Clinical Scholars Review - Columbia University School of Nursing

CSRClinicalVolume 5, Number 2, 2012ISSN 1939-2095ScholarsReviewThe Journal ofDoctoral Nursing PracticeSPRINGER PUBLISHING COMPANYwww.springerpub.com/csrColumbia UniversitySchool of Nursing

CSRClinicalScholarsReviewEditorJanice Smolowitz, DNP, EdD, DCCSenior Associate DeanProfessor of Clinical NursingDirector, Center for Clinical PracticeColumbia University School of NursingAssociate EditorsPractice ManagementThomas A. Mackey, PhD, NP-C, FAAN, DCC, FAANPAssociate Dean for PracticeUniversity of Texas Health Science Center atHouston School of NursingEducationMichael A. Carter, DNSc, DNP, FAAN, FNP/GNP-BCUniversity Distinguished ProfessorUniversity of Tennessee Health Science CenterCollege of NursingPractice EvidenceH. Michael Dreher, PhD, RNAssociate Professor, Department of AdvancedNursing RolesDrexel University College of Nursing and HealthProfessionsEthical and Legal IssuesAnne Griswold Peirce, RN, PhDProfessorAssociate Dean for Academic AffairsAdelphi University School of NursingCommunities of InterestCourtney Reinisch, DNP, DCC, FNPClinical Assistant Professor and Specialty DirectorFamily Nurse Practitioner ProgramRutgers College of NursingGlobal PerspectivesJennifer Smith, DNP, MBA, MPHSenior Associate DeanAssistant Professor of Clinical NursingDirector, WHO CenterColumbia University School of NursingBoard MembersRobert Brook, MD, ScDRand HealthColleen Conway-Welch, PhDDeanVanderbilt University School of NursingSarah Cook, DNPVice DeanColumbia University School of NursingRichard A. Cooper, MDUniversity of PennsylvaniaDepartment of MedicineJudy Honig, EdD, DNPDirector, DNP ProgramAssociate Dean of Student ServicesColumbia University School of NursingRobert Kane, MDProfessorUniversity of MinnesotaSchool of Public HealthKenneth W. Kizer, MDMedsphere Systems CorporationMary O’Neil Mundinger, DrPHEdward M. Kennedy Professor of Health PolicyColumbia University School of NursingPatricia Starck, DSNDeanUniversity of Texas at Houston School of NursingNancy Woods, PhD, RN, FAANProfessorBiobehavioral Nursing and Health SystemsUniversity of Washington School of Nursing

Author Guidelines for Clinical Scholars ReviewClinical Scholars Review is a biannual, peer-reviewed publication focused on clinical excellence in the application of evidence-based practiceof doctoral nursing. The mission of the Clinical Scholars Review is to support the advancement of the doctoral practice of nursing.Articles submitted for consideration discuss clinical practice and patient care; case studies; practice issues, including management, scope ofpractice, and reimbursement; ethical dilemmas, legal issues, and business practices; innovative methods of teaching and evaluating advancedpractice; and profiling the scholarly nature of clinical practice of nursing. As an innovative feature, students in clinical doctoral (DNP)programs will be asked to contribute original articles as well as serve as part of the review team for student submissions.Manuscript Preparation and Review: Manuscripts must be submitted electronically as a Word document, should be double-spaced withone-inch margins, and the font set to Times New Roman (12 points). A title page separate from the main manuscript must include the title;the names of all authors (including academic degrees and primary affiliations); and the name, mailing address, e-mail address, and telephonenumber of the corresponding author. The manuscript itself should include a title page without author identifiers. The manuscript shouldconform to the Publication Manual of the American Psychological Association, 6th Edition. Digital files for any figure should conform to tiff at300 ppi or eps. Please include written permission for previously published materials. A brief abstract should accompany the manuscript.Authors should supply a list of four to six keywords describing the scientific content of the article that should be used for indexing inbibliographic databases.Manuscripts submitted are for the exclusive use of Clinical Scholars Review and should not have been previously published or be presentlyunder consideration for publication elsewhere. All submissions must be accompanied by a copy of the following copyright statement:I affirm that the manuscript [insert title] is original and is not currently under consideration by any other publisher, that it containsnothing libelous or illegal, and that it does not violate any copyright or other right. Effective upon acceptance for publication,copyright to the above manuscript is hereby transferred to Springer Publishing Company, LLC. I hereby sign for and confirmagreement on behalf of myself and all coauthors.Manuscripts should be submitted electronically using Editorial Manager: http://editorialmanager.com/csrev/Original Research Contribution: These manuscripts include intervention studies, cohort studies, observational studies, survey research,cost-effectiveness analyses, and decision analyses. Each manuscript should clearly state an objective or hypothesis; design and methods;intervention; outcome measures; results; and limitations, discussion, and conclusion. Manuscripts may be prepared using traditional researchformat or Guidelines for Quality Improvement Reporting (Qual Saf Health Care 2008;17[Suppl. 1]:i13–i32. doi:10.1136/qshc.2008.029058).An abstract of no more than 200 words is required. Maximum length of manuscript is 3,000 words (not including abstract, tables, figures, andreferences), with no more than a total of four tables and/or figures.Systematic Review: These manuscripts critically assess clinical topics in the literature that address factors, including cause, diagnosis, prognosis,therapy, or prevention. All data sources should be searched and selected systematically for inclusion. The search, selection, and criticalassessment process should be described in the manuscript. For each data source, the type of study, population, intervention, exposure, andoutcomes are described. An abstract of no more than 200 words is required. Maximum length of manuscript is 3,000 words (not includingabstract, tables, figures, and references), with no more than a total of four tables and/or figures and no more than 50 references.Brief Report: These manuscripts are short reports that pertain to evidence-based practice, business of practice, clinical case reports, ethicsand law, and education. An abstract of no more than 100 words is required. Recommended length of manuscript is 1,500 words (not includingabstract, tables, figures, and references), with no more than a total of two tables and/or figures.DNP Dialogue or DNP Commentary: These manuscripts may address topic of interest to DNP role as it relates to nursing and interprofessionaldialogue, research, ethics, health policy, law, education, and current events. Commentaries should be scholarly and clearlypresented. Maximum length of submission is 1,000 words of text, with one small table or figure and no more than 10 references.The DNP Experience: These manuscripts are written in essay form for the purpose of explicating the experiences of the DNP students,residents, faculty, and practitioners as they affect the professional development and scholarship. Abstract is not required. Maximum lengthof submission is 1,500 words of text, with no more than five references.Case Studies: These manuscripts present cases of interest related to clinical practice. The manuscript begins with a paragraph that discussesthe reason for selecting the case, which is followed by the case vignette. The remaining portion of the manuscript uses scholarly inquiry to definethe problem and describe the underlying condition and associated challenges. Best clinical evidence for practice is presented to provide arationale for therapeutic interventions and actions taken to resolve the case. Recommendations for future practice and building evidence frompractice may be presented. An abstract of no more than 150 words is required. Maximum length of manuscript is 2,500 words (not includingabstract, tables, figures, and references), with no more than a total of four tables and/or figures and no more than 30 references.Authors may direct inquiries to: Janice Smolowitz, DNP, EdD, DCC, Editor, Clinical Scholars Review, Senior Associate Dean, ColumbiaUniversity School of Nursing, 630 West 168th Street, Box 6, New York, NY 10032. E-mail: js928@columbia.edu

Clinical Scholars ReviewThe Journal of Doctoral Nursing PracticeVolume 5, Number 2, 2012COMMENTARY/EDITORIALFrom the Editor .....................................................................................................................................................75Janice SmolowitzDIALOGUESThe American Board of Comprehensive Care Examination: Perspectives .............................................................77EDUCATIONOpportunities and Challenges Faced by Doctor of Nursing Practice-Prepared Faculty inAcademic Institutions: One School’s Story .......................................................................................................82Courtney E. Reinisch, Rachel Lyons, Richard Pesagno, Jeffrey Kwong, and Margret QuinnImplications for Palliative Care Nursing Education ...............................................................................................86Kim KueblerCultural Competence Education for Rural Clinic Nurses: A Comparison of Methods .........................................91Sue C. Field and Sue E. BellPRACTICE EVIDENCEEvaluating and Managing Uncomplicated Skin and Soft Tissue Infections Associated WithCommunity-Associated Methicillin-Resistant Staphylococcus aureus for Outpatients:A Review of the Literature ................................................................................................................................98Yvette WinsteadTime of Day and Accurate Weights for Patients With Heart Failure ..................................................................106Alice M. Siehoff and Catherine RyanVitamin D: Implications for Thyroid Surgery ......................................................................................................116Mary SullivanPRACTICE MANAGEMENTAdoption of a Pain Assessment Tool in Older Homebound Patients WithDementia in a Housecall Practice: A Dissemination Study ............................................................................124Jean-Claude K. ProvostAnesthesia Handoff: A Root Cause Analysis Based on a Near-Miss Scenario ....................................................132Eileen Y. Evanina and Nicole L. MonceauxETHICAL AND LEGAL ISSUESResearch Participation: A Moral Obligation? ......................................................................................................137Susan Doyle-Lindrud

GLOBAL PERSPECTIVESFrom the Editor ...................................................................................................................................................142Jennifer A. SmithMary Johnson, DNP, ACNP-BC, Visits Norway as Fulbright Specialist in Simulation Pedagogy ......................144Mary P. Johnson and Jennifer A. SmithCOMMUNITIES OF INTERESTRAND Health Research Highlights: Malpractice Risk, by Physician Specialty ..................................................147Reflective Response: Malpractice Risk, by Physician Specialty ............................................................................151Courtney ReinischClinical Scholars Review is published twice a year by Springer Publishing Company, LLC, New York.The opinions expressed in Clinical Scholars Review are those of the authors and not necessarily endorsed by Columbia University School of Nursing or SpringerPublishing Company, LLC. No responsibility is assumed for any injury, loss or damages arising from any errors or omissions or the use or operation of anyinformation, including but not limited to the methods, procedures, practices, instructions, or drug dosages, contained in this publication. No warranty, whetherexpress or implied, is made with respect to the material contained herein. Medicine is an ever-changing science and independent verification of diagnoses andtherapeutic practices, including drug dosages, should be made.Business Office: All business correspondence, including subscriptions, renewals, and address changes, should be addressed to Springer Publishing Company,LLC, 11 West 42nd Street, 15th Fl., New York, NY 10036. www.springerpub.comEditorial Office: Manuscripts for publication should be submitted electronically using Editorial Manager: www.editorialmanager.com/csrevSubscription Rates (per Year): For institutions: Print, $195; Online, $195; Print & Online, $250. For individuals: Print, $78; Online, $78; Print & Online, $117.Outside the United States—for institutions: Print, $217; Online, $195; Print & Online, $279. For individuals: Print, $78; Online, $78; Print & Online, $117.Articles for this journal are indexed/abstracted in ASSIA (Applied Social Sciences Index & Abstracts) and EMCare.Permission to reprint articles may be obtained from the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, info@copyright.com or on the web at www.copyright.com. This permission holds for copying done for personal or internal reference use only; it doesnot extend to other kinds of copying, such as copying for general distribution, advertising or promotional purposes, creating new collective works, or for resale.Requests for permissions or further information should be addressed to Springer Publishing Company, LLC.Postmaster: Send address changes to Clinical Scholars Review/Springer Publishing Company, LLC, 11 West 42nd Street, New York, NY 10036.Copyright © 2012 Springer Publishing Company, LLC, New York. ISSN 1939-2095

commentary/editorialFrom the EditorAs I write this editorial for the fall issue of ClinicalScholars Review, the Supreme Court ruled the PatientProtection and Affordable Care Act (PPACA) requirementthat individuals buy health insurance or pay apenalty is not a constitutional violation (Martin, 2012).Discussion of the implications of this decision began immediately.It is anticipated that the conversations willcontinue over the next few months as political representativesand spokespersons from various organizationsadvocate for their constituents. Given the history of thedevelopment of doctor of nursing practice (DNP) degreeprograms and curricula, DNP–prepared nurses have aunique opportunity to contribute to improving the healthcare system and patient outcomes through participationin implementation of the PPACA.In 2004, the American Association of Colleges ofNursing (AACN) recommended doctoral preparation foradvanced practice registered nurses (APRNs). Advancednursing practice was defined asany form of nursing intervention that influences healthcare outcomes for individuals or populations, includingthe direct care of individual patients, management ofcare for individuals and populations, administration ofnursing and health care organizations, and the developmentand implementation of health policy. (AACN,2004, p. 2)This recommendation addressed findings from Instituteof Medicine (1999, 2001, 2003) reports, whichidentified deficits in the delivery of health care services.Practice-focused doctoral programs were envisioned asproviding education to expand development of advancedcompetencies for complex practice, faculty, and leadershiproles; knowledge for nursing practice and patientoutcomes; and leadership skills for health care delivery(AACN, 2004, p. 4).DNP program curricula are designed to address scientificunderpinnings for practice, organizational andsystems leadership for quality improvement and systemsthinking, clinical scholarship and analytical methods forevidence-based practice, information systems/ technologyand patient care technology for the improvement andtransformation of health care, health care policy for advocacyin health care, interprofessional collaboration forimproving patient and population health outcomes, andadvanced nursing practice (AACN, 2006). Doctorallyprepared nurse practitioner (NP) competencies includeadvanced communication skills and expertise in collaboration,complex decision making, leadership, and knowledgeof the business of health care (National Organization ofNurse Practitioner Faculties, 2012). DNP-prepared NPsuse practice inquiry to improve health care delivery, healthoutcomes, and address health policy. They apply scientificknowledge in the provision of quality care and employskills in technology and information literacy. Based onthe development of DNP program curricula and cliniciancompetencies, these APRNs are poised to contribute toand lead health care initiatives. All of these competenciesare critical components of the PPACA.The PPACA is expected to provide insurance coveragefor 32 million previously uninsured Americans. Severalprograms associated with the Act have already beenimplemented. Changes will continue to be phased inuntil full implementation. The PPACA prevents healthplans from banning or dropping coverage for individualswho develop a medical condition (Office of the LegislativeCounsel, U.S. House of Representatives, 2010).Children with preexisting health conditions cannot bedenied coverage. Group health plans and policies sold toindividuals cannot restrict annual and lifetime dollar limitsfor essential health benefits. Dependent children mayreceive coverage under parents’ health insurance untilClinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Company 75http://dx.doi.org/10.1891/1939-2095.5.2.75

their 26th birthdays. Persons with preexisting conditionswill be able to purchase subsidized health insurancethrough a national high-risk pool. The Patient-CenteredOutcomes Research Institute was established to assistin health care decision making through disseminationof health outcomes and clinical effectiveness research.Medicare-insured patients with chronic illness will bemonitored and quality of care outcome indicators will belinked to physician reimbursement.DNP-prepared APRNs are educated to improvedelivery of health care services to individuals and populations.It is imperative that DNP/APRNs engage asfull partners in implementation of these new initiatives.CSR was established to build a network of scholarshipthat bridges academia and practice in clinical practice atthe doctoral nursing level, to shape the practice of nursingthrough focus on clinical excellence and evidencedbasedpractice, and to offer a repository for examplesof the highest level of clinical nursing and comprehensivecare (Smith, 2008). Comments and reflections regardingthe PPACA in relation to nursing practice areinvited.Janice Smolowitz, DNP, EdD, DCCEditorReferencesAmerican Association of Colleges of Nursing. (2004). AACNposition statement on the practice doctorate in nursing.Washington, DC: Author.American Association of Colleges of Nursing. (2006). Theessentials of doctoral education for advanced nursing practice.Retrieved from http://www.aacn.nche.edu/publications/position/DNPEssentials.pdfInstitute of Medicine. (1999). To err is human: Building a saferhealth care system. Washington, DC: National Academy Press.Institute of Medicine. (2001). Crossing the quality chasm: A newhealth care system for the 21st century. Washington, DC:National Academy Press.Institute of Medicine (2003). Health professions education: A bridgeto quality. Washington, DC: National Academy Press.Martin, R. (2012). How the affordable care act affects you. Retrievedfrom http://www.cbsnews.com/8301-505145_162-57463228/how-the-affordable-care-act-affects-you/National Organization of Nurse Practitioner Faculties. (2012).Nurse practitioner competencies: Amended 2012. Retrieved fromhttp://www.nonpf.com/associations/10789/files/NPCoreCompetenciesFinal2012.pdfOffice of the Legislative Counsel, U.S. House of Representatives.(2010). Compilation of the patient protection and affordable careact (as amended through May 1, 2010). Retrieved from http://housedocs.house.gov/energycommerce/ppacacon.pdfSmith, J. (2008). Welcome. Clinical Scholars Review, 1(1), 2.76 Smolowitz

dialoguesThe American Board ofComprehensive Care Examination:PerspectivesJanice Smolowitz, EdD, DNPColumbia University School of NursingFor the past 4 years, the American Board of ComprehensiveCare (ABCC; n.d.) has administered its certificationexamination to graduates of doctor of nursing practice(DNP) programs who meet defined and accepted standardsof practice for the provision of comprehensive care.The examination tests medical knowledge and understandingof the clinical science considered essential forthe sophisticated practice of comprehensive care, withemphasis on clinical management in ambulatory settings.Inpatient encounters of significant complexity that reflectcontemporary trends also are represented. The examinationprovides evidence of the competence necessary toassume independent responsibility for patient care acrossthe life span and clinical settings.Individuals and representatives of medical and nursingorganizations have expressed strong opinions regarding thisexamination and testing of medical knowledge by nurses(Mundinger, 2008). Because Clinical Scholars Review is focusedon excellence in the application of evidence-basedpractice and the advancement of doctoral nursing, the editorsbelieve it would be informative to explore the ABCCexamination from the perspective of DNPs who have successfullycompleted the certification process. An e-mailwas sent to all DNPs who have achieved the credential ofDiplomate in Comprehensive Care (DCC). Four questionswere posed. The DCCs were offered the opportunity to answerany or all of the q uestions in the following “Dialogue.”Responses appear in alphabetical order.Why did you decide to sit for this examination?In my mind, this exam helps distinguish betweenDNP programs that have an emphasis on advancedclinical care and those that have other foci such asleadership, teaching, or policy tracks. This exam wasthe culmination of my DNP education that demonstratedthat I had mastery of advanced clinical contentthat allows me to care for a broad spectrum of patientsacross the life span. This was especially important tome as I was trained in my master’s education with avery narrow focus (CRNA).—Dr. Ardizzone, DCCWhile I studied for my DNP degree with breathtakingspeed, various universities had changed the curriculumand the meaning of this degree. No longer exclusivelya higher clinical degree for nurse practitioners, it hadbecome a terminal degree for nursing in general. I amnot sure this was a bad thing, but I was very glad forthe opportunity to redefine or validate my area ofstudy with this exam.—Dr. Ares, DCCI decided to sit for the exam because I believedI could pass it and wanted to challenge myself todo so. Also, I actually enjoyed studying the material.—Dr. Auer, DCCWhen I found out about this certification exam andlooked at the curriculum, the initial thoughts that cameto my mind were that this is a very comprehensiveexam and that knowledge of this content wouldenhance my ability to be a much more proficientclinician. After all, being a better clinician is what Istrive for everyday and this was one of the ways for mestart.—Dr. Avadhani, DCCAfter I completed my DNP program, it just seemednatural that there would be a certification to validatemy clinical doctoral education as an NP. I searcheduntil I found the ABCC exam and started preparingimmediately to take the exam.—Dr. Diggins, DCCClinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Company 77http://dx.doi.org/10.1891/1939-2095.5.2.77

