics (age, gender, credentials, nursing experience, and critical care experience) and patients' characteristics (age, gender, race, education, delirium, agitation-sedation, severity of illness, level of consciousness, prior intubation history, days intubated prior to study enrollment, and type of intubation) on duration of nurse talk during the 3-min interaction observation., Results: Duration of nurse talk ranged from 0-123 s and varied significantly over the 4 observation sessions (p = .007). Averaging the duration of nurse talk over the observation sessions, differences in talk time between the units varied significantly by study group (p < .001). Talk duration was negatively associated with a Glasgow Coma Scale ≤14 (p = .008). Length of intubation prior to study enrollment had a curvilinear relationship with talking duration (linear p = .002, quadratic p = .013); the point of inflection was at 23 days. Nurse characteristics were not significantly related to duration of nurse talk., Conclusion: Length of time the patient is intubated, and the patient's level of consciousness may influence duration of nurse communication in ICU., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Little is known about communication between patients and their family members during critical illness and mechanical ventilation in the intensive care unit, including use of augmentative and alternative communication tools and strategies., Objectives: To identify (1) which augmentative and alternative communication tools families use with nonspeaking intensive care patients and how they are used, and (2) what families and nurses say about communication of family members with nonspeaking intensive care patients., Methods: A qualitative secondary analysis was conducted of existing data from a clinical trial testing interventions to improve communication between nurses and intensive care patients. Narrative study data (field notes, intervention logs, nurses' interviews) from 127 critically ill adults were reviewed for evidence of family involvement with augmentative and alternative communication tools. Qualitative content analysis was applied for thematic description of family members' and nurses' accounts of patient-family communication., Results: Family involvement with augmentative and alternative communication tools was evident in 44% of the 93 patients who completed the parent study protocol. Spouses or significant others communicated with patients most often. Main themes describing patient-family communication included (1) families being unprepared and unaware, (2) families' perceptions of communication effectiveness, (3) nurses deferring to or guiding patient-family communication, (4) patients' communication characteristics, and (5) families' experience with and interest in augmentative and alternative communication tools., Conclusions: Assessment by skilled bedside clinicians can reveal patients' communication potential and facilitate useful augmentative and alternative communication tools and strategies for patients and their families.

Objective: To describe the experience and perceptions of nurse study participants regarding a communication intervention (training and communication tools) for use with nonspeaking, critically ill patients., Research Methodology/design: Small focus groups and an individual interview were conducted with six critical care nurses. Transcripts were analysed using qualitative content analysis and constant comparison., Setting: Two ICUs within a large, metropolitan medical centre in western Pennsylvania, United States of America., Main Outcome Measures: Critical care nurses' evaluations of (1) a basic communication skills training programme (BCST) and (2) augmentative and alternative communication strategies (AAC) introduced during their study participation., Results: Six main categories were identified in the data: (1) communication value/perceived competence; (2) communication intention; (3) benefits of training; (4) barriers to implementation; (5) preferences/utilisation of strategies; and 6) leading-following. Perceived value of and individual competence in communication with nonspeaking patients varied. Nurses prioritised communication about physical needs, but recognised complexity of other intended patient messages. Nurses evaluated the BCST as helpful in reinforcing basic communication strategies and found several new strategies effective. Advanced strategies received mixed reviews. Primary barriers to practise integration included patients' mental status, time constraints, and the small proportion of nurses trained or knowledgeable about best patient communication practices in the ICU., Conclusions: The results suggest that the communication skills training programme could be valuable in reinforcing basic/intuitive communication strategies, assisting in the acquisition of new skills and ensuring communication supply availability. Practice integration will most likely require unit-wide interdisciplinary dissemination, expert modelling and reinforcement., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

During an ethnography conducted in an intensive care unit (ICU), we found that anxiety and agitation occurred frequently and were important considerations in the care of 30 patients weaning from prolonged mechanical ventilation. We conducted a secondary analysis to (a) describe characteristics of anxiety and agitation experienced by mechanically ventilated patients, (b) explore how clinicians recognized and interpreted anxiety and agitation, and (c) describe strategies and interventions used to manage anxiety and agitation with mechanically ventilated patients. We constructed the Anxiety/Agitation in Mechanical Ventilation Model to illustrate the multidimensional features of symptom recognition and management. Patients' ability to interact with the environment served as a basis for identification and management of anxiety or agitation. Clinicians' attributions about anxiety or agitation, and "knowing the patient," contributed to their assessment of patient responses. Clinicians chose strategies to overcome either the stimulus or the patient's appraisal of risk of the stimulus. This article contributes to the body of knowledge about symptom recognition and management in the ICU by providing a comprehensive model to guide future research and practice.