As a member of the charter class of the DNP programat Columbia University, I felt I was advancing thepractice by advancing my education and experience.The examination was an objective means to evaluatean advanced education without evaluating a specialtyarea.—Dr. Ficken, DCCThe discipline of medicine is the entity best understoodby insurers and health care industry analystsfor comparing the value of advanced practicen ursing. Although APNs are aware of our value, asare many patients and colleagues, insurers and healthindustry analysts may not be. Anecdotal informationis not as highly valued for making decisionsabout reimbursement, policy, and so forth; having aquantifiable tool like an exam for determining valueis the current standard for making these types ofdecisions. So, for this time in health care as it currentlyexists, the ABCC exam seems to be one ofthe better mechanism for demonstrating the worthof APNs.—Dr. Hannigan, DCCI wanted to validate my knowledge and skill; Ifelt this exam afforded me this opportunity.—Dr. Janotha, DCCAt the time I sat for the exam, I had 24 years ofnursing experience, which included all types of criticalcare and long-term care, and 18 years experienceas a family nurse practitioner in a variety of outpatientsettings, including obstetrics. I felt confidentthat my background and experience met the qualificationsof a “comprehensive care” provider; and thatgiven my clinical doctoral education, I would performwell on this exam. My decision was based moreon a personal professional goal than it was basedon the idea that the certification would propel mycareer.—Dr. Lindenberg, DCCCertification has long been a proven mechanismfor validating competence. With the DNP degreebeing relatively new, I felt by sitting for this exam,I could assist in enhancing the credibility and valueof the degree by contributing to the database to beacquired by individuals who had taken the exam orwho would be taking it in the future. Additionally,I viewed the exam as being rigorous and challenging.Having been a family nurse practitioner for20 years, I was curious to evaluate my performanceon the exam to validate my knowledge base andpractice patterns.—Dr. Lowrance, DCCAt the time, I served as a faculty member atColumbia and wanted to support the DNP degreeI also received from Columbia. The exam distinguishesthose who graduate with a clinical DNP andare able to provide independent comprehensive careversus a DNP graduate in leadership or informatics.—Dr. Lyons, DCCAfter I graduated from the DNP program, I waslooking for a challenge for myself. ABCC is a nationalrecognized exam that [is] comparable to USMLEStep 3, it was a good measurement of my academicachievement. And I was also hoping through thestudy and prep that I could reinforce the clinicalknowledge that I learned from the DNP program. Inaddition, another nice title behind my name is alwaysa pleasure.—Dr. Yao, DCCThere are board certifications for each level of practicein nursing. I feel it imperative if we wish to practiceat the highest level that we accomplish the highestlevel available for board certification. It validates whatwe know, and what we practice, and serves as a publicawareness of the level at which we are capable.How has the Diplomate of Comprehensive Carecredential influenced your professional relationships?It certainly is a conversation piece. When I give professionallectures, I am always asked what DCC standsfor. Further, it is on my e-mail signature, and I alwaysget questions about what it means. When I explainto people that it is an exam that is based on the blueprintfor the USMLE Step 3 exam and measures mymastery of advanced clinical care, it certainly sparksconversation.—Dr. Ardizzone, DCCThe physician I was working with when the exam presenteditself was very supportive and urged me to sitfor the test. Many of the physicians I work with donot know about the test but are supportive when theyhear about it.—Dr. Ares, DCCI don’t believe that most people I relate with professionallyare aware of the credential or what itmeans.—Dr. Auer, DCCAt this time, there is a huge gap in knowledge. Manypeople including NPs and DNP graduates do notknow about this certification. The NPs and DNPsthat I am in contact with and those who knowwhat this exam entails certainly recognize this as an78 Smolowitz

a chievement. After speaking to me several times onthis topic, one of my DNP classmates is looking totake the exam herself.—Dr. Avadhani, DCCMy physician colleagues recognize the comprehensiveeducation I received is at the doctoral level, and there ismore collegiality and respect.—Dr. Desjardins, DCC.At this point, it has helped me educate my peers onthe purpose of the exam. I have sent many future testtakers to the ABCC Website.—Dr. Diggins, DCCThere is still a lack of understanding of what thecredential is. When I am asked, it gives me theopportunity to explain what a DNP degree is andwhat DCC stands for.—Dr. Ficken, DCCSometimes, physicians are more accepting and collegialsince you have performed at a level on an examwith which they are familiar. One physician colleaguecommented, “I knew you would pass it.” Other APNsgenerally are accepting and see me as someone whocan be consulted with because I have demonstratedthis level of competence. However, many APNs areresistive and unfriendly in discussions of the exam. Ingeneral, though, professional relationships are morepositive because of it.—Dr. Hannigan, DCCI believe it has. I currently teach in a DNP programand encourage my students to sit for the ABCC exam.It provided me with credibility when I moved fromprimary care to specialty practice. I know many of myphysician colleagues also believe it provides credibilityto the progression.—Dr. Janotha, DCCInitially, quite a bit of attention was paid to me professionallyin the academic arena because I was thefirst nurse practitioner in my state to pursue andachieve this certification. Subsequently, when I appliedfor a new clinical management position, thisparticular accomplishment on my curriculum vitaeseemed to be an area that was repeatedly highlightedby my prospective employer. Now, often,when I am introduced or “bio’ed,” the Diplomate ofComprehensive Care is noted, and a brief explanationis given.—Dr. Lindenberg, DCCMost of my professional colleagues were/are unawareof the significance of this credential. I find myself explainingits history and purpose frequently. Once theexplanation is provided, others seem to understandthe value of it. Overall, I do believe the cr edentialhas enhanced my credibility among professionalcolleagues.—Dr. Lowrance, DCCI have not met too many people who have taken theexam, and those who have heard of the exam want toknow what it has done for my career. Professionallyand personally, I feel distinguished having completeda certification exam postdoc.—Dr. Lyons, DCCMy professional relationships have not been significantlyinfluenced by the DCC credential, maybebecause it is still a relatively new credential in thisfield.—Dr. Yao, DCCThe DCC seems to be recognized among those withinacademia. Unfortunately, it is not well known in theclinical arena and has not influenced any clinical professionalrelationships that I have. It has, however,been recognized by academic institutions. Having thedoctorate seems to be what is recognized more thanthe DCC.Would you encourage other graduates of DNPprograms to sit for this examination and if so, why?Absolutely! There should be a benchmark exam thatdemonstrates competency of advanced clinical concepts.The DNP degree has unfortunately become acatchall for some programs—add a couple of credits,stick a class here and there, peripherally participatein some research, and then congratulations, you havea doctorate. I believe the DNP means much morethan that; and to distinguish high-quality programsfrom the other programs, we need a robust psychometricallysound measurement that is valid acrossprograms, across nursing specialties, and healthcare.—Dr. A rdizzone, DCCThere are so many benefits to taking this exam.S tudying for it helped solidify what I learned in mydoctoral program as well as the clinical knowledgegained through experience. Preparing for the casesimulations was incredibly helpful because it forcedme in a greater way to think in terms of independentpractice.—Dr. Ares, DCCI would most certainly encourage nurse practitionergraduates from other DNP programs to take theexam. Unfortunately, very few DNP programs have aclinical focus. Therefore, the NPs who graduate fromnonclinical focus programs will need some motivationto take the exam. It is a fact that this is not an easyThe American Board of Comprehensive Care Examination: Perspectives 79

exam without going through a clinical DNP program.However, it is doable and the fact that it is a difficultexam makes it most rewarding to succeed in thisexam.—Dr. Avadhani, DCCYes, we need a standard exam to distinguish betweenclinical DNP graduates and those that focus on policyand administration.—Dr. Desjardins, DCC.Absolutely! As stated above, I have been propagatingthe exam and its value in NP circles professionally andacademically.—Dr. Diggins, DCCYes. A degree signifies you have satisfactorily completeda required education program. A certificationdemonstrates an objective evaluation of knowledge.—Dr. Ficken, DCCYes. I think that APNs who have been practicing for awhile can boost their sense of themselves professionallywith passing the exam and further educate the restof the health care world about our competence ashealth care providers. As stated before, it’s the onlymechanism at this point that is widely understood bypayors and policy makers demonstrating the value ofAPNs.—Dr. Hannigan, DCCI do encourage the graduates to sit for the exam.—Dr. Janotha, DCCI would because it has been one of the premier personalhighlights of my professional career. It is a culminationof many years of clinical experiences, patients,and health care settings.—Dr. Lindenberg, DCCI am a strong proponent for this exam. In additionto a part-time practice as an FNP, I am faculty in aDNP program. I am constantly encouraging theadvanced practice individuals to learn about and sitfor this exam. I think this certification is importantto validate competence and to help establish thecredibility of the DNP degree. I think as health carereform moves forward in whatever format, the DCCcredential will eventually be considered in terms ofthe removal of various barriers related to advancedpractice.—Dr. Lowrance, DCCInformation is key. I believe that more schools needto be informing DNP graduates of the exam. I alsobelieve that we have a need to change policy torecognize the DCC members as independent practiceproviders on the same reimbursement scale as ourmedical colleagues.—Dr. Lyons, DCCI do encourage other graduates of DNP program totake this exam, it is probably not the only way to convincethe world that you are capable; however, it is aneasier and faster way.—Dr. Yao, DCCYes, I think it should be a requirement. Once onecommits to obtaining the highest level of clinicalnursing education, it should be assumed that a boardexam would be paired. For instance, one would notattend a gastrointestinal fellowship and not sit for theGI boards and only take internal medicine boards.It is a responsibility to our profession to be able toachieve the level of practice not only in the classroombut on the certification level as well. Further, if it isgoing to become standard to achieve the DNP status,in the future, it should be made required to also passthe exam.This is a specialty examination. In accordance withthe LACE criteria, the examination could be used totest knowledge of nurse practitioners who providecare for individuals and families across the life span.Would you be supportive moving toward the ABCCexamination as a primary certification?This does give me pause—I think the examinationsthat we have for FNP, ANP, PNP, CNM, and CRNAsare already sound—I think the ABCC examinationshould be required in addition to and in lieu of specialtyexams. Specialty exams are usually writtenby and responsive to the needs of each individual,advanced nursing specialty, and the changing practice.I think it would not be feasible for the ABCC tocapture the nuances that are needed for specialtyexams.—Dr. A rdizzone, DCCThe knowledge required to pass this exam is in thearea of general medicine. Currently, we are first certifyingNPs with a specialized exam after their master’sprograms, then they go back to earn a moregeneralized DNP degree. This process seems backwardsto me. With the movement to require a DNP asthe entry-level degree for nurse practitioners, I wouldlike to see this exam qualify as the primary certification;specialty certifications could follow after that aspostdoctoral work or as fellowships.—Dr. Ares, DCCI would be in favor of moving toward the ABCC examas a primary certification. I believe it would be a morevalid test of competence for primary practice andwould be more widely recognized.—Dr. Auer, DCC80 Smolowitz

I strongly believe that all nurse practitioners whowant to be proficient health care providers should takethis exam as a primary certification. Specialty certificationsshould be secondary. For example, NPs whowant to practice in critical care such as myself shouldhave critical care certification as well but after the primarycertification.—Dr. Avadhani, DCCI believe the exam should be a standard for clinicaldegree programs. It recognizes individuals whoprovide comprehensive care across the life span andsettings.—Dr. Desjardins, DCC.It seems intuitive that this exam would be the solecertification required to validate the standard of competencerequired for the clinical practice, doctorate innursing graduate.—Dr. Diggins, DCCNo. The current method of certification allowscandidates to sit for a certification examination aftersuccessfully completing a program that focuses on aparticular area. The student who completed a NeonatalNurse Practitioner program would not have the sameeducational focus as the mental health nurse practitionerstudent. Passing the ABCC examination would notdemonstrate competence in the acute care area. Andeven if each student could pass the DCC exam, it wouldnot be a reflection of their education or training.The ABCC examination was geared toward testinga candidate’s general knowledge at a more advancedlevel.There has been debate regarding the DNP-preparednurse practitioners identifying themselves as “doctor.”The title doctor does not belong to one group. As aprofessional, I want to feel confident that my educationand passing of the ABCC examination reflexesthe highest level of training and objective evaluation ofmy advanced knowledge. If we have only one test for allnurse practitioners, we will not be able to demonstrateexcellence in any one field. Not all nurse practitionerswant to work autonomously at such an advancedlevel. If you do not allow for delineation of advancedpractice levels, then we are essentially taking a stepbackwards. The DCC will no longer represent epitomeof advanced training and practice.—Dr. Ficken, DCCI don’t know enough about what the advantagesor disadvantages of changing the existing certificationstructure would be to offer an opinion.—Dr. Hannigan, DCCAbsolutely I would support this. I believe that we, asNPs, need to certify that certification and maintenanceof certification encourage lifelong learning andprofessional development.—Dr. Janotha, DCCI would be supportive of the exam as a primary certificationbecause my advanced nursing practice philosophyis that one should be an accomplished generalistbefore practicing in a specialty field. By this means, thenurse practitioner can meet the basic health care needsof the individual in any setting; thus, closing the gapin our fragmented health care system. This standard isalso commensurate with our physician colleagues whoestablish competency as generalists first, in all settings,before they specialize.—Dr. Lindenberg, DCCI do not see this exam replacing certification examsoffered by ANCC and AANP. I do see this examas becoming a third option for primary certificationfor those who would prefer to take it in placeof one of the other two and could wholeheartedlysupport this move. Before this could happen, and soforth, there would need to be considerable dialogueamong professional organizations as well as continuedanalysis of the ABCC exam for validity. Mostimportantly, nursing regulatory agencies would needto accept the exam as being appropriate for primarycertification.—Dr. Lowrance, DCCYes—if we could change policy so that third-partyreimbursement reflected our certification much likeit does with MDs—I believe the public and our colleagueswould view DCC as the nationally recognizedstandard that it is.—Dr. Lyons, DCCI remain neutral for the last question. I think I needto understand the question a little more before I comeup with an answer.—Dr. Yao, DCCReferencesAmerican Board of Comprehensive Care. (n.d.). Examinationoverview. Retrieved from http://abcc.dnpcert.org/ExamDescription.shtmlMundinger, M. (2008). American Board of ComprehensiveCare certification (ABCC): Too close to medicine. ClinicalScholars Review, 1(2), 67–68.The American Board of Comprehensive Care Examination: Perspectives 81

EDUCATIONOpportunities and ChallengesFaced by Doctor of NursingPractice-Prepared Faculty inAcademic Institutions:One School’s StoryCourtney E. Reinisch, DNP, FNP, DCCRachel Lyons, DNP, PNP, DCCRichard Pesagno, DNP, PMHNPJeffrey Kwong, DNP, MPH, ANPMargret Quinn, DNP, PNPRutgers UniversityAs the number of doctor of nursing practice advancedpractice registered nurses (DNP APRNs) continues toincrease, a percentage of graduates from DNP programswill seek employment in academic institutions as faculty.This is consistent with the goal of the Institute of Medicine(Committee on the Robert Wood Johnson FoundationInitiative on the Future of Nursing, Institute ofMedicine, 2011) report to increase the number of nurseswith doctoral preparation and to alleviate the facultyshortages many institutions face. DNP-prepared nursingfaculty can serve as both intermediaries and translatorsbetween nursing practice and nursing education (Danzeyet al., 2011). Although these new faculty members areprepared with additional expanded clinical knowledge,systems education, and ethical and legal understanding,they will face both challenges and opportunities in theirnew roles.ChallengesAcademic institutions serve a tripartite mission of education,scholarship, and research. Clearly, DNP-preparedfaculty can meet the goal of educating students, yetchallenges are evident in the areas of scholarship andresearch. Perhaps it is because of the interpretation: Whatis DNP APRN scholarship? In what type of research canand will DNP APRNs engage?As expert clinicians, DNP APRNs must be recognizedas valued and respected colleagues among theirPhD- prepared faculty. It is research utilization and translationto practice that differentiates this terminal degree.In order to use and translate research and to maintaincredibility and expertise, DNP APRN faculty need tocontinue to practice on a regular basis.A key element in maintaining clinical expertiserequires the DNP APRN faculty to actively engage inclinical practice. This activity allows DNP APRN facultyto provide the most up-to-date educational opportunitiesto both undergraduate and graduate students theyteach. Given the unique structure of maintaining practicewithin an academic setting, workload assignmentsneed to take into account and support clinical practice.In addition, structuring and affording DNP APRN facultyopportunities to expand into roles that offer jointappointment status would facilitate opportunities forcontinued clinical practice, establishing expertise within82 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.82

the appointed clinical institution or agency, promoteavenues for expanded graduate and undergraduate learningopportunities, and augment opportunities to partnerwith the associated clinical institution to expand the implementationof evidence-based practice and guidelines toimprove patient outcomes, health care spending, clinicalstaff mentoring, and education. It is clear that institutionswishing to foster and support DNP APRN faculty needto support clinical practice.Tenure is a challenge for many institutions becausethis is not an option for many DNP APRN–preparedfaculty, and it may stem from the notion that the PhDis regarded as the accepted degree for university facultiesworldwide (Cronenwett et al., 2011). Tenure is not an optionfor members of some institutions and may conflictwith general university policies. In state institutions, theremay be union and state policies that do not permit tenurefor faculty with clinical appointments.Another challenge for new DNP-prepared facultyis mentorship. Mentorship is a challenge because thereare few experienced DNP-prepared faculty members.Without DNP leadership, there is a lack of direction forDNP-prepared faculty. Part of the challenge may be inhow the DNP graduate was prepared academically. Thefirst few academic DNP degree programs had a clinicalfocus, whereas, presently, many DNP programs offer variousspecializations including administration, leadership,and education. Ambiguity exists in academic preparation,which makes mentorship challenging. The preparation ofthe DNP graduate may not be congruent with the goalsand experience of the mentor.There is still great confusion among many researchfaculty relative to what DNP education entails and whatexpertise the DNP graduate is able to offer. This confusioncan add to the obstacles that prevent DNP and PhDfaculty from collaborating. Unfortunately, the identificationand articulation of ways in which DNP and PhDfaculty can partner have not been clearly identified. Thisnot only inhibits collaborative efforts but also can be anobstacle for the development of mentoring partnershipsfor DNP-prepared faculty members.Institutions with a research focus foster, encourage,and support junior faculty researchers. These faculty membersmay be afforded reduced teaching assignments or additionalfinancial compensation to allow time for researchproject development. The opportunity for similar supportor encouragement may not exist for DNP-prepared facultymembers. This obstacle again may exist as the trajectoryfor DNP scholarship has not yet been clearly articulated.Because many DNP graduates are clinicians, release timefor clinical practice may be a concern. Support for clinicalpractice may not coincide with the goals of a researchintensive institution. Maintaining clinical certification andlicensure also needs consideration because active practiceis typically a requirement for continued certification asthe advanced practice nurse within all specialties.OpportunitiesWhat opportunities does an academic appointment providefor DNP APRN faculty members? Where do theybest serve to meet the goals and needs of the institution,the students, and the profession? What happens to specialtypreparation as nurse practitioner programs move toDNP degrees?Capstone projects can present an opportunity forDNP faculty input. The development and design of thecapstone project are established by the institution. Questionsmay surface regarding what these projects shouldentail and what is deemed as a scholarly capstone projectfor doctoral level education. In addition, questions surfacerelative to what is a reasonable project, who shouldserve as committee members, and is it necessary forchairs of capstone projects to share clinical expertise asit relates to the content of the work? Questions have alsobeen raised as to what areas of practice would benefit orwork well as a capstone project. One thing is certain, it isessential that DNP-prepared faculty be included in theprocess. This is important for promoting best practicesas well as for allowing individuals who have completeda DNP education to be actively involved in the evolutionof this academic process. DNP faculty leadershipand input in these projects will result in refinement ofthe capstone project and promote discussion of DNPscholarship. DNP-prepared nurses should be activelyengaged in the education of DNP students at all phasesof the process.Educating nurses for advanced practice is another opportunityand goal for DNP-prepared faculty memberinput in the educational process. Students are affordedexcellent learning experiences because the DNP APRN–prepared faculty bring clinical expertise and knowledgeto the academic setting. Many current DNP-preparednurses bring a significant amount of clinical expertise totheir roles. DNP APRNs can bring clinical expertise tothe classroom and can provide case-based learning andsimulation experiences, consistent with recommendationsfrom the Future of Nursing report (Committee onthe Robert Wood Johnson Foundation Initiative on theFuture of Nursing, Institute of Medicine, 2011).Opportunities and Challenges in Academic Institutions 83