The oral hormonal agent anastrozole improves clinical outcomes for women with breast cancer, but women have difficulty taking it for the five-year course. The unique medication-taking experiences related to self-management of anastrozole therapy for women with early stage breast cancer are not known. Our purpose was to describe the medication-taking experiences for postmenopausal women with early stage breast cancer who were prescribed a course of anastrozole therapy. Twelve women aged 58 to 67 years, midway through therapy, participated in audio-recorded interviews. Women's medication-taking experiences involved a belief in their importance and an imperative to take anastrozole. We found that women's side effect experiences, particularly menopausal symptoms, were significant, but only one woman stopped anastrozole due to side effects. Medication-taking included routinization interconnected with remembering/forgetting and a storage strategy. Some women noted a mutual medication-taking experience with their spouse, but most felt taking anastrozole was something they had to do alone. Our results provide insight into the way some women with early stage breast cancer manage their hormonal therapy at approximately the midpoint of treatment. Next steps should include examinations of patient-provider communication, potential medication-taking differences between pre- and postmenopausal women, and the effects of medication-taking on clinical outcomes.

Women with vulval neoplasia often experience severe post-surgical complications. This study focuses on symptom experience of women during the first 6 months following surgical treatment for vulval neoplasia considering their socio-cultural context. In this qualitative study using a critical hermeneutic approach, narrative interviews were conducted. A purposeful sample of 20 patients was recruited from one Swiss and two German university hospitals. Content analysis was employed to analyse the transcribed interviews considering women's experiences and social perceptions. Narratives showed eight interrelated themes: delayed diagnosis, disclosed disease, disturbed self-image, changed vulva care, experienced wound-related symptoms, evoked emotions, affected interpersonal interactions and feared illness progression. The women experienced a general lack of information pertaining to above themes and all described strategies used to handle their situation, which affected their distress. The communication, assessment and treatment of symptoms were hampered by the society's and the health system's tendency to overlook these symptoms and leave them in the realm of the unspeakable. Health professionals need new strategies to support these women to recognise, assess and evaluate the seriousness of symptoms, and to communicate their symptom experience so that timely medical treatment is sought. This support may minimise potentially preventable complications and symptom-related distress., (© 2011 Blackwell Publishing Ltd.)

Communication problems experienced by nonspeaking, critically ill patients in the Intensive Care Unit (ICU) have serious implications for the physical and psychological well-being of patients and the quality of their care. These problems are most profound for those with prolonged critical illnesses who are at the highest risk of dying. Recently, speech language pathologist (SLP) services have been used to provide augmentative and alternative communication (AAC) assistance to this vulnerable group of patients, their caregivers, and medical staff. Here we present three clinical cases that illustrate the application of AAC strategies across different levels of illness severity and communication impairment for nonspeaking patients in the ICU. Both high-tech communication devices with voice output and low-tech options were used for each patient according to their motor and cognitive abilities. To accommodate fluctuations in patient status and communication needs, multiple AAC strategies were integrated into the communication repertoire and tailored for each case. Medical personnel involved in these cases attributed enhanced communication efficiency, improved ventilator weaning trials, and increased patient engagement to the AAC techniques. This approach has the potential to improve symptom communication and to ease suffering for seriously ill ICU patients with speech limitations.