DNP-prepared faculty may bring valuable experienceand knowledge, which can aid in program and curriculumdevelopment of DNP education programs. Although, likemany PhD-prepared faculty, DNP graduates have notreceived formal instruction in the educator role they offerimportant contributions to academic programs fromtheir clinical and education experiences. DNP programsare still new and evolving. Most programs are less than10 years old. Enhancing the education of future DNPgraduates affords future opportunities for DNP-preparedfaculty members.The Rutgers ExperienceIn a forward-thinking move, Rutgers University Collegeof Nursing appointed five DNP APRN–prepared facultyas clinical assistant professors. The university is a large,multicampus, state institution. These faculty members areexperienced and certified APRNs in the areas of adult,family, pediatric, and psychiatric mental health. Initially,the plan was to have these faculties serve in the role of aclinical instructor for undergraduate students in their clinicalexperiences. This move did make sense as the DNPpreparedfaculties are all practicing APRNs. It quicklybecame evident that this may not have been the best useof these faculties’ education and training. Instead, thesefaculties were placed in the role of educating and preparingboth nurse practitioner and undergraduate students.The DNP-prepared faculties were appointed to committees,which work to address the needs of students andthe college at large. They were given full voting privilegeson the committees they serve. Because these facultieshave clinical appointments, they are not eligible for tenurenor are they eligible to vote in the first level reviewcommittee. First level review is responsible for determiningappointments, reappointments, and promotions for allclinical and tenure-track faculty members. The only memberseligible to vote on this committee are tenured faculty.The DNP faculty will have no say in these decisions.Faculty with clinical appointments is not eligible fortenure at Rutgers. Not only are there university-wide policiesand procedures but there is also a union, and there arestate regulations that may never allow for tenure for thesefaculty members. This challenge goes beyond the collegeof nursing and may stem from what Billings (2008) wrotewhen the DNP degree was introduced—that the DNPdegree prepares graduates for clinical track appointmentsand not tenure-track appointments with job expectationsof teaching, service, and research. In a recent Nicholes andDyer study (2012), in 61% of institutions, DNP facultieswere eligible for tenure, but more than half reported thatthey did not include clinical practice in granting tenure.A current revision in the College of Nursing policy forclinical practice evaluation is underway. In contrast to thetenured faculty that are encouraged to focus on education,research, and scholarship, this clinical series appointmentis supporting teaching, scholarly clinical practice, and serviceas indicators for review for continued appointmentand promotion. This current cohort of DNP faculties willbe the first to be evaluated under these new criteria. ForDNP faculty, scholarship will be different from that ofcolleagues not directly involved in patient care. Boyer’s(1990) concept of the scholarship of application exploreshow knowledge can be applied to “consequential problems”and together with the scholarship of integration“foster a dynamic interaction for new intellectual understandings”as we seek to interpret, enhance collaborationacross disciplines, and encourage new insights throughevidence-based practice applications in clinical care. Thisconcept of scholarship may inform the DNP faculty asthey seek reappointment and promotion.Recommendations for the FutureAs more DNP graduates enter the workforce, somemay consider accepting faculty appointments. Loomis,Willard, and Cohen (2007) reported 55% of DNP graduateswere interested in nursing faculty positions. Prior toaccepting an appointment, candidates should considerthe institution’s vision and mission. Research institutionshave the expectation that faculty will primarily focus onthe development of programs of research and on obtainingexternal funding.Institutions with a primarily research focus may notbe a best fit for a DNP-prepared faculty member. The academicpreparation of the DNP focuses on the synthesisand application of research to clinical practice. The DNPpreparedAPRN’s ability for engagement in “traditional”research activities is limited. Most research intensiveinstitutions at this time offer no alternative articulationfor the DNP-prepared faculty with a similar tenure trajectory.Although external funding is a possible achievementfor the DNP graduate, there are obstacles. DNPsmay not be able to serve as a principal investigator, whichlimits funding eligibility.If the vision is to have the DNP-prepared faculty educateundergraduates in a hospital-based setting, this maynot be the best use of a primary care-prepared DNP APRN.Institutions seeking to hire DNP-prepared candidates maywant to consider what is the best role and cultivation of84 Reinisch et al.

these expert clinicians’ skills. Developing specific mentoringprograms as well as clearly delineated scholarshiptrajectories for DNP APRNs may prove to be beneficialfor potential faculty candidates and the institutions. It isevident that the DNP is a terminal degree and althoughnot research focused, maintains an integral part of nursingeducation. As such, equity as a terminal degree may bejust emerging. It will be interesting to follow how DNPpreparedfaculty are integrated in research institutions.ReferencesBillings, D. M. ( 2008). Managing your career as a nurse educator:Considering an academic appointment. Journal ofContinuing Education in Nursing, 39, 392–393.Boyer, E. (1990). Scholarship reconsidered: Priorities for theprofessoriate. Princeton, NJ: The Carnegie Foundation forthe Advancement of Teaching.Committee on the Robert Wood Johnson Foundation Initiativeon the Future of Nursing, Institute of Medicine. (2011).The future of nursing leading change, advancing health. Retrievedfrom http://books.nap.edu/openbook.php?record_id=12956Cronenwett, L., Dracup, K., Grey, M., McCauley, L., Meleis,A., & Salmon, M. (2011). The doctor of nursing practice:A national workload perspective. Nursing Outlook, 59, 9–17.Danzey, I. M., Ea, E., Fitzpatrick, J., Garbutt, S., Rafferty, M.,& Zychowicz, M. (2011). The doctor of nursing practiceand nursing education: Highlights, potential and promise.Journal of Professional Nursing, 27, 311–314.Loomis, J., Willard, B., & Cohen, J. (2007). Difficult professionalchoices: Deciding between the PhD and the DNP innursing. The Online Journal of Issues in Nursing, 12(1), 6.Nicholes, R., & Dyer, J. (2012). Is eligibility for tenure possiblefor the doctor of nursing practice-prepared faculty? Journalof Professional Nursing, 28, 13–17.Correspondence regarding this article should be directed toCourtney E. Reinisch, DNP, FNP, DCC, Rutgers University,College of Nursing, 180 University Ave., Newark, NJ 07102.E-mail: courtney_reinisch@rutgers.eduOpportunities and Challenges in Academic Institutions 85

EDUCATIONImplications for Palliative CareNursing EducationKim Kuebler, DNP, APRN, ANP-BCSchool of Nursing, Georgia Southern UniversityThe purpose of this project was to compare baccalaureate nursing students’ self-perceived knowledgewith objective test knowledge in the management of chronic diseases and their associated symptoms.Methodology included two regional nursing programs that have participated in this project( Southeastern [SE] and the Northeastern [NE] United States). Senior baccalaureate nursing studentsin their last semester were targeted and represent the entry level into the professional nursing role.Participants completed a self-rated knowledge survey and then completed a 45-item multiple choiceobjective knowledge examination on disease pathophysiology and symptom management. The resultsshowed a weak correlation in the SE cohort between self-perceived knowledge and objective-testedknowledge. The NE cohort had a negative correlation between self-perceived knowledge and the objectivetest measurement. There was no statistically significant difference in the objective testing betweencohorts. Both cohorts scored a mean of less than 50% on the objective examination.Keywords: chronic disease; symptoms; palliative care; nursing educationThe current debate on health care reform by the federalgovernment, health care providers, and the public is focusedon the concerns of an aging society as baby boomersbegan to move into Medicare eligibility. The unyieldingdemands that this will place on the national health careresources will affect nursing care and practice that is requiredto meet this burgeoning population. Nursing educationwill require new innovations, skills, and knowledgeto address the demands of the aging adult population livingwith costly, symptomatic, chronic diseases for severalyears before death.Currently, chronic diseases such as congestive heartfailure, cancer, chronic obstructive pulmonary disease,and diabetes are among the most prevalent and costlyhealth problems in the United States (Centers forDisease Control and Prevention [CDC], 2009). Theprolonged course of illness and disability that occursfrom chronic diseases often partner with concomitantsymptoms such as pain, shortness of breath, and depression.If these symptoms are left underevaluatedand undertreated, they can lead to decreased qualityof life and costly care for millions of Americans(CDC, 2009). Chronic disabling conditions contributeto major limitations in physical functioning, whichinclude activities of daily living, and currently affectmore than 1 of every 10 Americans or 25 million people(CDC, 2009).Palliative Care in the Management of Chronic DiseaseThe premise of palliative care relates to the optimal managementof the myriad of symptoms that are concomitantto chronic diseases. Optimal symptom managementcan help to improve physical functioning and patientperceivedquality of life (Brooksbank, 2009; WorldHealth Organization, 2007). Despite the symptom burdenassociated with the most common chronic diseases,patients with nonmalignant diseases are often underrepresentedin palliative care populations (Barnes et al., 2006;Brooksbank, 2009).86 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.86

Unfortunately, most clinicians perceive and associatepalliative care with terminal or end-of-life care only, whenthere is a withdrawal of active treatment as compared withthe active management of the disease process. Because ofthis, the management of distressing symptoms and thepsychosocial and spiritual support that accompanies comprehensivepalliative care is reserved for the last weeksand days of life and not integrated into the managementof chronic disease (Corcoran & Casarett, 2010; Gwyther,Bremmem, Obs, & Harding, 2009).Current Nursing Knowledge and PracticeNurses observe and acknowledge firsthand the demandsof chronic diseases in hospitals, clinics, and patient homes,and they understand how chronic diseases affect patientperceivedquality of life and increase the care burden forfamilies and caregivers (Partnership to Fight ChronicDisease [PFCD], 2008). An integral goal of nursing isto find ways to help prevent the symptomatic burden onchronic diseases. The use of palliative intervention (e.g.,rehabilitation) in the management of chronic diseases canbe used to reduce the symptoms that promote disease progression,improve optimal physical functioning, and reduceadmission into acute care settings (Pitta et al., 2006).Currently, nursing literature in the United States lackssignificant studies to evaluate palliative nursing knowledgeand skills in the management of chronic diseases.Studies of health care professional education programsin foreign countries has shown, however, that palliativecare skills and knowledge can occur through formal educationalprograms and professional development (Ferrellet al., 2007; Robinson et al., 2004). Without appropriateoutcome data on effective educational initiatives, nurseeducators in undergraduate, graduate, and professionaldevelopment levels will fail to recognize and address importantpalliative care learning needs (Schilariet, 2009).There is minimal literature to support the clinical knowledgeassociated with palliative decision making and howthis can affect symptom management, treatment options,advance directive communication, and caregiver supportfor patients with advanced chronic disease (Grant, Elk,Ferrell, Morrison, & von Gunten, 2009).Current information regarding nursing education inthe assessment, management, and follow-up of patientsliving with symptomatic disease is focused on the end oflife, when palliative interventions increase in intensity anduse. These same issues need to address those not at the endof their life but who still suffer from symptoms associatedwith chronic disease for several years before their death.Project PurposeThe purpose of this project was to evaluate senior Bachelorof Science in Nursing (BSN) students’ knowledge of chronicdisease management. A comparison was made between thecompletion of a self-perceived knowledge survey with aquantitative knowledge measurement on chronic diseasepathophysiology and palliative symptom management. Theinformation gained from this pilot project can be used toidentify the potential learning needs of nurses who will beentering into clinical practice and providing care to agingAmericans living with symptomatic chronic diseases forseveral years before dying. Nurses who are knowledgeableabout palliative care will be able to ensure optimal symptommanagement, help the patient to maintain physical functioning,reduce disease exacerbations, and support improvedquality of life (Davis & Kuebler, 2007; Pitta et al., 2006).The specific objective for this project was to compareBSN student nurses’ self-perceived knowledge with an establishedobjective quantitative measurement of nursingknowledge in the management of chronic disease statesand their associated symptoms.Conceptual ModelThe Macmillan nurse model, familiar in the United Kingdom,was used as the conceptual model for this project.Since 1975, Macmillan nurses have been instrumental inthe development of specialist palliative care services acrosstherapeutic settings throughout the United Kingdom(Seymour et al., 2002). The Macmillan nurse’s advancedpractice and specialty training promotes an in-depthknowledge of advanced disease pathophysiology as well asthe psychological, social, and spiritual needs of the patientliving with symptomatic advanced disease (Bullen, 1994;Kuebler & Moore, 2002; Scott, 1995; Webber, 1994).The Macmillan nurse model highlights how nursingeducation in palliative care and practice can be used andintegrated into the management of symptomatic chronicdisease. Although the health care systems between theUnited States and the United Kingdom differ, the effectiveuse and integration of nursing palliative practices inthe prolonged course of disease that extends several yearsbefore death is the impetus for its use in this doctor ofnursing practice (DNP) project.MethodsTwo BSN programs participated in this project. These programsrepresent differences in geography (southeast [SE]and northeast [NE]) and student population (state vs.Implications for Palliative Care Nursing Education 87

private institution). Three internal review board (IRB)exempt approvals were obtained. These IRB approvalswere obtained from the author’s academic institution andthe participating universities. The targeted participantsfor this project were senior BSN students in their finalsemester. These students were selected as representationinto the entry level of the professional nursing role.A typewritten description of this project was providedto a volunteer academic proctor at each institution. Thisdescription included the background and introductionof the project. A preselected date and time was selectedfrom each institution by the proctors. The proctors readthe instructions to each student cohort directly from theIRB-approved proctor instructions. Student participationwas voluntary and anonymous. The students were asked tofirst complete the self-rated knowledge survey. This surveywas used to evaluate three domains of nursing knowledgerelated to prevalent chronic disease states, management ofchronic disease, and optimal symptom management. Theresponses were based on a Likert scale of 1 (no knowledge)to 4 (very knowledgeable). This survey was created and basedon nursing process. The survey underwent two piloted sessionsand was used in the author’s DNP assignments.Following the completion and collection of the surveysby the proctor—the participants were then provided thechronic disease objective knowledge examination, a 45-itemquantitative multiple-choice knowledge measurementexamination on the pathophysiology of common chronicdisease states and optimal symptom management. Thisobjective examination has been peer reviewed, piloted bytest–retest, and is currently used by two state nursing associationsfor continuing education content and credits(Georgia Nurses Association, 2011). The students weregiven an hour to complete these instruments. Each proctorcollected the examinations and placed them along withthe knowledge surveys into a sealed envelope and mailedthem by an express package that required signature by theinvestigator on delivery.The nursing self-perceived knowledge survey wasused to capture the self-perception of the BSN students’knowledge on advanced chronic disease—this providedbaseline statistics. The objective examination was evaluatedby the percentage of individual correct answers.Statistical AnalysisA Pearson’s correlation coefficient was used to determine ifthere were correlations between self-perceived knowledgeand objective knowledge. In addition, a paired t test wasused to compare the two nursing cohorts. The effect sizewas analyzed for each of the results. The selection criteriaused for this project was limited to senior BSN studentsin their last semester of their nursing program at eachof the institutions. An alternate educational activity wasprovided each institution in the event student participantschose not to participate.ResultsAll eligible students at each institution participated fullyin the project. The SE cohort was n 5 36 participants andthe NE participants were n 5 54. The three domains ofthe self-rated knowledge survey include the knowledgelevel of prevalent chronic disease states, the managementof chronic diseases, and optimal management of symptomsassociated with chronic disease. Using the Likertscale response criteria, the highest score on the managementof prevalent chronic disease states in the SE was3.06 for diabetes mellitus. The lowest score for this cohortwas 2.42 for end-stage renal disease. The average overallscore for the SE was 2.71 for this domain. The NE cohortrated the highest score of 3.13 in diabetes mellitus andthe lowest score was 2.37 in the management of HIV/AIDS. The overall mean score was 2.66 for this domain.For the second domain of chronic disease management,the SE cohort scored the highest mean score of 3.08 in thearea of assessment, and the lowest score of 2.50 was in thearea of referral. The overall mean score for this domain was2.75. The NE cohort scored the highest in the area of assessmentat 2.96 and the lowest score of 2.17 in the area of referral.The overall mean for this cohort was 2.61. In the thirddomain of symptom management, SE scored the highestat 2.94 on depression, and the lowest score of 2.14 was oncachexia. The overall mean in this domain was 2.71. The NEcohort rated the highest score of 2.93 on dyspnea, and theirlowest score of 1.67 was on cachexia. The overall mean scorefor NE was 2.54. The overall mean score for the self-ratedknowledge survey for the SE was 2.722 (Mdn 5 2.715) andfor the NE, it was 2.602 (Mdn 5 2.610). The differencesbetween the overall mean score between the SE and theNE was statistically significant at .120 ( p , .01).The chronic disease objective knowledge examination isa multiple-choice evaluation of chronic disease pathophysiology(30 questions) and the optimal management ofconcomitant symptoms (15 questions). Comparing thechronic disease pathophysiology questions between the twoinstitutions, the mean score from the SE was 13.43, and theNE scored 13.94. The difference between these two scoresis statistically nonsignificant ( p . .05). In evaluating theexamination questions related to symptom management,88 Kuebler

TABLE 1.Nursing Self-Perceived Knowledge.Mean Scores for Self-Perceived Chronic Disease KnowledgeCohorts CV Cancer Stroke COPD Diabetes Obesity End-Stage Renal HIV/AIDSSE 2.56 2.56 2.56 2.86 3.06 3.05 2.42 2.65NE 2.72 2.49 2.63 2.59 3.13 2.91 2.52 2.37Mean Scores for Self-Perceived Management of Chronic Disease KnowledgeCohorts Assessment Evaluation Diagnosis Intervention Therapies Follow-up ReferralsSE 3.08 2.86 2.47 2.81 2.78 2.50NE 2.96 2.91 2.31 2.81 2.46 2.17Mean Scores for Self-Perceived Symptom Management KnowledgeCohorts Nonmalignant Pain Malignant Pain Dyspnea Dysphagia Depression Insomnia Fatigue CachexiaSE 2.53 2.65 2.89 2.81 2.94 2.72 2.97 2.14NE 2.63 2.44 2.93 2.67 2.76 2.48 2.72 1.67CV 5 cardiovascular; COPD 5 chronic obstructive pulmonary disease; SE 5 southeast; NE 5 northeast.the SE had a mean score of 7.43 and the NE had a meanscore of 7.54—this also is a nonstatistical finding ( p . .05).In comparing the two overall objective examination scores,the mean score for SE was 21.17 and the mean score forNE was 21.48. The differences between these two scores arestatistically nonsignificant ( p . .05).For the SE, the mean score on the self-perceivedknowledge survey was 2.72 and the mean score from theobjective examination was 21.7; in analyzing the data for acorrelation between self-perceived knowledge and objectivelytested knowledge, a correlation coefficient of 2.183was identified. NE’s mean score on the self-perceivedknowledge survey was 2.60 and the mean score on theobjective examination was 21.48; in analyzing the datafor a correlation between self-perceived knowledge andobjectively tested knowledge, a correlation coefficient of1.244 was identified. Both cohorts scored a mean of lessthan 50% on the objective examination.DiscussionThis DNP project has identified current gaps in nursingeducation as it relates to the integration of palliative carein the form of symptom management of prevalent chronicdiseases. The findings from this project can be used tosupport a paradigm shift in nursing education that can beused to improve the use of palliative interventions earlierin the course of chronic disease management.Scatter Plot for Objective Knowledge ScoresSoutheast CohortScatter Plot for Objective Knowledge ScoresNortheast Cohort4545404035353030Score2520Score25201515101055005 10 15 20 25 30 35 400010 20 30 40 50 60StudentsStudentsFigure 1. Scatterplot for objective knowledge scores.Implications for Palliative Care Nursing Education 89

The investigator had the expectation that the studentswould perceive their knowledge base higher than what theresults would be as determined through an objective testmeasurement. The findings in this project are discordant.The results found from the SE cohort matched authorexpectations—although a weak correlation (2.183), itstill represents an overestimation of the actual knowledgegained during their baccalaureate program in chronic diseaseand symptom management. In distinction from theSE cohort, the NE cohort demonstrated a weak positivecorrelation (1.244) between self-perceived and objectivetestedknowledge.The differences in self-perceived knowledge scoresbetween the two cohorts could represent several variables.These variables could represent differences in geographicallocations, clinical experiences, curriculum content,individual personality, and personal expectations. Furtherstudies are needed to better identify the specifics associatedwith these variables.The overall examination showed no statistically significantdifference; in addition, there was no statisticalsignificance between the two components of the examination(disease pathophysiology and symptom management).Both cohorts scored a mean of less than 50% onthe objective examination. The most likely cause for thisperformance is related to curriculum content. Palliativecare content may be absent, incomplete, or superficialwithin the existing curriculum of each institution. Theauthor did not review individual school curriculum andcontent covering chronic disease pathophysiology andsymptom management. The NE cohort has a pain andsymptom management faculty expert available to consulton curriculum mapping. The SE cohort has an end-stagerenal disease expert on faculty who contributes to curriculumdevelopment.ReferencesBarnes, S., Gott, M., Payne, S., Parker, C., Seamark, D.,Gariballa, S., & Small, N. (2006). Prevalence of symptomsin a community-based sample of heart failure patients.Journal of Pain and Symptom Management, 32, 208–216.Brooksbank, M. (2009). Palliative care: Where have we comefrom and where are we going? Pain, 144, 233–235.Bullen, M. (1994). Macmillan nurses: Fighting cancer withmore than medicine. RCN Nursing Update, 6, 3–8.Centers for Disease Control and Prevention. (2009). Healthyaging improving and extending quality of life among olderAmericans. Chronic Disease Prevention and Health Promotion.Retrieved from http://www.cdc.gov/NCCdphp/publications/aag/aging.htmCorcoran, A., & Casarett, D. (2010). Improving communicationand rethinking hospice care. Chest, 137, 1262–2163.Davis, M., & Kuebler, K. (2007). Palliative and end of lifecare perspectives. In K. Kuebler, D. Heidrich, & P. Esper(Eds), Palliative and end of life care clinical practice guidelines(2nd ed., pp. 19–32). St Louis, MO: Saunders Elsevier.Ferrell, B., Dahlin, C., Campbell, M., Paice, J., Malloy, P., &Virani, R. (2007). Evaluation of end-of-life nursing educationconsortium undergraduate faculty training program.Critical Care Nursing Quarterly, 30, 206–212.Georgia Nurses Association. (2011). Palliative care nursing continuingeducation program. Retrieved from http://www.gna.orgGrant, M., Elk, R., Ferrell, B., Morrison, S., & von Gunten,C. (2009). Current status of palliative care clinical implementation,education, and research. CA: A Cancer Journal forClinicians, 59, 327–335.Gwyther, L., Bremmem, F., Obs, D., & Harding, R. (2009).Advancing palliative care as a human right. Journal of Painand Symptom Management, 62, 1–8.Institute of Medicine. (2003). The 1st annual crossing the qualitychasm summit: A focus on community. Washington, DC:National Academies Press.Kuebler, K., & Moore, C. (2002). The Michigan advancedpractice nursing palliative care project. Journal of PalliativeMedicine, 5(5), 753–754.Partnership to Fight Chronic Disease. (2008). Almanac of chronicdiseases 2008 edition: Statistics and commentary on chronicdisease and prevention. Retrieved from http://www.fightchronicdisease.orgPitta, F., Troosters, T., Probst, V., Spruit, M., Decramer, M., &Gosselink, R. (2006). Physical activity and hospitalizationfor exacerbation of COPD. Chest, 129(3), 536–455.Robinson, K., Sutton, S., von Gunten, C., Ferris, F.,Molodyko, N., & Martinez, J. (2004). Assessment onthe education for physicians on end-of-life care (EPEC)project. Journal of Palliative Medicine, 7, 637–645.Schilariet, M. (2009). End-of-life nursing care: Statewide surveyof nurses’ education needs and effects of education. Journalof Professional Nursing, 25(3), 170–177.Scott, G. (1995). Challenging conventional roles in palliativecare. Nursing Times, 91(3), 38–39.Seymour, J., Clark, D., Hughes, P., Bath, P., Beech, N., et al. (2002).Clinical nurse specialists in palliative care. Part 3. Issues forthe Macmillan nurse role. Palliative Medicine, 16, 386–394.Webber, J. (1994). A model response. Nursing Times, 90(25),66–68.World Health Organization. (2007). Cancer control knowledgeinto action, WHO guide for effective programs in palliativecare. Geneva, Switzerland: World Health Organization.Correspondence regarding this article should be directed to KimKuebler, DNP, APRN, ANP-BC, School of Nursing, GeorgiaSouthern University, Statesboro, GA 30460. E-mail: kkuebler@georgiasouthern.edu90 Kuebler