Background: The inability to speak during critical illness is a source of distress for patients, yet nurse-patient communication in the intensive care unit has not been systematically studied or measured., Objectives: To describe communication interactions, methods, and assistive techniques between nurses and nonspeaking critically ill patients in the intensive care unit., Methods: Descriptive observational study of the nonintervention/usual care cohort from a larger clinical trial of nurse-patient communication in a medical and a cardiothoracic surgical intensive care unit. Videorecorded interactions between 10 randomly selected nurses (5 per unit) and a convenience sample of 30 critically ill adults (15 per unit) who were awake, responsive, and unable to speak because of respiratory tract intubation were rated for frequency, success, quality, communication methods, and assistive communication techniques. Patients self-rated ease of communication., Results: Nurses initiated most (86.2%) of the communication exchanges. Mean rate of completed communication exchange was 2.62 exchanges per minute. The most common positive nurse act was making eye contact with the patient. Although communication exchanges were generally (>70%) successful, more than one-third (37.7%) of communications about pain were unsuccessful. Patients rated 40% of the communication sessions with nurses as somewhat difficult to extremely difficult. Assistive communication strategies were uncommon, with little to no use of assistive communication materials (eg, writing supplies, alphabet or word boards)., Conclusions: Study results highlight specific areas for improvement in communication between nurses and nonspeaking patients in the intensive care unit, particularly in communication about pain and in the use of assistive communication strategies and communication materials.

This article presents an interpretive case analysis of an older adult's experience with treatment decision making for acute myeloid leukemia. Interview and observational data were compared and contrasted with key constructs in behavioral decision theory to analyze theoretical utility and fit. Decision making involved a complex interplay among the patient, treating clinicians, and family members. While some constructs of decision theory, such as trade-offs, avoidance-avoidance, and the certainty effect, showed utility for decision making in geriatric oncology, this case demonstrated that individual preferences for treatment may be expressed in quality of life preferences rather than a specific treatment decision. The Cage, a major theme in this case, represented the trap of two undesirable choices in treatment decision making, as well as the imprisoning consequence of aggressive medical treatment for advanced cancer. Further decision making research is needed to develop practice-level theory that can more effectively support and guide treatment decision making in geriatric oncology., (Copyright 2011, SLACK Incorporated.)

Objective: To describe patterns of bath care for patients who are weaning from prolonged mechanical ventilation (PMV) and to explore the association between bathing and weaning trial duration., Methods: Descriptive correlational study. Clinical records from 439 weaning trial days for 30 patients who required PMV were abstracted for bathing occurrences during weaning trials, within 1 hour before a trial, and nocturnally., Results: Most baths occurred during weaning trials (30.8%) or at night (35.3%), and less frequently (16%) within 1 hour before a trial. No significant effects were found on trial duration for nocturnal bathing or bathing within 1 hour before a trial. By using random coefficient modeling, weaning duration was shown to be longer when bathing occurred during a weaning trial (P < .05), even when controlling for age, severity of illness, and days on bedrest., Conclusion: Bathing occurred during approximately one third of PMV weaning trials. Baths during PMV weaning trials were associated with longer weaning trial duration., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Bathing is a fundamental nursing care activity performed for or with the self-assistance of critically ill patients. Few studies address caregiver or patient-family perspectives about bathing activity during weaning from prolonged mechanical ventilation (PMV)., Objective: To describe practices and beliefs about bathing patients during weaning from PMV., Methods: Secondary analysis of qualitative data (observational field notes, interviews, and clinical record review) from a larger ethnographic study involving 30 patients weaning from PMV and the clinicians who cared for them using basic qualitative description., Results: Bathing, hygiene, and personal care were highly valued and equated with "good" nursing care by families and nurses. Nurses and respiratory therapists reported "working around" bath time and promoted conducting weaning trials before or after bathing. Patients were nevertheless bathed during weaning trials despite clinicians' expressed concerns for energy conservation. Clinicians recognized individual patient response to bathing during PMV weaning trials., Conclusion: Bathing is a central care activity for patients on PMV and a component of daily work processes in the intensive care unit. Bathing requires assessment of patient condition and activity tolerance and nurse-respiratory therapist negotiation and accommodation with respect to the initiation or continuation of PMV weaning trials during bathing. Further study is needed to validate the impact (or lack of impact) of various timing strategies for bathing patients who are on PMV., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Facilitating students' knowledge and ability to care for critically ill older adults is a daunting task for even the most experienced teacher. Faculty, preceptors, and mentors must address the seemingly dichotomous objectives of training practitioners capable of providing safe, technologically advanced care intended to restore hemodynamic stability tempered by the simultaneous goal of providing person-centered, culturally competent, age-appropriate interventions. This article provides specific approaches to prepare baccalaureate nursing students for some of the challenges experienced when caring for critically ill older adults, including teaching strategies, clinical competency behaviors/activities, and postconference topics. By creating a safe environment for asking questions, sharing their expertise and experiences, and adequately addressing individual learning styles, teachers can begin to instill the passion, commitment, and knowledge needed to care for this vulnerable population., (Copyright 2010, SLACK Incorporated.)

Aim: This paper is a description of a method to develop and conduct a customized psycho-educational intervention fidelity assessment as part of pilot work for an efficacy study. A tool designed to assess treatment fidelity to a psycho-education intervention for patients with end-stage renal disease and their surrogate decision makers, Sharing the Patient's Illness Representations to Increase Trust, is presented as an illustration., Background: Despite the specificity and idiosyncrasy of individual interventions and the call to systematically evaluate treatment fidelity, how to accomplish this goal has not been clarified. Tools to adequately measure treatment fidelity are lacking., Methods: We developed the Sharing the Patient's Illness Representations to Increase Trust Treatment Fidelity Assessment tool by identifying elements that were idiosyncratic to the intervention and those that could be adapted from existing tools. The tool has four components: overall adherence to the intervention content elements; pacing of the intervention delivery; overall dyad responsiveness; and, overall quality index of intervention delivery. The study was undertaken between 2006 and 2008., Results: Inter-rater reliability ranged from 0.80 to 0.87 for the four components. The tool showed utility in training and monitoring, such as detecting unplanned content elements delivered and the use of proscribed communication behaviours., Conclusion: Psycho-educational interventions are one of the most common types of nursing interventions worldwide. Use of fidelity assessment tools customized to the individual interventions may enhance systematic evaluation of training and monitoring treatment fidelity.

Ascertaining the symptom experience of chronically critically ill (CCI) patients is difficult because of communication impairment and fluctuations in patient cognition and physiologic conditions. The use of checklist self-report ratings is hampered by the inability of most CCI patients to respond verbally to symptom queries. In addition to the communication problems caused by mechanical ventilation, the apparently diverse idioms of symptom expression add to the potential for miscommunication regarding symptom experience. Although patient communication impairment is a major barrier to symptom identification, symptom assessment and treatment are fundamental components of nursing care for CCI. This article reviews and describes the unique constellation of symptoms experienced by many critically ill patients. We report our observations of symptom communication among CCI patients and nurses and discuss inconsistency in the language of symptom expression among nurses and patients. Clinically applicable strategies to improve nurse-patient symptom communication and suggestions for refinement of symptom assessment in chronic critical illness are provided.

The aim of this study was to test the user performance, satisfaction and acceptability of the Helping Hand™ (B&O Medicom) electronic medication adherence monitor. Using a mixed-method design, we studied 11 kidney transplant patients and 10 healthy volunteers during three weeks. Although testing showed positive usability aspects, several areas requiring technical improvement were identified: the most important obstacles to usability and acceptability were the weak sound signal, problems loading the medication, and the fact that only one medication could be used at a time.

This randomized controlled trial tested an intervention, Sharing Patients' Illness Representations to Increase Trust (SPIRIT), designed to enhance communication regarding end-of-life care between African Americans with end-stage renal disease (ESRD) and their chosen surrogate decision makers (N = 58 dyads). We used surveys and semi-structured interviews to determine the feasibility, acceptability, and preliminary effects of SPIRIT on patient and surrogate outcomes at 1 week and 3 months post-intervention. We also evaluated patients' deaths and surrogates' end-of-life decision making to assess surrogates' perceptions of benefits and limitations of the SPIRIT while facing end-of-life decisions. We found that SPIRIT promoted communication between patients and their surrogates and was effective and well received by the participants., ((c) 2009 Wiley Periodicals, Inc.)