EDUCATIONCultural Competence Educationfor Rural Clinic Nurses:A Comparison of MethodsSue C. Field, DNP, RN, CNENorthland Community and Technical CollegeSue E. Bell, PhD, RN, PHCNS, BCMinnesota State University School of Nursing, MankatoAccording to the United States Department of Healthand Human Services (USDHHS; 2008), health disparitiesare a major problem. The Institute of Medicine (IOM;2002) report, Unequal Treatment: Confronting Racial andEthnic Disparities in Healthcare, identified greater healthcare disparities for persons who are members of minoritygroups in the United States even when findings areadjusted for health care insurance and income. The IOMreported that bias, prejudice, and stereotyping contributedto disparities in the quality and competence of care receivedby culturally diverse populations.Giger et al. (2007) defined cultural competence asgeneral knowledge about the culture and an ability to accepta person’s beliefs, although they may be foreign tothe caregiver. Multiple studies have demonstrated thateducational programs are effective in increasing culturalcompetence in health care providers (Beach, Cooper, &Robinson, 2004; Beach et al., 2005; California Endowment,2003; Lampley, Little, Beck-Little, & Xu, 2008;Registered Nurses Association of Ontario [RNAO],2007; Schim, Doorenbos, & Borse, 2006), and that culturaleducation is needed to assist nurses to acquire theability to care for others of diverse backgrounds in a culturallyappropriate manner.The importance of cultural competence education inthe upper Midwest United States is magnified by the rapidincrease in culturally diverse populations. The Hispanic/Latino population has increased 73% in North Dakotaand 75% in Minnesota since 2000 (Pew HispanicCenter, 2012). The percentage of nonwhite population inNE North Dakota increased from 7% in 2000 to 10% in2008 and is expected to increase to more than 12% by 2025(U.S. Census Bureau, 2010). The number of Asians,Latinos, and African Americans in Minnesota is expectedto double in the next three decades and the nonwhitepopulation to grow from 14% to 25% by 2035 (McMurray,2009). This increase in population diversity accentuatesthe need for culturally competent caregivers.RNAO (2007) suggested that education regardingcultural norms, beliefs, and values relevant to a culturalgroup fosters cultural understanding in health care providers,and that self-awareness is the first step in theprocess of cultural competence. Beach et al. (2005) acknowledgedthat both long (more than 1 week in length)and short (less than or equal to 8 hr) interventions arepossibly effective means of increasing cultural competencefor those in attendance. Limited education of 60–75 minincreased cultural competence scores for hospice nurses(Schim et al., 2006).Increasing culturally competent care is one of the goalsof Minnesota’s Medicare Quality Improvement Organization—StratisHealth (Stratis Health, n.d.). Toward thisend, Stratis Health (2008a, 2008b) developed a series ofDVDs entitled Culture Matters in 2008, and two of theseDVDs included interviews of health care providers fromthe Hispanic/Latino and Somali cultures. The DVDs weredeveloped around six topic areas, which included culturalbackground, role of religion and health care beliefs, socialClinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Company 91http://dx.doi.org/10.1891/1939-2095.5.2.91

values, decision making, health care considerations, andsuggestions for health care providers.ObjectiveThe objective of this project was to determine which oftwo education options was better for improving culturalcompetence in rural clinic nurses. The project comparedcultural competence scores of rural clinic nurses who completedtwo Culture Matters (Hispanic/Latino and Somali)DVDs (Stratis Health, 2008a, 2008b) with facilitated CultureMatters discussion guides to rural clinic nurses whocompleted the DVDs without the facilitated discussionguides. The conceptual framework for this project wasThe Process of Cultural Competence in the Delivery of HealthCare Services: A Model of Care (Campinha-Bacote, 2002).Five interrelated constructs were addressed in the model:cultural awareness (a self-evaluation of one’s own culturalbiases), cultural skill (the ability to perform a cultural assessment),cultural knowledge (cultural beliefs, values, andpractices), cultural encounters (number of experiences),and cultural desire (internal drive for understanding).Campinha-Bacote (2002) theorized that culturally competenthealth care providers delivered a higher standard ofculturally competent care to their patients.According to Campinha-Bacote (2002), cultural competencyoccurred on a continuum with cultural incompetenceon one end and cultural proficiency on the other.The intervention for this project was designed to assistrural clinic nurses to progress along that continuum.Although there were several reports on the generaleffectiveness of cultural competence education in the literature,there were limited studies on the effect of DVDswith or without discussion when educating nurses to provideculturally competent care. Two qualitative studies(Neville, Heppner, & Louis, 1996; Sammons & Speight,2008) found that DVDs and discussions were effectivein teaching cultural competence. Students identified themost helpful educational strategies for increasing theircultural competence as videos, discussion, in-class speakers,and experiential activities (Sammons & Speight,2008). Neville et al. (1996) found that videos and classdiscussions helped students to increase cultural competence.The California Endowment (2003) identifieddiverse strategies, including DVDs and discussions, asuseful in cultural education.Choi and Johnson (2007) concluded that video wasmore effective than text for increasing student satisfaction,comprehension, and retention of educational materialin a college course. However, there were no statisticallysignificant differences in student satisfaction, comprehension,and retention between using a DVD with discussionand a DVD without discussion. Choi and Johnson’s studypopulation consisted of students in a social science major.Thus, best practices (California Endowment, 2003) andqualitative research findings (Neville et al., 1996; Sammons& Speight, 2008) identified the use of DVDs and,possibly, discussion for increasing cultural competence.DesignA quasi-experimental pretest–posttest design was usedto determine whether there was a significant differencein cultural competence scores between rural clinic nurseswho viewed Culture Matters Hispanic/Latino and SomaliDVDs with facilitated use of Culture Matters discussionguides as compared to rural clinic nurses who viewedthe DVDs without the facilitated discussion guides. TheCulture Matters discussion guides were developed by theprimary author to accompany the Culture Matters DVDs.Because the California Endowment (2003) and Pearsonet al. (2007) recommended that educational materialsbe evaluated by representatives of the cultural community,a focus group of eight members of the Hispanic/Latino community viewed the Culture Matters Hispanic/Latino DVD with the discussion guides, and a focus groupof six members of the Somali community viewed theSomali Culture Matters DVD with the discussion guidesto ensure face validity. Both cultural groups verified theaccuracy of the material in the discussion guides.MethodologyThe participants in the project were rural clinic nurses(primarily licensed practical nurses [LPNs] and registerednurses [RNs]) working at two distinct clinics in Minnesotaand North Dakota. The participants were nurses whovolunteered to be present for the education. Prior to thestudy, potential participants were sent information regardingthe project’s purpose and the risks and benefits ofparticipation. Participation was voluntary and confidential.Participants were informed that they could withdrawfrom the project at any time without employment consequences.Because this project had a research componentbeyond quality improvement, institutional review board(IRB) approval was received prior to the initiation of theeducational sessions and data collection.Participants attended four consecutive weekly sessions.The first session consisted of a PowerPoint presentationdeveloped by the first author that explored thedemographics of the region, identified the nurses’ cultural92 Field and Bell

ackgrounds, and explored stereotypical cultural assumptionsand behaviors of health care providers. The first sessionwas similar for both groups.In the second, third, and fourth sessions, the CultureMatters DVDs of the interviews with Hispanic/Latino and Somali health care providers were viewed bythe nurse participants. The rural clinic nurses in Group Iviewed the Hispanic/Latino and Somali Culture MattersDVDs for 40 min each week followed by a 20-min discussionusing the Culture Matters discussion guides witha facilitator (the first author). The participants in Group Iattended the sessions as a group that met over the lunchhour at work. The rural clinic nurses in Group II watchedthe DVDs as a group before work for 40 min each session.Group II did not use the discussion guides.Outcome MeasuresTABLE 1.The instrument used to collect data regarding culturalcompetence was the Inventory for Assessing the Process ofCultural Competence Among Healthcare Professionals—Revised (IAPCC-R) developed by Campinha-Bacote(2002). The IAPCC-R consisted of 25 questions andfive interrelated constructs: cultural awareness, culturalskill, cultural knowledge, cultural encounters, and culturaldesire. Each question was arranged with responses on a4-point Likert scale. There were five questions for eachof the constructs with a range in scores from 5 to 20. Thescores on the five constructs were totaled to determine thecultural competence level. The total cultural competencescores for the instrument ranged from 25 to 100. Consistentwith the view that cultural competence occurs ona continuum, levels measured by the instrument were asfollows: culturally incompetent (25–50), culturally aware(51–74), culturally competent (75–90), and culturally proficient(91–100). Reliability of the instrument has beenmeasured in multiple studies and among various populationsincluding nursing students, registered nurses, baccalaureatenurse graduates, and nurse practitioners withan average Cronbach’s alpha of .83 (Campinha-Bacote,2002, p. 120). (The IAPCC-R for this population of ruralclinic nurses yielded a reliability coefficient Cronbach’salpha of .78). Construct validity was determined in studiesby Campinha-Bacote (1999) and Capell, Dean, andVeenstra (2008).The nurses in Group I (n 5 31) completed the educationusing the facilitated Culture Matters discussionguides; the nurses in Group II (n 5 29) completed theeducation without the facilitated discussion guides.The nurses in Group I had 4 hr (1 hr per week) of educationaltime, and the nurses in Group II had 3 hr ofeducational time (1 hr the first week, followed by 40-minsessions during Week 2, 3, and 4). The 60 participantscompleted the IAPCC-R in Sessions 1 and 4 and the demographicsurvey in Session 1 (Tables 1 and 2).FindingsDemographic Variables Between ClinicsDemographics Group I (n 5 31) Group II (n 5 29)Gender 100% female 100% femaleRace 97% White 97% WhiteEducation 75% LPN, 19% RN, 79% LPN, 21% RN6% OtherAge 42.48 years (Mean)** 50.48 years(Mean)**Length of 13.77 years (Mean) 16.10 years (Mean)employmentYears in nursing 20.36 years (Mean)* 27.27 years(Mean)*Note. LPN 5 licensed practical nurse; RN 5 registered nurse.*p , .05. **p , .01.The participants in the study ranged from 22 to 66 yearsof age. A comparison of the demographic characteristicsof the two groups of clinic nurses is found in Tables 1and 2. Statistically significant increases were found forcultural awareness, cultural knowledge, and cultural skills(p , .05) for both Groups I and II. Cultural encounterswere significantly increased (p , .05) among the nursesin Group II. Cultural encounters scores also increased(13.31 [SD 5 0.29] to 13.37 [SD 5 0.3] points) inGroup I; however, this was not a statistically significantchange as found on Tables 3 and 4.Prior to and after the education, there were no participantsin the culturally incompetent or culturally proficientTABLE 2.Hours of Prior Cultural EducationPrior CulturalEducation Group I (n 5 31) Group II (n 5 29)0 hr 22% 45%1 hr 19% 24%2 hr 22% 21%3 hr 6% 0%4 hr 19% 0%5 or more hours 12% 10%Mean 2.19 (SD 5 1.75)* 1.17 (SD 5 1.54)**p , .05.Cultural Competence Education 93

TABLE 3. Mean Scores on the Five Cultural Constructs of the Inventory for Assessing the Process of Cultural Competence AmongHealthcare Professionals—RevisedGroup I/Group II Awareness M (SD) Skill M (SD) Knowledge M (SD) Encounters M (SD) Desire M (SD)Pre Group I 13.4 (.27) 12.1 (.47) 10.3 (.41) 13.3 (.29) 15.5 (.36)Post Group I 15.2 (.27) 13.6 (.46) 12.6 (.43) 13.4 (.30) 15.8 (.37)Pre Group II 13.3 (.30) 12.2 (.27) 9.3 (.36) 12.7 (.28) 15.8 (.34)Post Group II 14.8 (.30) 14.3 (.27) 12.2 (.36) 13.6 (.29) 16.4 (.34)Note. M 5 mean; SD 5 standard deviation.score ranges. The data were normally distributed. The meancultural competence score before the education in Group Iwas 64.4 (SD 5 7.4) and in Group II was 63.5 (SD 5 5.2).After the education, the mean cultural competence scorein Group I was 70.5 (SD 5 7.9) and Group II was 71.3(SD 5 5.8). Total cultural competency scores for Group Ibefore education ranged from 51 to 85; and after education,the scores ranged from 55 to 90. Group II scores beforeeducation were from 55 to 76; and after education, thescores were from 58 to 83 (Figure 1). Mean scores beforeand after the education for both groups were in the culturallyaware category (51–74). These changes in total culturalcompetence scores were statistically significant (p ,.001) for both groups, but the education did not move theparticipants beyond the culturally aware category. Therewere no statistically significant differences between thetwo groups on the before or after education total culturalcompetence scores. However, the percentage of nurses inGroup I who were culturally competent increased from6% before the education to 27% after the education, andthe percentage of nurses who were culturally competentin Group II increased from 3% to 30%.LimitationsGeneralization of the findings is limited by the smallsample size, the geographic area, (upper Midwest), andthe lack of diversity among the nurses and the populationof the region.DiscussionThe mean age of the participating nurses, the mean yearsof nursing experience, and the mean number of hours ofcultural education were significantly different betweenthe two groups as displayed in Tables 1 and 2. The oldernurses (Group II) had completed fewer prior cultural educationhours. This finding probably reflects the relativenewness of cultural education in nursing degree programsand continuing education for health care professionals,particularly education for rural clinic nurses. Whetherthese statistical differences between the groups made adifference in the results is not clear. However, no associationwas identified between educational level of the nurses(LPN, diploma RN, associate degree RN, and BSN) andthe number of hours of cultural education.Cultural education significantly increased three of fivecultural competence constructs in Group I and four of fiveconstructs in Group II. According to Campinha-Bacote(2002), the intersection of the five constructs was whatdetermined cultural competence. If a health care providerscored lower in one of the constructs, this constructcould be worked on to improve the balance of the otherfour constructs (Campinha-Bacote, 2002). There was aTABLE 4. T-Test Statistic for Preintervention and Postintervention Differences of Construct and Total Cultural Competence Scores onthe Inventory for Assessing the Process of Cultural Competence Among Healthcare Professionals RevisedConstruct Group I (n 5 31) Group II (n 5 29) Differences Between (N 5 60)Cultural awareness t(31) 5 4.63, p , .001* t(29) 5 3.66, p , .001* t(60) 5 0.05, p , .27Cultural skill t(31) 5 2.31, p , .01* t(29) 5 5.44, p , .001* t(60) 5 0.62, p , .55Cultural knowledge t(31) 5 3.86, p , .001* t(29) 5 5.55, p , .001* t(60) 5 1.85, p , .96Cultural encounter t(31) 5 0.13, p , .45 t(29) 5 2.10, p , .02* t(60) 5 1.50, p , .95Cultural desire t(31) 5 0.57, p , .28 t(29) 5 1.24, p , .11 t(60) 5 0.48, p , .52Cultural competence total t(31) 5 9.79, p , .001* t(29) 5 6.03, p , .001* t(60) 5 2.83, p , .76*p , .05, **p , .01, ***p , .001.94 Field and Bell

Pre Group I Post Group I Pre Group II Post Group II141210Number of participants8642050–55 50–60 61–65 66–70 71–75 76–80 81–85 86–90Total cultural competence scoresFigure 1. Total cultural competence scores before and after education for Group I and Group II.statistically significant increase in cultural awareness inboth groups. This increase may indicate progress towardrespect for other cultural groups as well as an awareness ofone’s own cultural biases and stereotypical beliefs.A statistically significant increase in cultural skill andcultural knowledge was also identified in both groups.This result corresponded to the RNAO’s (2007) recommendationthat education should be employed to increaseboth knowledge and skill in cultural care. Campinha-Bacote (2007) stressed the importance of nurses understandingthe patient’s worldview, which is attainedthrough knowledge of the traditions, practices, and beliefsof diverse populations. Cultural encounters increasedsignificantly in Group II but not in Group I. The moreencounters a health professional has with different cultures,the more comfortable that individual will become(Campinha-Bacote, 2007). The observed differences inencounters may relate more to the clinic populations thanto the study interventions and may be why cultural encountersonly increased significantly in one group.Of the five constructs, cultural desire was scoredhighest in both groups. The educational sessions were notmandatory, and the nurses chose to come to the sessions;this may be why cultural desire was scored higher thanthe other four constructs by the participants. Accordingto Campinha-Bacote (2007), cultural desire must comefrom within and develops the other four areas of culturalcompetence.There were statistically significant increases in bothgroups for total cultural competence levels. These resultsreplicated previous studies that established cultural educationas a method for increasing cultural competencein health care providers (Beach et al., 2004; Beach et al.,2005; California Endowment, 2003; Lampley et al., 2008;RNAO, 2007; Schim et al., 2006). This study also replicatedChoi and Johnson’s (2007) finding of no statisticallysignificant difference in results between use of an educationalDVD with discussion and use of an educationDVD without discussion. Regardless, discussion guidesand facilitated discussion may make cultural educationmore interesting and engaging for participants accordingto qualitative studies (Neville et al., 1996; Sammons &Speight, 2008). According to the California Endowment(2003), best practice in cultural education is achieved byincorporating various educational strategies, includingDVDs and discussion.Implications for PracticeCultural education was effective in increasing total culturalcompetence scores in 60 rural clinic nurses. Therewas evidence that cultural education increased culturalcompetence levels of nurses (Beach et al., 2004; Beachet al., 2005; California Endowment, 2003; Lampley et al.,2008; RNAO, 2007; Schim et al., 2006). This study providedadditional support for this finding and added to theCultural Competence Education 95