Purpose: The purpose of this study is to explore mothers' perspectives about reproductive health (RH) discussions with their adolescent daughters with diabetes., Methods: This study of mothers used a sequential explanatory mixed-method design with 2 phases. Phase 2, the focus of this report, was a qualitative descriptive study using open-ended semistructured telephone interviews. Ten mothers from a larger study sample were selected by purposeful sampling. Qualitative content analysis techniques were used to analyze the interview transcripts., Results: The following 4 themes describing mothers' perspectives about RH discussions with their adolescent daughters with diabetes were identified: (1) maternal awareness, (2) maternal knowledge, (3) triggers for initiating RH discussions, and (4) maternal fears/concerns. Several mothers were aware of their daughters' sexual activity and were aware that their daughters should preplan a pregnancy. They knew that an unplanned pregnancy may have detrimental effects on their daughters' health and feared that their daughters would have an unplanned pregnancy. A major trigger for mothers to initiate RH discussions was when a daughter had a steady boyfriend. Mothers' fears and concerns were focused around their daughters' having an unplanned pregnancy. Overall, mothers reported they were not comfortable with RH conversations., Conclusions: Mothers fear unplanned pregnancies for their daughters with diabetes and want to discuss RH issues with them but are uncomfortable doing so. Diabetes educators could be instrumental in educating and providing communication skills to mothers to help foster RH communication with their adolescent daughters with diabetes.

Background: We previously noted that older adults admitted to surgical ICUs (SICUs) are at high risk for delirium. In the current study, we describe the association between the presence of delirium and complications in older SICU patients, and describe the association between delirium occurring in the SICU and functional ability and discharge placement for older patients., Methods: Secondary analysis of prospective, observational, cohort study. Subjects were 114 consecutive patients >or= 65 years old admitted to a surgical critical care service. All subjects underwent daily delirium and sedation/agitation screening during hospitalization. Outcomes prospectively recorded included SICU complication development, discharge location, and functional ability (as measured by the Katz activities of daily living instrument)., Results: Nearly one third of older adults (31.6%) admitted to an SICU had a complication during ICU stay. There was a strong association between SICU delirium and complication occurrence (p = 0.001). Complication occurrence preceded delirium diagnosis for 16 of 20 subjects. Subjects with delirium in the SICU were more likely to be discharged to a place other than home (61.3% vs 20.5%, p < 0.0001) and have greater functional decline (67.7% vs 43.6%, p = 0.023) than nondelirious subjects. After adjusting for covariates including severity of illness and mechanical ventilation use, delirium was found to be strongly and independently associated with greater odds of being discharged to a place other than home (odds ratio, 7.20; 95% confidence interval, 1.93 to 26.82)., Conclusions: Delirium in older surgical ICU patients is associated with complications and an increased likelihood of discharge to a place other than home.

Medical emergency teams (METs) were developed to respond more rapidly to changes in patient condition. While effective, METs do not address events prior to the response. This study examined differences in patient, nurse, and organisational characteristics for 108 MET calls on five medical and five surgical units in a university hospital. MET calls occurred more often on the day shift (p = 0.007) for medical (p = 0.036), but not surgical, patients. Of the 108 events, 44% were delayed, defined as events with documented evidence that pre-established criteria for a MET call were present for >30 min. More delays occurred on the night shift (p = 0.012). Delayed events were not related to the number of patients assigned (p = 0.608). However, there was a trend for more delays when more patients were assigned (4:1 = 21% vs 6:1 = 43%). In a logistic regression model, shift and patient-unit-match (medical, surgical) were significant predictors of delays. The model correctly predicted 68% of delayed events. Study findings indicate that a combination of patient, nurse and organisational characteristics influence timely rescue.

This paper describes a quasi-experimental three-phase sequential cohort design used in the Study of Patient-Nurse Effectiveness with Assisted Communication Strategies (SPEACS) to test two interventions to improve nurse-patient communication in the intensive care unit (ICU). The sample consists of 10 nurses and 30 nonspeaking ICU patients in each phase (total n=90 nurse-patient dyads). Observational techniques (video recording, transcription, and rating) measure nurse-patient communication performance. Descriptive and covariate data are collected through clinical assessment tools, questionnaires, and field notes. We discuss the practical and scientific considerations in constructing and implementing this type of clinical trial. Specifically, primary threats to validity, history and the Hawthorne effect, are considered and efforts to minimize and track these potential threats are described.