ody of knowledge by specifically addressing the use ofDVDs for cultural education with or without discussionguides and facilitated discussion.Of the five constructs, cultural desire did not statisticallyincrease in either group. This may be related to the high levelsof cultural desire prior to the training and the realization bythe nurses in the sample of their need for cultural education.The addition of an intervention that is directed specificallytoward increasing cultural desire may be beneficial.Cultural education is needed to decrease the healthcare disparities throughout the United States, and culturaleducation of nurses cannot be taken for granted, particularlyin rural communities and at facilities in which nursestend to be employed over many years. As was seen in thisstudy, years of experience in nursing did not equate witheducation in the delivery of culturally competent care.Future efforts are necessary to ensure that cultural educationis available for all nurses regardless of setting. Withoutcultural education, health disparities will continue toexist, and where health disparities exist, the quality of careis compromised. Cultural education must be offered as ameans to increase the quality of care to the ever more diversepopulations presenting in health care settings.The IAPCC-R can be used with diverse groups ofnurses to provide a standard measure of cultural competence.The ease of administration and the organization ofthe instrument make it an attractive product for measurementof cultural competence; however, the cost of the instrumentis a limitation.Cultural education does increase cultural competencein rural clinic nurses as measured by the IAPCC-R. Theuse of discussion guides with facilitated discussion does notappear to increase the cultural competence levels of ruralclinic nurses more than DVD education without discussion.Clinics and other health care facilities should assess theneed for cultural education at their facilities by identifyingthe diverse populations served and determining the culturaleducation deficits among the providers of care to implementpurposeful cultural education as a means to increase qualityof care. The use of DVDs has the potential to address culturalcompetence deficits in a cost-effective manner that caneasily be incorporated into busy clinic schedules.ReferencesBeach, M., Cooper, L., & Robinson, K. (2004). Strategies forimproving minority healthcare quality (AHRQ PublicationNumber 04-E008-1). Retrieved from the Agency forHealthcare Research and Quality Website: http://www.ahrq.gov/clinic/epcsums/minqusum.htmBeach, M. C., Price, E. G., Gary, T. L., Robinson, K., Gozu,A., Palacio, A., . . . Cooper, L. A. (2005). A systematicreview of health care provider educational interventions.Medical Care, 43(4), 356–373. Retrieved from theCINAHL database.California Endowment. (2003). Principles and recommendedstandards for cultural competence education of health care professionals.Retrieved from http://www.calendow.org/uploadedFiles/principles_standards_cultural_competence.pdfCampinha-Bacote, J. (1999). A model and instrument foraddressing cultural competence in health care. Journal ofNursing Education, 38(5), 203–207.Campinha-Bacote, J. (2002). The process of cultural competencein the delivery of healthcare services: A model of care.Journal of Transcultural Nursing, 13(3), 181–184. Retrievedfrom CINAHL database.Campinha-Bacote, J. (2007). The process of cultural competencein the delivery of healthcare services. The journey continues.Cincinnati, OH: Transcultural C.A.R.E. Associates.Capell, J., Dean, E., & Veenstra, G. (2008). The relationshipbetween cultural competence and ethnocentrism ofhealth care professionals. Journal of Transcultural Nursing,19(5), 121.Census (2010). http://www.pewhispanic.org/census-2010/Choi, H. J., & Johnson, S. D. (2007). The effect of problembasedvideo instruction on learner satisfaction, comprehensionand retention in college courses. British Journalof Educational Technology, 38(5), 885–895. http://dx.doi.org/10.1111/j.1467-8535.2006.00676.xGiger, J., Davidhizar, R. E., Purnell, L., Harden, J., Phillips, J., &Strickland, O. (2007). American academy of nursing expertpanel report: Developing cultural competence to eliminatehealth disparities in ethnic minorities and other vulnerablepopulations. Journal of Transcultural Nursing, 18(2), 95–102.Retrieved from CINAHL database.Institute of Medicine. (2002). Unequal treatment: What healthcareproviders need to know about racial and ethnic disparitiesin health care. National Academy of Sciences. Retrievedfrom http://www.iom.edu/?id=16740Lampley, T. M., Little, K. E., Beck-Little, R., & Xu, Y. (2008).Cultural competence of North Carolina nurses. HomeHealth Care Management and Practice, 20(6), 454–461.Retrieved from Sage database.McMurray, M. (2009). Population notes (OSD-09-136).Retrieved from the Minnesota State Demographic CenterWebsite: http://www.demography.state.mn.usNeville, H. A., Heppner, M. J., & Louis, C. E. (1996). Theimpact of multicultural training on white racial identityattitudes and therapy competencies. Professional Psychology:Research and Practice, 27(1), 83–89. Retrieved fromPsycINFO database.Pearson, A., Srivastava, R., Craig, D., Tucker, D., Grinspun, D.,Bajnok, I., . . . Gi, A. (2007). Embracing cultural diversity96 Field and Bell

for developing and sustaining a healthy work environmentin healthcare. International Journal of Evidence Based Healthcare,5, 54–91. Retrieved from CINAHL database.Registered Nurses Association of Ontario. (2007). Embracingcultural diversity in health care: Developing cultural competence.Toronto, Ontario: Registered Nurses Associationof Ontario. Retrieved from http://www.rnao.org/Page.asp?PageID=122&ContentID=1200Sammons, C. C., & Speight, S. L. (2008). A qualitative investigationof graduate-student changes associated with multiculturalcounseling courses. The Counseling Psychologist,36(6), 814–838. Retrieved from ProQuest database.Schim, S. M., Doorenbos, A. Z., & Borse, N. N. (2006). Enhancingcultural competence among hospice staff. The AmericanJournal of Hospice & Palliative Care, 5, 404–411. Retrievedfrom the Cochrane database.Stratis Health. (n.d.) Cultural competency. Retrieved from StratisHealth Care Website: http://www.culturecareconnection.org/resources/training/dvd-series.htmlStratis Health. (2008a). Culture matters: Providing culturallyappropriatehealth care in Minnesota-Hispanic/Latino [DVD].Bloomington, MN: Stratis Health and U-Care. Availablefrom http://www.culturecareconnection.org/resources/training/dvd-series.htmlStratis Health. (2008b). Culture matters: Providing culturallyappropriatehealth care in Minnesota-Somali [DVD].Bloomington, MN: Stratis Health and U-Care. Availablefrom http://www.culturecareconnection.org/resources/training/dvd-series.htmlU.S. Department of Health and Human Services. (2008). Healthcare disparities report 2007. (AHRQ Publication No. 08-0041). Rockville, MD: Author. Retrieved from the USD-HHS Website: http://www.ahrq.gov/qual/qrdr07.htmU.S. Census Bureau. (2010). State and county quick facts. Retrievedfrom http://quickfacts.census.gov/qfd/index.htmlWilbur, V. (2008). Factors that influence the cultural competence ofnurse practitioner students. Dissertation Widener University,Chester, PA. Unpublished doctoral dissertation.Correspondence regarding this article should be directed to SueC. Field, DNP, RN, CNE, Northland Community and TechnicalCollege, 1101 Highway One E., Thief River Falls, MN 56701.E-mail: sue.field@northlandcollege.eduCultural Competence Education 97

PRACTICE EVIDENCEEvaluating and ManagingUncomplicated Skin and SoftTissue Infections AssociatedWith Community-AssociatedMethicillin-Resistant Staphylococcusaureus for Outpatients:A Review of the LiteratureYvette Winstead, DNP, FNP-BC, MSN, CRNP, RN, MS, MBA, MAThomas Jefferson University , Jefferson School of Nursing, Philadelphia, PAPurpose: The purpose of this literature review is to determine how clinicians evaluate and manage uncomplicatedskin and soft tissue infections caused by Staphylococcus aureus. Data Source: The researchtopic is explored based on an electronic search for literature published between 2003 and 2008 inMEDLINE and PubMed. The following search terms were used to secure noteworthy academic studies:skin abscess incision and drainage, incision and drainage, skin and soft tissue abscesses, uncomplicatedskin and soft tissue abscesses, and antibiotics for soft tissue infections. Conclusions: A clinicalpractice guideline based on evidence-based practice will provide clinicians with an appropriate treatmentprotocol for uncomplicated skin and soft tissue abscesses. An evidence-based clinical practiceguideline has the potential to positively influence patient outcomes and eliminate the unnecessary useof antibiotics. Implications for Practice: The Centers for Disease Control and Prevention (CDC)guidelines for the management of skin and soft tissue infections should be adopted by all clinicians inan effort to standardize treatment. Furthermore, clinicians must stay informed about the epidemiologicaland treatment of emerging organisms in their patient populations.Background and SignificanceIn the last 12 years, ambulatory care visits for skin and softtissue infections (SSTIs) have grown exponentially. Pallinet al. (2008) conducted a retrospective study at U.S. emergencydepartments (EDs), which encompassed 1.2–3.4million ED visits between 1993 and 2005. The NationalHospital Ambulatory Medical Care Survey was used inthis study, which indicates that the number of ED visitsfor SSTIs nearly tripled, and the use of antibiotics for com-munity-acquired methicillin-resistant Staphylococcus aureus(CA-MRSA) also increased from 1993 to 2005. In 1993,SSTIs were diagnosed at 1.2 million versus 3.4 million in2005. The study data demonstrates that from 1993 to 2005,the number of U.S. ED visits for SSTIs increased significantlyand parallel with the emergence of CA-MRSAand appropriate antibiotics were prescribed. In anotherretrospective study conducted by Fridkin et al. (2005) toevaluate MRSA infections in a study population from98 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.98

2001 to 2002, it was observed that a total of 1,647 cases ofCA-MRSA infections represented between 8% and 20%of all MRSA isolates. Naimi et al. (2003) evaluated 4,612patients for epidemiological and microbiological characteristicsof CA-MRSA with health care–associated MRSA(HA-MRSA) cases, which involved 1,100 MRSA infectionsof which 131 (12%) were community acquired, and937 (85%) were health care associated; 32 (3%) could notbe classified because of lack of information. SSTIs weremore common among community-acquired cases (75%)than among health care–associated cases (37%). Approximately25% of all S. aureus infections were MRSA. Thestudy findings indicated that CA-MRSA strains did notoriginate in health care settings and that their microbiologicalfeatures may have contributed to their emergence in thecommunity. Consequently, the current literature indicatesthat MRSA is a common infection, which supports theneed for implementing an evidence-based guideline in theED setting. In 2007, the Centers for Disease Control andPrevention (CDC) issued management guidelines; however,evidence indicates that clinicians are not consistentlyusing these guidelines in practice.Search StrategyA search of the published literature between 2003 and2008 was conducted using MEDLINE and PubMed. Thefollowing search terms were used to secure noteworthyacademic studies: skin abscess incision and drainage,incision and drainage, skin and soft tissue abscesses, uncomplicatedskin and soft tissue abscesses, skin and soft tissueinfections, community-associated methicillin-resistantStaphylococcus aureus, CA-MRSA, and antibiotics for softtissue infections. The exclusion criteria included complicatedskin and soft tissue infections caused by pathogensother than those caused by community-associatedmethicillin resistant Staphylococcus aureus and health careassociatedmethicillin-resistant Staphylococcus aureus.Literature ReviewClassificationSeveral classifications have been proposed for SSTIs. SSTIshave been grouped as follows: infection of normal skin,infection complicating a chronic skin disorder, acute versuschronic, localized versus diffuse, and non-necrotizing versusnecrotizing infections. There is also a proposed classificationsystem that divides SSTIs into local and systemic signs andsymptoms of infection and the presence of comorbidities(Eron & Lipsky, 2003).The classification system that groups SSTIs into uncomplicatedand complicated infections is the most widelyused schematic (DiNubile & Lipsky, 2004; CDC, 2008).Uncomplicated SSTIs are defined as simple abscesses, impetiginouslesions, furuncles, and cellulitis. ComplicatedSSTIs are categorized as infections involving deeper skinstructures requiring formal surgery (major abscesses, infectedulcers, and burns) along with an underlying medicalcondition that adversely impacts treatment success. Inaddition, infections caused by anaerobic or gram-negativeorganisms are categorized as complicated SSTIs (CDC,2008). This literature review is focused on uncomplicatedSSTIs associated with CA-MRSA.Risk FactorsIn terms of risk factors, the primary vehicle of transmissionof CA-MRSA is via hands, which may becomecontaminated by contact with colonized or infected individuals,colonized or infected body sites of other persons,or devices, items, or environmental surfaces contaminatedwith body fluids containing CA-MRSA, and poor hygiene(Archibald, Shapiro, Pass, Rand, & Southwick, 2008;Begier et al., 2004; Gordon & Lowy, 2005; Lee et al., 2004;Romano, Lu, & Holton, 2006). The risk factors associatedwith CA-MRSA are presented in Table 1.Clinical Presentation and EvaluationSSTIs have a wide range of clinical presentations includingcellulitis, impetigo, boils, folliculitis, carbuncles, furuncles,and abscesses. The large majority of these presentationsare a result of S. aureus. The terminologies used to defineSSTIs are provided in Table 2 (Naimi et al., 2003; Wolff,Johnson, Suurmond, & Johnson, 2005).Laboratory evaluation of SSTIs is necessary to identifythe organism. Therefore, culture and sensitivity testingis helpful regarding the presence of CA-MRSA in thecommunity. Wound cultures should be obtained from thepatient because these results are especially important formanaging SSTIs within the local community, signs of systemicinfection, recurrent SSTIs, initial treatment failures,and patients who are immunocompromised (Gorwitzet al., 2006). However, Abrahamian and Shroff (2007)noted that it is not necessary to obtain wound culturesfor uncomplicated abscesses in stable patients because ofexpense. However, wound cultures can be beneficial formonitoring pathogen and susceptibility in local communitiesbecause it relates to empirical therapy guidance(Abrahamian & Shroff, 2007). Stevens et al. (2005)concluded that high-risk patients with SSTIs should beEvaluating and Managing Skin and Soft Tissue Infections 99

TABLE 1. Risk Factors for Skin and Soft Tissue InfectionsCaused by Community-Associated Methicillin-ResistantStaphylococcus aureusAthletes (especially contact sports)ChildrenDay care facilities (contact with hospitalized patients diagnosedwith MRSA)Household contacts (with persons diagnosed with CA-MRSA)Incarcerated personsIntravenous drug usersMen who have sex with menNative AmericansPersons who are obese or overweightPacific IslandersPersons with a history of recurrent CA-MRSA infectionsSharing personal items or equipment that has not been properlycleaned (towels, sports protective equipment)Shaving body hairSkin trauma (turf burns, cuts, or sores)SoldiersMRSA 5 methicillin-resistant Staphylococcus aureus; CA-MRSA 5community-acquired methicillin-resistant Staphylococcus aureus.TABLE 2.TermAbscess or BoilCarbuncleCellulitisFolliculitisFurunclesImpetigoSkin and Soft Tissue Infections TerminologyDefinitionsA pocket of infected fluid with a thickwall around itA confluence of furunclesInfection of the dermis and deep tissuesInflammation of a hair follicleAbscess (boil) originating from a hairfollicleVesicles and bullae on exposed areas,typically honey crustedtreated with incision and drainage, wound cultures, andantibiotic therapy, which are congruent with Gorwitzet al. (2006) and CDC (2007) guidelines for strategicallymanaging SSTIs associated with CA-MRSA.When conducting laboratory testing, S. aureus shouldbe tested for susceptibility to beta-lactam antibiotics, gentamicin,trimethoprim-sulfamethoxazole (TMP-SMX),tetracycline, erythromycin, clindamycin, vancomycin,linezolid, and daptomycin (Kaplan, 2005). Several methodsexist for testing susceptibility, among them are agardilution, broth macrodilution, microdilution, disk diffusion,D-test, and short-incubation automated instrumentsystems, and antimicrobial gradient. There are advantagesand disadvantages to each of the aforementioned methods.It should be noted that the D-test is used to evaluateinducible clindamycin resistance. Therefore, the D-test isa valuable laboratory method for determining treatmentoptions. The type of testing performed will be determinedby the microbiology laboratory in accordance with theNational Committee for Clinical Laboratory Standards.Pharmacologic Management OnlyIt should be noted that the typically prescribed antimicrobialsfor the treatment of CA-MRSA in outpatientsinclude topical 2% mupirocin, TMP-SMX, clindamycin,tetracycline, or doxycycline. Topical 2% mupirocin is usedfor less severe cases when the use of a systemic antibioticis not recommended. The forthcoming section will focuson oral antibiotics and/or surgical drainage literature.Four prospective studies, both randomized controlledtrials (RCTs) and observational studied, explored the relationshipbetween managing of SSTIs with antibioticsalone and cure rates. A prospective randomized, doubleblindstudy compared cefditoren 200 mg or 400 mgtwice a day (BID) with either cefuroxime 250 mg BID orcefadroxil 500 mg BID for the treatment of uncomplicatedSSTIs (N 5 1685). The most common infections notedin the patients were cellulitis (26%), wound infections(25%), and simple abscesses (15%). The findings indicatedthat the clinical cure rate and tolerability of cefditorenwere comparable to those of cefuroxime and cefadroxil.The clinical cure rates were 85% (443/523) for cefditoren200 mg, 83% (427/516) for cefditoren 400 mg, 88%(234/265) for cefuroxime, and 85% (211/248) for cefadroxil,which indicates that cefditoren was comparable tocefuroxime and cefadroxil (Bucko, Hunt, Kidd, & Hom,2002).A second prospective study (N 5 280) explored whetherempirical therapy for MRSA should be given only topatients with suspected CA-MRSA infections who haverisk factors for the acquirement of MRSA. Of the 280 patientsthat participated in the study, 180 were adult patientswith community-associated Staphylococcus aureus infection.Among the study participants, 108 (60%) had MRSAinfections, and 78 (40%) had methicillin-susceptible Staphylococcusaureus (MSSA) infection. MRSA infections wereassociated with a younger population (p , .0001); skin/soft tissue infection (p 5 .015); snorting/smoking illegaldrugs (p 5 0.01); recent incarceration (p 5 0.03); lowercomorbidity index (p 5 0.01); more frequent visits to bars,raves, and/or clubs (p 5 0.03); and higher frequency oflaundering clothes in hot water (p 5 0.05). The three strongest/mostsignificant risk factors were close contact with100 Winstead

someone with a skin infection in the past 30 days, snortingdrugs in the preceding 12 months, and incarceration inthe prior 12 months. The clinical and epidemiological riskfactors in persons hospitalized for community-associatedStaphylococcus aureus infection cannot reliably distinguishbetween MRSA and MSSA (Miller et al., 2007). Thus,the results have significant implications for the choice ofempirical antibiotic therapy for suspected S. aureus infections,infection control, and patient outcomes.A third prospective randomized trial examined empiricaltherapy with TMP-SMX or doxycycline for outpatientspresenting to an ED with skin and soft tissueabscesses requiring wound packing after incision anddrainage. The results indicated that 23 patients (68%)had abscess cultures positive for MRSA. Four (12%) ofthe abscess cultures were positive for MSSA, whereas2 (6%) were negative. There was no significant differencenoted between the clinical failure rate of empiricalTMP-SMX therapy and doxycycline therapy. Therefore,this study demonstrated that incision and drainagealone is appropriate for managing SSTIs (Cenizalet al., 2007). Although TMP-SMX is not approved byFood and Drug Administration (FDA) to treat SSTIs associatedwith CA-MRSA, in vitro data and clinical experiencesupport using this antimicrobial (Hasty et al., 2007;Purcell & Fergie, 2005; Rihn et al., 2005.). TMP-SMXhas been widely used, especially in geographic areas withresistance to clindamycin (Kaplan, 2005; Purcell & Fergie,2005). Kaplan (2005) and Lee et al. (2004) have notedthat adding rifampin to TMP-SMX can benefit thepatient with SSTI. In addition, the Sanford Guide recommendstwo double-strength TMP-SMX tablets twicedaily to provide adequate serum levels and maximize theconcentration-dependent killing (Gilbert, Moellering,Eliopoulos, & Sande, 2008). However, this recommendationhas not been supported by prospective human studiesthat demonstrate the superiority of two double-strengthTMP-SMX tablets versus one double-strength TMP-SMX tablet course of therapy.The use of clindamycin has been supported by in vitrosusceptibility studies and clinical experience (Martinez-Aguliar, Hammerman, Mason, & Kaplan, 2003). Clindamycinmay be used when the organism is susceptibleto both clindamycin and erythromycin. The laboratoryshould perform a D-test when the isolate is susceptibleto clindamycin but resistant to erythromycin to identifyerythromycin-induced resistance to clindamycin (Kaplan,2005; Martinez-Aguliar et al., 2003).Tetracyclines such as doxycycline and minocyclinecan be used to treat CA-MRSA if local isolates displaya high susceptibility rate (Ruhe & Menon, 2007; Ruhe,Monson, Bradsher, & Menon, 2005). These drugs shouldbe avoided in children younger than 9 years old, pregnantpatients, and nursing mothers.A prospective observational study with 69 childrenwith positive wound cultures for MRSA explored theappropriate management of SSTIs. Two patients wereadmitted for treatment. The remaining 67 patients weretreated and discharged with antibiotics. In terms of the67 patients, five were discharged with appropriate antibiotics(concordant with results of sensitivity testing),whereas 62 patients were discharged with antibiotics towhich the MRSA isolate was not susceptible (discordantwith results of the sensitivity testing). The five patientstreated with concordant antibiotics improved, and 94%(58/62) treated with discordant antibiotics also improved.Thus, no clinical difference was noted between concordantand discordant antibiotic therapy (Lee et al., 2004).Pharmacologic and NonpharmacologicManagementFour prospective studies investigated the epidemiology,prevalence, and management of SSTIs. Davis et al. (2007)conducted a prospective study for patients (N 5 102) withCA-MRSA infections at four teaching hospitals in theMidwestern United States to evaluate the molecular epidemiologyof methicillin resistance, to determine risk factorsfor MRSA, and to assess the impact of CA-MRSAon the outcomes of patients. The statistical analysis forthe study indicated that 14% of patients with CA-MRSAinfections had household contacts with similar infectionsand 46% were hospitalized. The clinical success rate ofthe initial therapy was 61%, whereas recurrences yielded18%. The cure rate for patients who received antimicrobialtherapy compared to those who did not receive antimicrobialtherapy was 61% and 38% respectively, regardlessof whether surgical incision and drainage was performed.The study concluded that CA-MRSA infections are morecommon among younger patients with prior antimicrobialexposure, and patients infected with CA-MRSA areencountering additional risks in the community that arecontributing to CA-MRSA infections.A second prospective study was conducted by Moran,Amii, Abrahamian, and Talan (2005) with 96 patients ata county-owned hospital to determine the prevalence ofCA-MRSA among a group of ED patients with SSTIs.The descriptive data from this study indicated that MRSAwas isolated from 44 (46%) of 96 patients, of which 8 wereoutpatients and 36 were admitted to the hospital. AnEvaluating and Managing Skin and Soft Tissue Infections 101

increase in MRSA infections was noted in the data collectedfrom 2001 to 2002 and January 2003–March 2004.During 2001–2002, the proportion of MRSA infectionswas 29% (14/49 patients). The data from January 2003to March 2004 generated MRSA infections of 64%(30/47 patients). Therefore, the percentage of SSTIscaused by MRSA increased from 29% (2001–2002) to64% ( January 2003–March 2004).In contrast to Moran et al. (2005), Moran et al. (2006)conducted a prospective multicenter study with 422 adultpatients at university-affiliated EDs in 11 U.S. cities toassess the prevalence of CA-MRSA among adult patients.The data indicated that 320 of the 422 patients (76%) hadwound cultures that grew S. aureus isolates. Completetreatment information was available for 406 patients inthe study (96%). In terms of these patients, the followingtreatments were conducted: 66% (267) received incisionand drainage only, 10% (39) received antibiotics only, and5% (21) did not receive incision and drainage or antibiotics.Sixty-four percent of the patients were prescribed antistaphylococcalpenicillin or cephalosporin. In the study,174 patients had cultures that grew MRSA isolates, ofwhich 100 (57%) were empirically given discordant antibiotictherapy. Follow-up information was available for248 (59%) patients. Complete resolution of the infectionwas reported by 238 (96%) of these patients, with no significantdifferences noted between patients with MRSAversus non-MRSA. Similarly, no significant differenceswere noted in the study results between patients withMRSA who were treated with sensitivity concordant antibioticsversus sensitivity discordant antibiotics, whichindicates that incision and drainage alone may be sufficientfor treatment.A prospective randomized, placebo-controlled studyof oral antibiotics after incision and drainage in a populationwith a high prevalence of MRSA was conductedwith 166 patients at an inner-city, hospital-based clinic.Fifty-two percent (87/110) of the cultures grew MRSA.No meaningful difference was noted in the rate of clinicalcure between patients receiving cephalexin (86%) andthose receiving a placebo (93%), which indicates thatantibiotics are not necessary for treatment.Four retrospective studies involved chart reviewsregarding clinical presentation, incisional drainage, andantibiotic therapy. A retrospective chart review study wasconducted in a Los Angeles-based practice to evaluatethe clinical presentation and treatment of CA-MRSAskin infections. The statistical data indicates that a total of39 patients (26.7% of total S. aureus infections) presentedwith MRSA. In this study, cutaneous abscesses were notedas the most common presentation for a MRSA infection.The following data was yielded from presenting patients:69.9% with abscesses, 13.0% with folliculitis, 4.3% withparonychia, 8.7% with impetigo, and 4.3% with cellulitis/woundinfections. Those patients who presented withcutaneous abscesses were treated with incision and drainage(30 of 32 abscesses) along with antimicrobial therapy(Iyer & Jones, 2004).A second retrospective study involved a medical recordreview at a clinic to determine if SSTIs managed with incisionand drainage resolved even when treated with discordantantibiotics. A record review after treatment showedthat 99.1% of the sensitivity-discordant antibiotic therapy–treated infections (241/242) demonstrated full resolution,whereas patients treated with sensitivity-concordantantibiotics showed a 98.8% (164/166) full resolution. Whenadjusted to include the patients lost to follow-up, thesegroups deviate slightly, with a 92% cure rate in the discordanttherapy group and a 99% cure rate in the concordanttherapy group, which signifies that antibiotics may beunnecessary after incision and drainage (Paydar, Hansen,Charlebois, Harris, & Young, 2006).A third retrospective study, involved a cohort studywith 492 adult patients to determine the role of antimicrobialtherapy for the treatment of uncomplicatedSSTIs. In addition to antibiotics, most patients alsoreceived incision and drainage. Ruhe, Smith, Bradsher,and Menon (2007) found that treatment was successfulfor 95% (296/312) of patients who received effectiveantimicrobial therapy compared with 87% (190/219) ofpatients who received ineffective antimicrobials. Thestudy concluded that patients can benefit from antibiotictherapy (Ruhe et al., 2007).In the last study, Stevens et al. (2005) used previouslyconducted studies to develop practice guidelinesfor the diagnosis and management of SSTIs. Stevens etal. demonstrated that subinhibitory concentrations ofbeta-lactam nafcillin induced and enhanced toxin productionin virulent CA-MRSA strains. Thus, it is possiblethat some of the ineffective antimicrobials prescribed topatients with CA-MRSA abscesses actually worsened theinfection by increasing toxin production. Stevens et al.recommends managing SSTIs with incision and drainagewithout a wound culture or antimicrobial therapy unlesscompelling conditions exist such as multiple lesions,gangrene, impaired host defenses, extensive cellulitis, orsevere systemic symptoms of infection (i.e., high fever).In addition, Stevens et al. concluded that high-riskpatients with SSTIs should be treated with incision anddrainage, wound cultures, and antibiotic therapy.102 Winstead

Prevention in the CommunityIt is important to practice good hygiene in the communityto prevent and control CA-MRSA. The CDC (2008) hasmade the following recommendations for the preventionand control of CA-MRSA in the community:1. Wash hands thoroughly with soap and water or usean alcohol-based hand sanitizer.2. Keep cuts and scrapes clean and covered with abandage.3. Avoid contact with other people’s wounds orbandages.4. Avoid sharing personal items (towels, razors,clothing, exercise equipment, brushes, combs,soaps, make-up, or lotions).SummaryIn terms of the literature reviewed, it is recommendedto use incision and drainage only for the treatment ofuncomplicated SSTIs in low-risk patients (CDC, 2007;Cenizal et al., 2007; Gorwitz et al., 2006; Lee et al.,2004 ; Moran et al., 2006 ; Paydar et al., 2006 ; Rajendranet al., 2007). However, studies conducted by Ruheet al. (2007) and Stevens et al. (2005) support incisionand drainage as the first line of treatment but to prescribeantimicrobials if deemed necessary based on cultureresults and failure to heal with incision and drainage alone.This approach for managing uncomplicated SSTIs willalleviate prescribing antibiotics unnecessarily and potentiallyreduce drug resistance. However, incision and drainagecombined with antibiotic therapy should be used tomanage all high-risk patients (Fridkin et al., 2005; Naimiet al., 2003; Stevens et al., 2005). Conversely, the Rajendranet al. (2007) study contradicts the aforementionedrecommendation. Rajendran et al. concluded that empiricalantibiotics are not necessary for uncomplicated SSTIsthat are treated with incision and drainage alone, includingcommunities with a high prevalence of MRSA. However,it is recommended to culture all purulent woundsbecause this data will assist the clinician in identifyingthe type of microbe and the necessity for prescribingan appropriate antibiotic (Fridkin et al., 2005; Gorwitzet al., 2006; Naimi et al., 2003; Stevens et al., 2005).Nevertheless, it is recommended to prescribe antibioticsfor all SSTIs associated with cellulitis (Bucko et al.,2002; CDC, 2007; Gorwitz et al., 2006; Iyer et al., 2004;Stevens et al., 2005).Prospective human trials are needed to determine andjustify the use of two double-strength TMP-SMX tabletsversus one double-strength TMP-SMX tablet for the treatmentof CA-MRSA. Furthermore, large-scale prospectivestudies are recommended to determine the appropriatetreatment protocol for SSTIs associated with CA-MRSA.Practice ImplicationsConsequential to the recognized increase in SSTIs relatedto CA-MRSA, the CDC colleagues led by Dr. Gorwitz(2006) published Strategies for Clinical Management ofMRSA in the Community. The CDC (2007) also issueda treatment algorithm for the management of SSTIs foroutpatients and has recommended that clinicians includeMRSA in the differential diagnosis of SSTIs. Gorwitzet al. and the CDC (2007) recommended managing SSTIswith incision and drainage, wound cultures, patient education,and follow-up patient care within 48 hours. TheCDC guideline (CDC, 2007; Gorwitz et al., 2006) forstrategically managing SSTIs in outpatients recommendsantibiotics for patients who present with cellulitis. Consequently,based on the observed increase in uncomplicatedSSTIs, it is imperative that EDs develop a procedureto adopt the CDC (2007) guideline by implementing astandardized treatment protocol and training staff to usethe protocol to improve patient outcomes.ReferencesAbrahamian, F. M., & Shroff, S. D. (2007). Use of routinewound cultures to evaluate cutaneous abscesses for community-associatedmethicillin-resistant Staphylococcus aureus.Annals of Emergency Medicine, 50(1), 66–68.Archibald, L. K., Shapiro, J., Pass, A., Rand, K., & Southwick, F.(2008). Methicillin-resistant Staphylococcus aureus infectionin a college football team: Risk factors outside the lockerroom and playing field. Infectious Control Hospital Epidemiology,29(5), 450–453.Begier, E. M., Frenette, K., Barrett, N. L., Mshar, P., Petit, S.,Boxrud, D. J., . . . Hadler, J. L. (2004). A high-morbidityoutbreak of methicillin-resistant Staphylococcus aureusamong players on a college football team, facilitated bycosmetic body shaving and turf burns. Clinical InfectiousDiseases, 39(10), 1446–1453.Bucko, A. D., Hunt, B. J., Kidd, S. L., & Hom, R. (2002).Randomized, double-blind, multicenter comparison oforal cefditoren 200 or 400 mg BID with either cefuroxime250 mg BID or cefadroxil 500 mg BID for the treatment ofuncomplicated skin and skin-structure infections. ClinicalTherapeutics, 24(7), 1134–1147.Cenizal, M. J., Skiest, D., Luber, S., Bedimo, R., Davis, P., Fox,P., . . . Hardy, R. D. (2007). Prospective randomized trialof empiric therapy with trimethoprim-sulfamethoxazole orEvaluating and Managing Skin and Soft Tissue Infections 103

doxycycline for outpatient skin and soft tissue infectionsin an area of high prevalence of methicillin-resistant staphylococcusaureus. Antimicrobial Agents and Chemotherapy,51(7), 2628–2630.Centers for Disease Control and Prevention. (2007). Treatmentalgorithm for skin and soft tissue infections. Retrieved fromhttp://www.cdc.gov/mrsa/mrsa_initiative/skin_infection/mrsa_algorithm.htmlCenters for Disease and Prevention (2008). Community-associatedMRSA information for the public. Retrieved from http://www.cdc.gov/ncidod/dhqp/ar_MRSA_ca_public.html#8Davis, S. L., Perri, M. B., Donabedian, S. M., Manierski, C.,Singh, A., Vager, D., . . . Zervos, M. J. (2007). Epidemiologyand outcomes of community-associated methicillinresistantstaphylococcus aureus infection. Journal of ClinicalMicrobiology, 45(6), 1705–1711.DiNubile, M. J., & Lipsky, B. A. (2004). Complicated infectionsof skin and skin structures: When the infection is more thanskin deep. Journal of Antimicrobial Chemotherapy 53(Suppl.S2), ii37–ii50.Eron, I. J., & Lipsky, B. A. (2003). Managing skin and soft tissueinfections: expert panel recommendations on key decisionpoints. Journal of Antimicrobial Chemotherapy, 52, S1.Fridkin, S. K., Hageman, J. C., Morrison, M., Sanza, L. T.,Como-Sabetti, K., Jernigan, J. A., . . . Farley, M. M. (2005).Methicillin-resistant staphylococcus aureus disease in threecommunities. The New England Journal of Medicine, 352(14),1436–1444.Gilbert, D. N., Moellering, R. C., Eliopoulos, G. M., & Sande,M. A. (2008). The Sanford guide to antimicrobial therapy(38th ed). Sperryville, VA: Antimicrobial Therapy.Gordon, R. J., & Lowy, F. D. (2005). Bacterial infections in drugusers. New England Journal of Medicine, 353, 1945–1954.Gorwitz, R. J., Jernigan, D. B., Powers, J. H., Jernigan, J. A.,& Participants in the Centers of Disease Control andPrevention-Convened Experts Meeting on Managementof MRSA in the Community. (2006). Strategies for clinicalmanagement of MRSA in the community: Summary of anexperts’ meeting convened by the Centers for Disease Controland Prevention. Retrieved from www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_ExpMtgStrategies.pdfHasty, M. B., Klasner, A., Kness, S., Denmark, T. K., Ellis, D.,Herman, M. I., & Brown, L. (2007). Cutaneous communityassociatedmethicillin-resistant staphylococcus aureus amongall skin and soft tissue infections in two geographically distantpediatric emergency departments. Academic EmergencyMedicine: Official Journal of the Society for Academic EmergencyMedicine, 14, 35–45.Iyer, S., & Jones, D. H. (2004). Community-acquired methicillinresistantstaphylococcus aureus skin infection: A retrospectiveanalysis of clinical presentation and treatment of a localoutbreak. Journal of the American Academy of Dermatology,50(6), 854–858.Kaplan, S. L. (2005). Treatment of community-associatedmethicillin-resistant Staphylococcus aureus infections.Pediatric Infectious Disease Journal, 24(5), 457–459.Lee, M. C., Rios, A. M., Aten, M. F., Mejias, A., Cavuoti, D.,McCracken, G. H., Jr., & Hardy, R. D. (2004). Managementand outcome of children with skin and soft tissue abscessescaused by community-acquired methicillin-resistantstaphylococcus aureus. The Pediatric Infectious Disease Journal,23(2), 123–127.Martinez-Aguliar, G., Hammerman, W. A., Mason, E. O., Jr.,& Kaplan, S. L. (2003). Clindamycin treatment of invasiveinfections caused by community-acquired methicillinresistantand methicillin-susceptible Staphylococcus aureusin children. Pediatric Infectious Disease Journal, 22, 593–601.Miller, L. G., Perdreau-Remington, F., Bayer, A. S., Diep, B., Tan,N., Bharadwa, K., . . . Spellberg, B. (2007). Clinical and epidemiologiccharacteristics cannot distinguish communityassociatedmethicillin-resistant staphylococcus aureus infectionfrom methicillin-susceptible S. aureus infection:A prospective investigation. Clinical Infectious Diseases:An Official Publication of the Infectious Diseases Society ofAmerica, 44(4), 471–482.Moran, G. J., Amii, R. N., Abrahamian, F. M., & Talan, D.A. (2005). Methicillin-resistant staphylococcus aureus incommunity-acquired skin infections. Emerging InfectiousDiseases, 11(6), 928–930.Moran, G. J., Krishnadasan, A., Gorwitz, R. J., Fosheim, G. E.,McDougal, L. K., Carey, R. B., & Talan, D. A. (2006).Methicillin-resistant S. aureus infections among patientsin the emergency department. The New England Journal ofMedicine, 355(7), 666–674.Naimi, T. S., LeDell, K. H., Como-Sabetti, K., Borchardt, S. M.,Boxrud, D. J., Etienne, J., . . . Lynfield, R. (2003). Comparisonof community- and health care-associated methicillinresistantstaphylococcus aureus infection. JAMA: The Journalof the American Medical Association, 290(22), 2976–2984.Pallin, D. J., Egan, D. J., Pelletier, A. J., Espinola, J. A.,Hooper, D. C., & Camargo, C. A., Jr. (2008). IncreasedUS emergency department visits for skin and soft tissueinfections, and changes in antibiotic choices, during theemergence of community-associated methicillin-resistantstaphylococcus aureus. Annals of Emergency Medicine,51(3), 291–298.Paydar, K. Z., Hansen, S. L., Charlebois, E. D., Harris, H. W.,& Young, D. M. (2006). Inappropriate antibiotic use in softtissue infections. Archives of Surgery (Chicago, Ill.: 1960),141(9), 850-4; discussion 855–856.Purcell, K., & Fergie, J. (2005). Epidemic of communityacquiredmethicillin-resistant Staphylococcus aureus infections:a 14-year study at Driscoll Children’s Hospital.Archives of Pediatrics & Adolescent Medicine, 159, 980–993.Rajendran, P. M., Young, D., Maurer, T., Chambers, H.,Perdreau-Remington, F., Ro, P., & Harris, H. (2007).104 Winstead

Randomized, double-blind, placebo-controlled trial ofcephalexin for treatment of uncomplicated skin abscessesin a population at risk for community-acquired methicillinresistantstaphylococcus aureus infection. AntimicrobialAgents and Chemotherapy, 51(11), 4044–4048.Rihn, J. A., Posfay-Barbe, K., Harner, C. D., Macurak, A.,Farley, A., Greenawalt, K., & Michaels, M. G. (2005).Community-acquired methicillin-resistant Staphylococcusaureus outbreak in a local high school football team unsuccessfulinterventions, Pediatric Infectious Disease Journal, 25,841–853.Romano, R., Lu, D., & Holton, P. (2006). Outbreak ofcommunity-acquired methicillin-resistant Staphylococcusaureus skin infections among a collegiate football team.Journal of Athletic Training, 41(2), 141–145.Ruhe, J. J., & Menon, A. (2007). Tetracyclines as an oraltreatment option for patients with community onset skinand soft tissue infections caused by methicillin-resistantStaphylococcus aureus. Antimicrobial Agents Chemotherapy,51(9), 3298–3303.Ruhe, J. J., Monson, T., Bradsher, R. W., & Menon, A. (2005).Use of long-acting tetracycline for methicillin-resistantStaphylococcus aureus infections: Case series and reviewof the literature. Clinical Infectious Disease, 40(10), 1429–1434.Ruhe, J. J., Smith, N., Bradsher, R. W., & Menon, A. (2007). Community-onsetmethicillin-resistant staphylococcus aureus skinand soft-tissue infections: Impact of antimicrobial therapy onoutcome. Clinical Infectious Diseases: An Official Publication ofthe Infectious Diseases Society of America, 44(6), 777–784.Stevens, D. L., Bisno, A. L., Chambers, H. F., Everett, E. D.,Dellinger, P., Goldstein, E. J., & Wade, J. C. (2005). Practiceguidelines for the diagnosis and management of skin andsoft-tissue infections. Clinical Infectious Diseases: An OfficialPublication of the Infectious Diseases Society of America,41(10), 1373–1406.Wolff, K., Johnson, R. A., Suurmond, R., & Johnson, R. A.(2005). Fitzpatrick’s color atlas & synopsis of clinical dermatology(5th ed.). New York, NY: McGraw-Hill.Acknowledgments. The author would like to thank Dr. BethAnn Swan, PhD, CRNP; Dr. Denita Winstead, PhD, MS, RN;Dr. Jennifer Bellot, RN, PhD; Flourine Winstead; Sherry Winstead,BS; Walter Winstead III; and George Winstead, AS forthe many hours of consultation.Correspondence regarding this article should be directed to YvetteWinstead, DNP, FNP-BC, MSN, CRNP, RN, MS, MBA, MA,Thomas Jefferson University, Jefferson School of Nursing, 901Walnut Street, Philadelphia, PA 19107. E-mail: yvette.winstead@jefferson.eduEvaluating and Managing Skin and Soft Tissue Infections 105