Objectives: The research was designed to describe the care and communication processes during weaning from long-term mechanical ventilation (LTMV). A portion of those findings, specifically, how family members interact with the patient and respond to the ventilator and associated intensive care unit bedside equipment during LTMV weaning, are reported here., Methods: Ethnography was conducted in a medical intensive care unit (MICU) and step-down MICU following 30 adults who were being weaned from LTMV (>4 days). Data collection involved field observations conducted from November 2001 to July 2003; interviews with patients, family members, and MICU clinicians; and clinical record review., Results: Family members were present at the patients' bedside during 46% of weaning trials and interacted with patients through touch, talking, and surveillance. Families' bedside surveillance activities were interpretive of numeric monitor displays and laboratory values, protective of patient safety and comfort, and often focused exclusively on weaning. Interpretive language and surveillance were learned from and imitative of clinician behaviors. Clinicians characterized the family's presence as helpful, a hindrance, or having no effect on the weaning process. Quantitative analysis using random coefficient modeling examining the effect of family presence on length of weaning trials showed significantly longer daily weaning trials when families were present (P < .0001)., Conclusion: Critical care clinicians influence families' acquisition of interpretive surveillance skills at the bedside of patients who are being weaned from LTMV. This study provides a potentially useful conceptual framework of family behaviors with long-term critically ill patients that could enhance the dialogue about family-centered care and guide future research on family presence in the intensive care unit.

Background: Mixed methods research approaches can be applied to nursing and healthcare. Multiple perspectives and different types of data (e.g., social-behavioral data, numerical outcome measures, or clinical variables) often are needed to examine complex clinical problems and health behaviors fully. Although qualitative and quantitative methods are recognized widely as complementary for studying and explaining human phenomena, methodological techniques for combining and analyzing mixed methods data have received less attention., Objectives: To describe techniques for mixed methods data combination and analyses using three different design approaches., Methods: Data combination and analysis techniques are presented using the following approaches: (a) mixed methods event analysis, (b) concurrent-mixed analysis for complementarity and completeness, and (c) concurrent nested analysis to provide a broader understanding of phenomena and enrich the description of participants., Results: Research exemplars from topical areas such as weaning from long-term mechanical ventilation, medication-taking among community-dwelling persons with dementia, health control beliefs after lung transplantation, and recovery from subarachnoid hemorrhage are presented. Simple and complex matrix construction and a variety of graphical displays are used to illustrate data combination and analysis techniques for mixed methods research., Discussion: The techniques for mixed methods data combination and analysis presented have the potential to advance the use and refinement of mixed methods research, thereby expanding the repertoire of methodologies to study complex phenomena of interest to nurses.

Background: Among survivors of prolonged mechanical ventilation, preferences for this treatment have rarely been explored., Objectives: To elicit preferences of survivors of prolonged mechanical ventilation (>or=7 days) and factors influencing these preferences., Methods: A descriptive, cross-sectional survey design was used. Subjects were recruited from intensive care units in a tertiary care hospital and from long-term care facilities. Each subject (n = 30) was asked to reflect on the decision to use mechanical ventilation; rate current health, pain/discomfort in the intensive care unit and from mechanical ventilation, perceived family financial burden, and emotional/physical stress related to mechanical ventilation; identify changes that would influence preference for mechanical ventilation; and answer questions about quality of life, functional status, depressive symptoms, and communication., Results: Most subjects (75.9%) would have chosen mechanical ventilation. Median days of mechanical ventilation and tracheostomy were greater for subjects who would have chosen mechanical ventilation (98.5 vs 70), as were median days of tracheostomy (102 vs 64). Patients who would not have chosen mechanical ventilation had more depressive symptoms and were more likely to be insured by Medicare. No other variables differed between groups. Patients who preferred mechanical ventilation would change their preference on the basis of their families' emotional/physical stress and financial burden. Patients who did not prefer mechanical ventilation would change their preference if the family financial burden and emotional/physical stress were reduced and current health improved., Conclusions: Most patients would have chosen mechanical ventilation. Survivors' preferences were influenced by their current health and families' financial burden and stress.