PRACTICE EVIDENCETime of Day and Accurate Weightsfor Patients With Heart FailureAlice M. Siehoff, DNP, MS, RN-BCChamberlain College of NursingCatherine Ryan, PhD, RN, APN, CCRNUniversity of Illinois-ChicagoHeart failure (HF) is a significant health problem in the United States. It is estimated that5.8 million Americans currently live with a diagnosis of HF (American Heart Association, 2010).Despite the fact that daily weight monitoring of patients with HF in the hospital has long been astandard part of monitoring effectiveness of treatment, the literature is lacking recommendationsbased on evidence specific to the optimal time of day for weighing inpatients. The clinical questionunder consideration is the following: In hospitalized patients with HF, does consistently measuringweights in the evening compared to early morning accurately reflect differences in net weight gainor loss?In this quasi-experimental, prospective cohort pilot study, 29 patients who met inclusion criteriawere weighed in the morning and again in the evening. Results of this study revealed predictable differencesfor morning (M 5 3.09, SD 5 2.06) and evening weights (M 5 2.47, SD 5 1.80); t(28) 5 22.602,p 5 .015. For study patients with three consecutive days of weights (N 5 24), Pearson product-momentcorrelations revealed a statistically significant correlation between individual differences/changes ina.m. and p.m. weights, r(22) 5 .752, p , .001.The implication for clinical practice is that weights should be measured at a consistent time of day.This may be the morning or evening.Keywords: heart failure; weights; nonpharmacologic treatment; time of dayHeart failure (HF) is a significant health problem in theUnited States. The estimated prevalence for HF in Americanadults aged 20 years and older in 2006 was 5.8 million;3.1 million males and 2.7 million females (AmericanHeart Association [AHA], 2010). HF affects more than10% of persons older than 65 years (McConaghy & Smith,2004). Although the incidence of HF has not declined intwo decades, survival after diagnosis has increased overall,with less improvement in survival in the older adultand women (AHA, 2010; Lloyd-Jones et al., 2009; Rosamondet al., 2007). Hospital discharges for HF increasedfrom 877,000 in 1996 to 1,106,000 in 2006 (AHA, 2010;Lloyd-Jones et al., 2009). The estimated direct and indirectcost of HF in the United States for 2010 is projectedto be approximately $39.2 billion (AHA, 2010).Clinical ProblemFluid retention, which can be evidenced by weight gain,is often used by clinicians as an indicator of worseningHF and a decline in overall cardiac function. Diuretictherapy is a mainstay in the treatment of exacerbationsof many forms of HF and is commonly used to preventfluid retention and to treat signs and symptoms of sodium106 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.106

etention and fluid overload. Diuretic dosages are oftenadjusted based on body weight (Prasun, Kocheril, Klass,Dunlap, & Piano, 2005).Daily weight monitoring is valuable for monitoringvolume status and evaluation of various therapies such asdiuretic use for patients with HF (Wingate, 2007) and haslong been used in hospital and home settings as a standardpart of monitoring overall fluid status (Sulzbach-Hoke,Kagan, & Criag, 1997). Daily weighing is also part of thepractice guidelines stipulated by the American College ofCardiology and AHA Task Force on practice guidelinesin the 2009 focused update for the management of HFin adults.Given the importance of weight monitoring for evaluationof fluid status and diuretic therapy, nursing staff arerequired to measure daily weights in hospitalized patientswith HF. Traditionally, this task has been accomplishedby night shift staff on many nursing units, beginning veryearly in the morning. To complete all necessary nursingtasks with the early morning weights, night shift staffmembers on one nursing unit have begun to awaken patientsas early as 5:00 a.m. Unfortunately, there is a disturbinglack of evidence that this is indeed best practice.This, coupled with the fact that patients complain aboutbeing awakened very early in the morning to be weighed,forces the conclusion that more studies are needed todetermine the optimal time of day for obtaining dailyweights for patients with HF.Because investigators have not examined the optimaltime of day for measurement of body weight, there is nostandard time of day for measuring body weight withinthe hospital setting, and the tradition of any nursing unitbecomes the basis for practice. The purpose of this study isto determine the impact on net weight gain or loss whenpatients with HF are weighed in the evening as comparedto early morning.Review of LiteratureSearch terms used for review of literature includedheart failure, fluid overload, weights and congestiveheart failure, management and heart failure, and treatmentand heart failure. Search engines queried includedCINAHL and PubMed from years 2000 to 2010, yielding33 articles. The Cochrane Collaboration, in additionto guidelines published by the American College ofCardiology, the Canadian Cardiovascular Society, andAgency for Healthcare Research and Quality, were alsoreviewed for pertinent guidelines for care of patientswith HF.In the literature, time of day for accomplishing dailyweights is suggested in the following three ways: firstthing in the morning, at a consistent time each day, or atno specified time of day. However, consistency regardingtime of day recommended for weighing is variable, andauthors often do not cite scientific evidence behind timeof day and weighing behaviors.Morning WeightsThe 2005 Agency for Healthcare Research and Qualityguidelines for management of chronic heart failure includethe recommendation for weight monitoring onregular basis. It is suggested that weighing become part ofa regular daily routine, such as “after the morning toilet”(p. 7). It is also recommended that health care providersbe alerted for unexpected weight gain greater than 2 kg in3 days to adjust diuretic dose.Arnold et al. (2006), reporting for the expert panel forthe Canadian Cardiovascular Society, also provide recommendationson nonpharmacological management of patientswith HF. In these recommendations, sodium andweight management is advised through interventions suchas dietary salt restriction, fluid intake restriction, and dailyweight monitoring. Daily morning weight monitoring isadvised specifically for patients with fluid retention or congestionnot easily controlled with diuretics, or in patientswith significant renal dysfunction (Class I, Level C).Lesperance, Bell, and Ervin (2005) completed a retrospectivereview of 20 medical records of patients admittedto the hospital with diagnostic code ICD-9 forHF to determine the presence of documented dischargeinstructions specific to weight gain. The authors recommendthat patients with HF be given discharge instructionsthat include daily weighing and recording in themorning. Although recommendations for obtaining dailyweights in the morning are included, there is no citationor evidence related to the basis of this recommendationfor morning weights.In addition, nursing texts make recommendationsregarding weights in patients with HF. Similar to therecommendations mentioned previously, Moser andRiegel (2008) recommend that patients with HF weighthemselves in the morning after urination, using the samescale and while wearing similar clothing.Consistent Time of Day for WeightIgnatavicius and Workman (2006) suggest that bodyweight is the most reliable indication of fluid gain orloss. These authors assert that daily or sequential weightsHeart Failure and Daily Weights 107

should be carried out at the same time each day. This recommendation,however, is directed toward clients withmalnutrition and obesity and not patients with HF.New recommendations (Guideline 4.5) have been developedby the American College of Cardiology Foundationand the AHA for care of hospitalized patients withHF. In the 2009 focused update, the recommendationis made to carefully monitor the effect of HF treatmentthrough measurements such as fluid intake and output,vital signs, and body weight measured at the same timeeach day ( Jessup et al., 2009). This new recommendationis a Class I, Level C recommendation ( Jessup et al., 2009).The Class I designation indicates that the recommendationis based on evidence; however, there is no citation fromresearch literature attached to these recommendations tosubstantiate this “evidence.” The Level C indicates thatthe recommendation is based on consensus of experts,case studies, or standard of care ( Jessup et al., 2009).No Specified Time for WeightSeveral studies describe clinician management and selfcarebehaviors of patients. In these studies, the importanceof patient education and follow-up is examined. Riegel,Moser, Powell, Rector, and Havrenek (2006) surveyed290 HF expert clinicians to determine consistency in nonpharmacologicmanagement of patients with HF. Expertclinicians included physicians ( primarily cardiologists)and nurses (primarily advanced practice nurses). The findingsin this study indicate wide variability on advice givenby expert HF clinicians to patients regarding weightmonitoring.Daily weights are important in the inpatient and outpatientmanagement of HF; yet, time of day for weights isnot consistently addressed and appears to be incompletelystudied. If a recommendation for time of day is given, itis most commonly that daily weights should be measuredafter voiding in the morning. To regulate diuretics mosteffectively, measurement of body weight must be doneroutinely and consistently. Health care providers mustassist patients by providing clear and consistent messagesregarding measurement of body weight.MethodsSettingThe setting for this study was a 36-bed adult cardiacmedical–surgical unit. This nursing unit is located withina large community hospital in the western suburbs ofChicago. The patients on this unit have various cardiacdiagnoses, including acute myocardial infarction, recentcardiac surgery, and various dysrhythmias. There is a largepopulation of patients with HF who are typically admittedto this unit for symptom exacerbation and management.Prior to beginning recruitment of study patients, approvalwas obtained by the institutional review board (IRB).Study DesignThe study design for this quasi-experimental pilot study isa prospective cohort design. Study patients were weighedin the early morning and then reweighed in the eveningbetween 8:30 and 9:00 p.m. The time for the eveningweight was selected after staff input and consideration ofnursing workflow in the evening. The weights were measuredjust prior to evening cares and administration of theevening medications at 9:00 p.m. All daily weights forstudy subjects were recorded from the electronic medicalrecord using a data collection tool created for this study(see Appendix).Study PopulationThe study population in this study was to include a conveniencesample of 75 patients admitted with a diagnosisof HF to the 36-bed adult medical–surgical cardiac stepdownunit. Inclusion criteria for this study were patientswho (a) were admitted with a primary diagnosis of HF orfluid overload, (b) were ambulatory, (c) were able to standon a scale, and (d) had no problems with balance. Exclusioncriteria included patients with (a) a primary diagnosisother than HF or fluid overload, (b) patients with renalfailure, (c) patients who were unable to follow directionsor provide informed consent because of cognitive impairment,or (d) non-English–speaking patients.All patients with HF who agreed to participate in thisstudy were given information about the study. Informationconsisted of verbal information given by the researcherafter completion of all admission-related procedures.In addition, study patients signed a written informedconsent form prior to the beginning of this study.Definition of TermsThe operational definition of weight is the number ofkilograms that a person weighs using a platform scale.A scale is an instrument used to measure body weight(Taber’s Cyclopedic Medical Dictionary, 2005). Ambulatoryis defined in Taber’s Cyclopedic Medical Dictionary (2005)as “able to walk, not confined to bed” (p. 84). In this study,the definition of ambulatory also includes those patients108 Siehoff and Ryan

who have a written physician or nurse practitioner order tobe out of bed. In addition, Taber’s Cyclopedic Medical Dictionarydefines balance as “coordination and stability of thebody in space” (p. 217). Patients included in this study havebeen assessed by their care provider to be coordinated, stable,and safe without assistance when out of bed.Method of Data CollectionPatients with HF on the study unit are routinely weighedearly in the morning. Study patients were weighed in themorning per current nursing unit routine as well as inthe evening prior to evening cares and administration ofevening medications. Patients were weighed in a hospitalgown and slippers after voiding by either the traineddata collectors or the principal investigator. Speciallydesignated platform scales—Scale-Tronix model 5002and Scale-Tronix model 5702—were used to measuredaily weights. Both of these scales are portable stand-onscales for use with ambulatory patients. The weight limitfor model 5002 is 880 lb (400 kg), and the weight limitfor model 5702 is 1,000 lb (454 kg). The precision of thescales is to one tenth of a kilogram (Scale-Tronix, 1997).There are two scales on the unit that were used for patientsin predetermined and preassigned room numbers.They were checked and found to be in good workingorder by the clinical engineering department prior toproject implementation and on a monthly basis for theduration of the study.On this nursing unit, obtaining weights is a commontask for nurses as well as patient care technicians. The volunteerdata collectors were four staff members, two registerednurses, and two patient care technicians. Prior to the startof the research project, all data collectors completed a briefeducational program given by the research team. The educationalprogram plan included defined learning objectives,content, and educational strategies indicated in Table 1.The educational program was created in collaboration withthe registered nurse data collectors. The overall goal of theeducation for data collectors was to review the purpose andprocedures for this study as well as rationale for measuringdaily weights and correct use of the platform scales. Competencyin use of the platform scale was verified by returndemonstration. Education for each data collector took placeduring work hours and on the nursing unit.All of the data collectors had experience measuringbody weight with the scales on the nursing unit. All staffmembers were inserviced on the proper use of the scaleswhen they were initially purchased. All data collectorswere asked to collect data in a pleasant and cooperativemanner. They participated in this study on a voluntarybasis and during work hours. Data collectors were availableon all nursing shifts and all days of the week.As per routine on this nursing unit, all weights were recordedin the electronic medical record. Weights recordedon the electronic medical record were transcribed onto thedata collection tool by the principal investigator or datacollectors. Figure 1 illustrates the data collection plan.TABLE 1.Education Plan for Data CollectorsLearning Objective Content Educational StrategyDiscuss rationale for measuringdaily weights in patients with HFList steps for correctly measuringweight on balance scaleDemonstrate procedure forobtaining accurate weightsDemonstrate documentation ofweight in medical recordNote. HF 5 heart failure.1. Monitor fluid volume status and progress (Wingate, 2007).2. Evaluate various therapies for patients with HF such as diuretic use(Wingate, 2007).3. Weight gain is one sign used by clinicians as an indicator ofworsening HF (Chaudhry, Wang, Concato, Gill, & Krumholz, 2007).1. Make sure patient is wearing hospital gown and slippers.2. Turn on the scale and calibrate to zero scale.3. Assist patient to scale.4. Assist patient onto platform of scale.5. Instruct patient to stand still and read weight after digital numbershave stopped fluctuating.6. Ask patient to step off of platform and assist back to chair or bed(Campbell & Altman, 2004).Individual demonstration of steps outlined above.Documentation of weight in electronic medical record.Lecture/discussionLecture/discussionReturn demonstrationReturn demonstrationHeart Failure and Daily Weights 109

Patient admitted to cardiac stepdown unit withdiagnosis of heart failure or fluid overload.scale, Scale-Tronix model 5702, was minimal (0.1 kg).Scale-Tronix model 5002 demonstrated more variabilityup to 0.9 kilogram from room to room.Data AnalysisPaired t test and Pearson product–moment correlationswere used. Data were analyzed for patients with a minimumof 3 days of data.Reliability/ValidityAfter creation of the data collection tool, the content andformat of the tool was verified by a cardiac educator andthe two of the data collectors who are staff nurses on thestudy unit. In addition to recording weights, the time anddosage of diuretics, clothing worn by the patient duringweighing, and intake and output measures were recordedon the data collection tool.ImplementationResearcher/data collectors notified by assistantnurse manager or charge nurses.Patient found to meet inclusion criteria. Writtenconsent obtained.Data collected daily from electronic medicalrecord and recorded on data collection tool byresearcher or data collectors.Data managed according to data collection plan.Figure 1. Data collection plan. Adapted from Polit, D., &Tatano-Beck, C. (2008).Description of Project ImplementationThe nursing unit was divided geographically in half, andthe two scales were assigned for use in specific roomson the unit. The room assignments for scales were listedon the top of each scale to help ensure that the correctscale was used for each weight. Each scale was taken toeach assigned room and placed in the same location inthe patient room to determine presence of variability ofweights. It was determined that the variability for oneResultsDuring the study time period, approximately 300 patientswere discharged from the nursing unit with a diagnosis ofHF or fluid overload. Of these, 66 patients met the inclusioncriteria and were enrolled in the study. One patientdeclined to participate. Of the 66 patients enrolled in thestudy, a minimum of 3 days of data (a total of six weights)were obtained for 29 patients. Three consecutive days ofweights were obtained on 24 patients. Thirty-seven studypatients did not have 3 days of data for the followingreasons:• Discharged from the hospital (n 5 24)• Missing weight measurement because of invasiveprocedures (n 5 7)• Transfer off of nursing unit (n 5 4)• Change in condition, which included an exclusioncriteria (n 5 2)Of the 29 study patients, 17 were males with a meanage of 65 years (range: 37–84 years) and 12 were femaleswith a mean age of 73.8 years (range: 53–85 years). Lengthof hospital stay for males ranged from 4 to 12 days(M 5 6.5 days), and length of hospital stay for femalesranged from 4 to 10 days (M 5 6.25 days). Table 2 summarizesadditional characteristics of the study sample.All weights were measured and recorded in kilograms(kg). The mean increase in individual patient weight froma.m. to p.m. was 0.53 kg. Over the course of the study, themean difference in individual a.m. weights was 3.09 kg,and the mean difference in individual p.m. weights was2.4 kg.A paired samples t test was conducted to comparedifferences in morning and evening weights. There werepredictable differences for morning (M 5 3.09, SD 5 2.06)and evening weights (M 5 2.47, SD 5 1.80); t(28) 522.602, p 5.015.For study patients with three consecutive days of data(N 5 24), Pearson product–moment correlations werecompleted for the absolute values of differences/change ina.m. weights and the absolute values of differences/changesin p.m. weights. As seen in Table 3, Pearson product–moment correlation coefficient revealed a statisticallysignificant correlation between individual differences/changes in a.m. and p.m. weights, r(22) 5 .752, p , .001.110 Siehoff and Ryan

TABLE 2.Study Sample CharacteristicsMales N 5 17 Females N 5 12Age mean (min, max) 65 (37,84) 73.8 (53,85)Marital status Married: 11Widowed: 1Divorced: 3Single: 2Married: 4Widowed: 3Divorced: 2Single: 3BNP on admission (range) (N 5 17) 168–2,734 pg/ml (N 5 11) 269–4,108 pg/mlEjection fraction (range by ultrasound) (N 5 16) 20%–60% (N 5 8) 10%–60%Length of time with symptoms prior toadmission (range)Diuretics usedComorbidities1–60 days 1–30 daysLasix: 15Bumex: 1Lasix and Bumex: 1Lasix and spironolactone: 1Chronic ischemic heart disease 13 9Atrial fibrillation 11 5Hyperlipidemia 11 5Chronic heart disease 4 4Chronic renal insufficiency 5 3Hypertension 5 3Type 1 diabetes mellitus 2 1Type 2 diabetes mellitus 2 3Note. BNP 5 brain natriuretic peptide.Lasix: 5Bumex: 6Lasix and Bumex: 0Lasix and spironolactone: 0TABLE 3.Statistical CorrelationsA.M. Weight MeanP.M. Weight MeanA.M. Absolute Valueof Difference SumP.M. Absolute Valueof Difference SumA.M. weight meanPearson rSig. (two-tailed)1.00**, .001.507*.011.625**.001P.M. weight meanPearson rSig. (two-tailed)1.00**, .001.501*.013.628**.001A.M. absolute value of difference sumPearson rSig. (two-tailed).507*.011.501*.013.752**, .001P.M. absolute value of difference sumPearson rSig. (two-tailed).625**.001.628**.001.752**, .001*Correlation significant to the .05 level (two-tailed).**Correlation significant to the .01 level (two-tailed).Heart Failure and Daily Weights 111

DiscussionA goal of therapy for hospitalized patients with HF isdiuresis. Monitoring changes in body weight is a basic yetimportant part of management of patients with a diagnosisof HF. Despite that fact, little investigation has beendone to date to determine the best time of day for weighingpatients. Whenever possible, care processes in clinicalenvironments must match scientific knowledge and nursingworkflow patterns as well as patient preferences.Results of this study show a perfect correlationbetween individual patient’s a.m. mean weights and p.m.mean weights. Thus, changes in a.m. weights can also beassumed for p.m. weights. In addition, small differencesin weight were noted from morning to evening, frommorning to morning, and from evening to evening, whichwas expected because of the goals of therapy related todiuresis. Results of this study support the measurement ofweight either in the morning or in the evening.A limitation of the study was the small sample size of29. A challenge in this study was the high dropout rate forstudy patients. Of the 66 patients who provided consent forstudy, 3 days of data were obtained for 29 patients. Threeconsecutive days of data were obtained for 24 patients.In addition, patients in this study underwent differenttherapeutic regimens and had varying degrees of renal function,which may affect the rate and amount of diuresis.The study patient population was limited to hospitalizedambulatory patients with HF in one setting. Futureresearch could include an HF population in a differentsetting, study of different patient populations, or patientswho are bedridden and weighed with bed scales.The implication for clinical practice is that the time ofday in which weights are obtained is not as important asconsistency in measurement. Time of day for weights forthe hospitalized ambulatory HF population, whether inthe morning or evening, should be consistently measuredand in accordance with nursing workflow and patientpreference.ReferencesAmerican Heart Association. (2010). Heart disease and strokestatistics—2010 update. Retrieved from www.americanheart.org/downloadable/heart/12356599094heart%20Stroke%20update.pdfArnold, M., Liu, P., Demers, C., Dorian, P., Giannetti, N.,Haddad, H., . . . White, M. (2006). Canadian cardiovascularsociety consensus conference on heart failure 2006:Diagnosis and management. Canadian Journal of Cardiology,22(1), 23–45.Author. (1997). Scale-Tronix: Second generation weighingsystems operating and service manual. White Plains, NewYork.Campbell, B., & Altman, G. (2004). Physical assessment. In Altman,G. (Ed.), Delmar’s fundamental and advanced nursing skill(pp. 68–69). Clifton Park, NY: Thomson Delmar Learning.Chaudhry, S., Wang, Y., Concato, J., Gill, T., & Krumholz, H.(2007). Patterns of weight change preceding hospitalizationfor heart failure. Circulation, 116(14), 1549–1554. http:dx.doi.org/10.1161/CIRCULATIONAHA.107.690768Guidelines for the diagnosis and treatment of chronic heart failure.(2005). Retrieved from http://www.guideline.gov/summary.aspx?doc_id7301&nbrIgnatavicius, D., & Workman, M. L. (Eds.). (2006). Interventionsfor clients with malnutrition and obesity. In Medicalsurgicalnursing: Critical thinking for collaborative care(pp. 1423–1424). St. Louis, MO: Elsevier Saunders.Jessup, M., Abraham, W., Casey, D., Feldman, A., Francis, G.,Ganiats, T., . . . Yancy, C. (2009). 2009 focused update:ACCF/AHA guidelines for the diagnosis and managementof heart failure in adults: A report of the American Collegeof Cardiology Foundation /American Heart Associationtask force on practice guidelines. Circulation, 119(14),1977–2016. http://dx.doi.org/10.1016/j.jacc.2008.11.009Lesperance, M., Bell, S., & Ervin, N. (2005). Heart failure andweight gain monitoring. Lippincott’s Case Management,10(6), 287–293.Lloyd-Jones, D., Adams, R., Carnethon, M., DeSimone,G., Ferguson, T. B., Flegal, K., . . . Hong, Y. (2009).Heart disease and stroke statistics—2009 update: A reportfrom the American Heart Association StatisticsCommittee and Stroke Statistics Subcommittee. Circulation,119, e21–e181. http://dx.doi.org/10.1161/CIRCULATIONAHA.108.191261McConaghy, J. R., & Smith, S. R. (2004). Outpatient treatmentof systolic heart failure. American Family Physician, 70(11),2157–2164, 2067–2069.Moser, D. K., & Riegel, B. (2008). Cardiac nursing: A companionof Braunwald’s heart disease. St. Louis, MO: Saunders.Polit, D., & Tatano-Beck, C. (2008). Nursing research: Generatingand assessing evidence for nursing practice. (8th ed).Philadelphia, PA: Lippincott Williams & Wilkins.Prasun, M., Kocheril, G., Klass, P., Dunlap, S., & Piano, M.(2005). The effects of sliding scale diuretic titration in patientswith heart failure. Journal of Cardiovascular Nursing,20(1), 62–70.Riegel, B., Moser, D. K., Powell, M., Rector, T. S., &Havrenek, E. P. (2006). Nonpharmacologic care by heartfailure experts. Journal of Cardiac Failure, 12(2), 149–153.Rosamond, W., Flegal, K., Friday, G., Furie, K., Go, A.,Greenlund, K., . . . Hong Y. (2007). Heart disease and strokestatistics—2007 update: A report from the American HeartAssociation Statistics Committee and Stroke StatisticsSubcommittee. Circulation, 115(5), e172.112 Siehoff and Ryan