Purpose/objectives: To describe the communication of patients who received electronic speech-generating devices (SGDs) following surgical procedures for head or neck cancer., Design: Exploratory, complementary mixed methods., Setting: Otolaryngology surgical inpatient unit of an urban teaching hospital., Sample: 10 purposively selected patients with a mean age of 57.1 years (SD = 12.8 years) and moderately severe illness (Acute Physiology and Chronic Health Evaluation III score mean = 27.1 + 13.2) who had SGDs in their hospital rooms for 9.1 + 6.2 days., Methods: Observation, interviews, questionnaires, and clinical record review., Main Research Variables: Communication methods, communication content, SGD use, communication quality (i.e., ease and user satisfaction), barriers to SGD use, and patient clinical characteristics., Findings: SGDs were used in message construction in 8 (17%) out of 48 total observed communication events. Writing (31%) and nonverbal communication (46%) were the most frequently observed primary methods of communication used by patients with head and neck cancer postoperatively. Five patients demonstrated occasional SGD use with or without cuing, and one used the SGD as the dominant communication method. Ease of Communication Scale scores showed only slightly less difficulty with communication when compared to a historic control group. Patients initiated communications more often when SGDs were used in message construction. Poor device positioning, staff unfamiliarity with SGDs, and patient preference and ability for writing were barriers to SGD use., Conclusions: Although writing and making gestures were the most common communication methods, SGDs were used successfully by selected patients and may be particularly beneficial for constructing complex messages during conversation., Implications for Nursing: SGDs may be an appropriate assistive communication strategy for postoperative patients with head and neck cancer. Nurses can facilitate effective patient communication with SGDs by cuing patients on device options and positioning SGDs within easy reach.

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: E-mail is actively discussed as a promising method for clinical communication, but little study of patient and family preferences regarding its use has been done. This study aimed to describe patients' and family members' interest in and use of E-mail with their surgeons and nurses after head and neck cancer surgery., Methods: Surveys were distributed to patients and family members attending postoperative clinic visits. Seventy-four patients and 35 caregivers completed the surveys., Results: Although one in three patients expressed interest in E-mailing their clinicians, only 9.5% reported actually doing so. Symptom management and prescription refills were the most common issues addressed by E-mail. Few family members expressed any interest in using E-mail., Conclusions: The findings suggest that E-mail communication between patients with head and neck cancer or their family members with surgeons and nurses is not common. Interest in using E-mail tends to be stronger among patients than family members., ((c) 2005 Wiley Periodicals, Inc.)

Background: "Telephone tag" for questions about postoperative symptoms and other concerns often engenders dissatisfaction. E-mail use may improve communication between patients and clinicians. This study aimed to describe surgeons' and nurses' use of E-mail with patients and their caregivers after head and neck cancer surgery., Methods: We conducted a cross-sectional national survey of head and neck nurses and surgeons., Results: Ninety-six percent of surgeon and 87% of nurse respondents used E-mail, but only 40% and 25%, respectively, used it with patients. More than 50% of both clinician groups that used E-mail with patients have done so for 2 to 5 years and began this practice at the request of patients. Surgeons not using E-mail with patients were twice as likely as nurses to cite privacy and liability issues, as well as time management and miscommunication concerns., Conclusions: Some clinicians use E-mail with patients, most often by patient request. Medicolegal and clinical ramifications require further study., (2004 Wiley Periodicals, Inc.)

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.

The purpose of this paper is to describe the psychosocial process of the symptom experience associated with the threat of organ rejection after lung transplantation. A grounded theory approach, including theoretical sampling and constant comparative analyses, was used in a sample of 14 lung transplant recipients who varied in age, gender, underlying lung disease, experience with rejection, and time since transplantation. 'Striving for normalcy' was the core process linking each of the four stages of the symptom experience and interpretation: naïveté, vulnerability, discovery, and insight. Each stage was marked by an initiating event, a predictable symptom response, and a dialectic (an internal struggle between recipients' personal perceptions of the situation and the juxtaposed understandings of the situation that they gleaned from transplant clinicians). Each stage was also labeled with a descriptor of the aspect of striving for normalcy that accounted for the variation in the symptom responses that recipients exhibited, the dialectics they faced, and the exemplars for each stage of the process. During the stage of naïveté, recipients were elated at improvements after transplantation, and often denied or delayed reporting symptoms. Once they experienced a rejection episode they entered the stage of vulnerability and became more vigilant about symptoms. The discovery stage was marked by the realization that rejection lacked characteristic symptoms; therefore, it was important to recognize any changes from their baseline condition. Recipients who achieved the insight stage realized that until they gave up some independence in exchange for interdependence, extended periods of normalcy eluded them, and embraced a reciprocal relationship with the transplant team. Knowledge that recipients' experience evolves over time from furtive hope during the stage of naïveté to qualified hope during the insight stage, directs us to intervene using stage-specific interventions to promote better symptom recognition and reporting.