Sulzbach-Hoke, L. M., Kagan, S., & Criag, K. (1997). Advancepractice: Weighing behavior and symptom distress of clinicpatients with HF. MEDSURG Nursing, 6(5), 288–293.Taber’s cyclopedic medical dictionary (20th ed.). (2005). Philadelphia,PA: F. A. Davis Company.Wingate, S. (2007). Caring for persons with advanced heartfailure. Home Healthcare Nurse, 25(8), 511–520.Correspondence regarding this article should be directed to AliceSiehoff, DNP, MS, RN-BC, 535 Williamsburgh, Glen Ellyn, IL60137. E-mail: asiehoffrn@msn.comHeart Failure and Daily Weights 113

Appendix: Data Collection Tool: HF and Weights StudyAdmission date _________________ Length of time with HF __________________ Discharge date _____________Subject no _____________ Age___________ Gender______________A.M. WeightVarianceFrom A.M.Weight FromPrevious DayP.M. WeightVarianceFrom A.M.Weight FromPrevious DayMedications/Doses/Times:ACE, ARB, Diuretics, orNatracorDay 1: Admissiondate__________BUN ________Creatinine_____Adm weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____If knownAdm weight________Time __________Staff initials _____Is patient wearinggown and slippers only?Yes_____ No_____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Day 2:Date_________BUN ________Creatinine_____Weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____Weight________Time __________Staff initials _____Is patient wearinggown and slippers only?Yes_____ No_____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Day 3Date_________BUN ________Creatinine_____Weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____Weight________Time __________Staff initials _____Is patient wearinggown and slippers only?Yes_____ No_____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Day 4Date_________BUN ________Creatinine_____Weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____Weight________Time __________Staff initials _____Is patient wearinggown and slippers only?Yes_____ No_____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Day 5Date_________BUN ________Creatinine_____Weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____Weight________Time __________Staff initials _____Is patient wearinggown and slippers only?Yes_____ No_____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Last 8 hr I _____ O _____(Continued)114 Siehoff and Ryan

Appendix: Data Collection Tool: HF and Weights Study (Continued)Admission date _________________ Length of time with HF __________________ Discharge date _____________Subject no _____________ Age___________ Gender______________A.M. WeightVarianceFrom A.M.Weight FromPrevious DayP.M. WeightVarianceFrom A.M.Weight FromPrevious DayMedications/Doses/Times:ACE, ARB, Diuretics, orNatracorDay 6Date_________BUN ________Creatinine_____Weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____Weight________Time __________Staff initials _____Is patient wearing gownand slippers only?Yes_____ No_____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Last 8 hr I _____ O _____Comorbidities: Circle all that apply diabetesChronic ischemic heart disease Hyperlipidemia Atrial fibrillation Type 1 diabetesType 2 diabetes Renal failure Chronic pulmonary disease HypothyroidismOther: _________________________________________________________________________________________Heart Failure and Daily Weights 115

PRACTICE EVIDENCEVitamin D: Implications forThyroid SurgeryMary Sullivan, DNP, ANP-BC, ACNP-BCUniversity of Massachusetts, Worcester, Graduate School of NursingThyroid and parathyroid surgeries are performed each year on more than 140,000 adults in the UnitedStates. Hypocalcemia is one of the most frequent complications of total thyroidectomy—a procedureused for both benign and malignant pathologies of the thyroid gland. In most situations, disruption ofcalcium homeostasis is felt to be related to disturbance of the parathyroid glands during exploration.Because the parathyroid glands control the amount of calcium in the blood, postoperative supplementationof oral calcium is routine in these cases. When only one side of the neck is explored, the contralateralparathyroid glands are expected to sustain calcium balance; therefore, routine supplementationhas not been the standard. The author and colleagues found unexpected symptomatic hypocalcemia inthree patients undergoing unilateral neck exploration of the thyroid gland over a 4-month period. Thisreport addresses how the interprofessional team identified the unexpected problem, examined potentialcauses and contributing factors, and have changed their approach to care for thyroid and parathyroidsurgery patients. One of the initial case examples will be described in detail to illustrate the problem.Keywords: vitamin D; vitamin D deficiency; thyroid surgery; hypocalcemiaCase ExampleA 29-year-old Black female presented to the emergencyroom with complaints of chest pain. Past medical historywas significant for migraines and anxiety disorder. In addition,during a recent routine gynecologic exam, atypicalcells were noted on Pap smear. A loop electrosurgicalprocedure (LEEP) for management of this abnormal Papsmear was pending. Her current medications were paroxetine,quetiapine, and clonazepam. She reported anallergy to Lamictal. She is a single mother of two who isdisabled secondary to her anxiety disorder. She states thatshe does not smoke, consume alcohol, or use recreationaldrugs. Her past surgical history was significant only for adilation and curettage following a miscarriage. Completeevaluation for chest pain ensued, and her symptoms weredetermined to be related to her anxiety disorder. Cardiacworkup, including EKG and troponin levels, was normal.Her basic metabolic panel and complete blood countswere noted to be normal as well. During her physicalevaluation, she was noted to have a palpable left thyroidnodule. Thyroid function studies obtained in the emergencyroom were normal. Her family history was negativefor thyroid diseases and cancer. She reported no history ofradiation exposure.She was referred to endocrinology for evaluation. Aneck ultrasound revealed a dominant 3-cm nodule in theleft lobe of the thyroid with a 1.7 mm 3 3 mm nodule inthe right lobe. An ultrasound-guided biopsy of the dominantleft-side nodule demonstrated an atypical follicularlesion. Referral was made to an endocrine surgeon for consultationand a left thyroid lobectomy was recommended.After her surgical endocrinology consultation, she choseto undergo a left thyroid lobectomy. Her surgical procedurewas uneventful and the recurrent laryngeal nerve wasintact. The left-sided parathyroid glands were identifiedand dissected down with the blood supply intact. She wasadmitted to the hospital overnight for observation per endocrinesurgery hospital protocol. She reported adequaterelief with oral pain medication, tolerated a regular diet,116 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.116

and she was subsequently discharged home on the morningof postoperative Day 1. A postoperative clinic visitwas scheduled in 1 week with the nurse practitioner forevaluation and pathology discussion.The patient called the surgeon’s office on postoperativeDay 5 complaining of a “funny pain” and was initiallyevaluated by the nurse practitioner via telephone.She was advised to come in for further evaluation of thiscomplaint and was seen in the office that afternoon. Duringher evaluation by the nurse practitioner in the clinic,she complained of a “pins and needle” sensation in herhands and feet. On physical exam, she was found to beafebrile, with normal pulse and blood pressure. Her voicewas strong, and she was having no difficulty swallowing.She was found to have a positive Chvostek’s sign. She hadnot been discharged on calcium carbonate (TUMS) forcalcium supplementation because she had a unilateralneck exploration. She was given TUMS in the office withimmediate improvement noted. She had blood drawn toevaluate her calcium and vitamin D levels. Her surgicalpathology report was pending and she was scheduled fora follow-up visit for reevaluation and pathology discussionin 1 week. Her calcium level returned in the normalrange, 8.7 mg/dl (drawn after consumption of TUMS),and her vitamin D level was insufficient, noted to be20 ng/ml. Normal vitamin D levels are 30–100 ng/ml. Shewas started on calcitriol 0.25 mg by mouth twice daily for2 weeks and TUMS, three tablets thrice daily, per protocolfor postoperative symptomatic hypocalcemia.At her second postoperative visit, she was taperedfrom her calcium and vitamin D supplementation perinstitution protocol and was noted to be asymptomatic.Her pathology report revealed an oncocytic variant ofpapillary thyroid cancer, 2.5 cm 3 2 cm 3 1.6 cm. Shewas scheduled for completion thyroidectomy and referredback to endocrinology for initiation of radioactive iodineablative therapy after the scheduled thyroidectomy andongoing management of her vitamin D deficiency.Clinical ProblemThyroid and parathyroid surgery include the usual risksrelated to surgery and anesthesia including heart attack,stroke, bleeding, infection, and death (Forrest, Rehder,Cahalan, & Goldsmith, 1992; see Table 1). The specificrisks associated with thyroid surgery include damage tothe recurrent laryngeal nerve and damage to the parathyroidglands (Bellantone et al., 2002). Both complicationsare more likely to occur after total or near total thyroidectomycombined with lymph node dissection, a surgicalsituation where both sides of the neck are explored(Bellantone et al., 2002). Damage to the recurrent laryngealnerve occurs in approximately 1% of patients (Serpell& Phan, 2007). However, transient temporary paresis canoccur up to 60% of the time, resulting in hoarseness andtendency toward aspiration (Roh & Park, 2006). Permanentdamage to the parathyroid gland occurs in 0.8%–3%of patients after total thyroidectomy (Roh, 2006).Hypoparathyroidism is the most frequent complicationof total or near total thyroidectomy, occurring in up to onethird of patients (Roh, 2006). Hypoparathyroidism manifestsin patients as symptomatic hypocalcemia (WalkerHarris & Jan De Beur, 2009).Role of Calcium in the BodyCalcium plays a pivotal role in the body. This mineralserves both biochemically and physiologically in cellfunctions. Bone serves as the storage organ for calcium.Through complex mechanisms, calcium is released intothe blood stream as an ion and assists in transmissionTABLE 1.Risk Associations of Thyroid and Parathyroid SurgeryComplicationPercentage of OccurrenceHypocalcemia—transient parathyroid paresis Up to 60%–75%Permanent hypocalcemia caused by PTH damage 0.8%–3%Damage to recurrent laryngeal nerve 1%Transient recurrent laryngeal nerve paresisUp to 60% (hoarseness which is temporary)Heart attack ,1% (0.05)Stroke ,1% (0.04)Death ,1% (0.08)Hematoma ,1% (0.2)Infection ,1% (0.8)Note. PTH 5 parathyroid hormone.Vitamin D 117

of elements across the cell membrane as well as servingas a cofactor for enzymes and proteins. Through thesemechanisms, calcium plays an essential role in bone andskeletal structure, mediating the constriction and relaxationof blood vessels, nerve impulse transmission, musclecontraction, as well as the activation of the coagulationcascade, which stops bleeding through clot formation.Role of Vitamin D in Calcium AbsorptionVitamin D is a fat-soluble vitamin that is naturally presentin very few foods, is available as a supplement, andis generally obtained endogenously through exposure ofskin surfaces to the sun. Vitamin D is essential for calciumabsorption in the gut. Vitamin D is also essentialto maintain adequate serum calcium and phosphate concentrations,which are necessary to facilitate normal bonemineralization and prevent hypocalcemic tetany.Symptomatic Hypocalcemia After Thyroid SurgerySymptomatic hypocalcemia after thyroid/parathyroid surgeryis well documented in the endocrinology literature.Hypocalcemia has been recognized as the most commoncomplication affecting up to 75% of patients undergoingthyroid or parathyroid surgery (Chia et al., 2006). Withmore than 140,000 adults having thyroid or parathyroidsurgery each year in the United States, the risk of untreatedhypocalcemia cascading into morbid or lethal conditionsis significant (Nahas, Farrag, Lin, Belin, & Tufano, 2006).Postoperative hypocalcemia is generally self-limiting withoutmajor side effects or complications. However, symptomatichypocalcemia is a concern because its manifestationmay be delayed. The serum calcium level may slope downwardfor greater than 24 hr postoperatively, and clinicallysignificant symptoms such as tingling and numbness canrapidly progress to laryngeal spasm resulting in loss ofairway and, ultimately, death. Symptomatic hypocalcemiarequires clinical treatment resulting in a delay in dischargeand/or readmission (Bellantone et al., 2002; Kurukahveciogluet al., 2007; Roh, Park, Rha, & Park, 2008). As a resultof these findings, calcium supplementation for patientsat risk for symptomatic hypocalcemia is considered thestandard of care (Bellantone et al., 2002; Kurukahveciogluet al., 2007; Payne et al., 2005; Roh & Park, 2006).Related studies demonstrated the use of adding vitaminD in the postoperative setting where possible devascularizationor auto transplant of parathyroid glands occurs(Glinoer, Andry, Chantrain, & Samil, 2000; Yamashitaet al., 1999). More practitioners now include vitamin Dwith calcium supplementation to avoid hypocalcemia inpatients undergoing total thyroid and parathyroid surgery,or surgery involving autotransplant of parathyroid glandsto prevent symptomatic hypocalcemia and its associatedcomorbidities as described (Abboud et al., 2008; Bellantoneet al., 2002; Erbil et al., 2009; Payne et al., 2005;Roh & Park, 2006).In general, cases involving unilateral neck explorationsuch as thyroid lobectomy, interventions for supplementingcalcium or vitamin D are not initiated based on the expectationthat the contralateral glands will accommodate.Literature SearchesA search of literature using PubMed, Ovid, and guidelinerepository (Cochrane Database, National GuidelineClearinghouse, and The Endocrine Society) was conducted.The search terms generated were thyroid andparathyroid surgery; unilateral thyroid surgery; symptomatichypocalcemia; clinical practice guideline (CPG);and vitamin D physiology, deficiency, inadequacy, and insufficiency.A search of the literature involving unilateralsurgeries did not reveal any published references specificto the prediction of or management strategies to treat orprevent postoperative hypocalcemia in this patient population.Three CPGs were identified. Two guidelines havebeen published by the American Association of ClinicalEndocrinologists (2006) with the American Associationof Endocrine Surgeons (2005) that focused on the diagnosisof primary hypoparathyroidism, whereas the other presentedthe management of thyroid nodules. There was nodetail on postoperative management or mention of issuesassociated with hypocalcemia or vitamin D inadequacy.The British Association of Endocrine Surgeons (2003)has published a guideline for surgical management of endocrinediseases including diagnosis and surgical decisionmaking; again, with no mention of the role of vitamin D orhypocalcemia. Guidelines for surgical management of patientsundergoing thyroid surgery need to include the patientpopulation undergoing unilateral procedures as well.The potential risk of vitamin D inadequacy in this patientpopulation necessitates addressing the prevention and/ortreatment of symptomatic hypocalcemia when only oneside of the thyroid gland is explored at time of surgery.The literature search initially focused on reports fromthe endocrinology and otolaryngology literature becausethese two surgical specialty groups perform most thyroidand parathyroid procedures. This search yielded no clearanswer for unilateral exploration and the observed symptomaticpostoperative hypocalcemia. Next, the emergingliterature on the importance of vitamin D in an extensive118 Sullivan

ange of medical conditions, including calcium homeostasis,was considered.Vitamin D: Etiology and PathophysiologyA review of the vitamin D literature revealed (a) therole vitamin D plays in calcium metabolism, (b) the linkbetween vitamin D deficiency and its prevalence in thenortheast, and (c) the need to consider vitamin D levelsin the management of this surgical population in theperioperative period.Vitamin D is involved in calcium and phosphorus metabolism.A wide range of tissues and cells are influencedby vitamin D, including the immune system, pancreas,cardiovascular, musculoskeletal, and brain (Holick, 2007).Vitamin D is called the “sunshine vitamin” because mostabsorption is through sunlight. Humans get their vitaminD through three routes: skin absorption, food intake, anddietary supplements. There are two forms of vitamin D:vitamin D 2(also called ergocalciferol), which comes fromirradiation of the plant sterol ergosterol and yeast; andvitamin D 3(known as cholecalciferol), which is found incod liver oil or oily fish and is made in the skin (Holick,2006). Both forms undergo conversion in the liver to anactive form of vitamin D. The active form of vitamin D isa steroid hormone, which has its own receptor, vitamin D 3receptor. This receptor occurs throughout the body tissues.The term vitamin D represents both vitamin D 2and D 3.A pictorial depiction is seen in Figure 1.Vitamin D is synthesized through the skin afterexposure to UVB radiation. The UVB irradiation of theskin triggers photolysis of 7-dehydrocholesterol to previtaminD 3in the plasma membrane of the skin. Theskin temperature rapidly converts previtamin D 3to vitaminD 3. This form of vitamin D 3from the skin as wellas any other dietary or supplemental form of vitamin Dundergoes hydroxylation in the liver to form 25(OH)D(or 25-hydroxyvitamin D), which is the main metaboliteof vitamin D 2and D 3. However, this form of vitamin Dis biologically inactive. The active form of vitamin D is1,25-dihydroxyvitamin D. The active form of vitamin Dis produced when the biologically inactive form producedin the liver is converted by the kidney to an activeform. This form of vitamin D is found in tissues such7-dehydrocholesterolDiet/supplementsUV light skinCholecalciferol(Vitamin D 3)Ergocalciferol(Vitamin D 2)LiverCalcidiol(25-hydroxyvitamin D)KidneyCalcitriol(1,25-dihydroxyvitamin D)24,25-dihydroxyvitamin D↑ Intestinal absorptionof calciumBone resorption↓ Renal Ca 2 andphosphate excretionFigure 1. Pathways of vitamin D synthesis. Metabolic activation of vitamin D to calcitriol and its effects on calcium and phosphate homeostasis.The result is an increase in the serum calcium and phosphate concentrations. Reproduced with permission from Pazirandeh S,Burns DL. Overview of vitamin D. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA 2012. Copyright © 2012 UpToDate, Inc.For more information visit www.uptodate.comVitamin D 119

as colon, breast, bone, prostate, and placenta (Holick,2007).Limited foods (fatty fish, fish liver oils, liver, and butteror commercially fortified foods such as milk) contain asignificant source of vitamin D. Most people acquire mostof their vitamin D through direct sunlight; thus, regularreplacement of vitamin D is essential as limited amountscan be stored in fatty tissue.Vitamin D levels (250HD) are measured by serumevaluation. Serum 250HD is the best indicator of vitaminD status. It reflects vitamin D produced from the skin,food, and supplements. The normal range is 30–100 ng/ml(Medline: http://www.nlm.nih.gov/medlineplus/ency/article/003569.htm). Levels below 30 ng/ml are consideredinadequate. Many sources further classify levelsbelow 30 ng/ml into two distinct categories: insufficientand deficient. In this classification system, inadequacy isdefined as 20–30 ng/ml and deficient levels as ,20 ng/ml.Regardless of the classification system, all levels below 20are considered lacking and require intervention (Palottiet al., 2003).Vitamin D Deficiency: EpidemiologyHolick (2006) reported that Vitamin D deficiency is epidemicin many populations worldwide. A meta-analysisof randomized controlled trials (RCTs) on vitamin Dsupplementation and total mortality concluded that intakeof average doses of vitamin D supplements seemedto be associated with decreases in mortality rates fromlife-threatening conditions including cancer, cardiovasculardisease, and diabetes mellitus (Autier & Gandini,2007). Vitamin D inadequacy constitutes a generally unrecognizedsignificant epidemic worldwide with evidenceof inadequacy in healthy children; young adults, particularlythose of African American descent; and middle agedto older adults (Holick, 2006).It has been noted that specific races and certain geographicareas have higher prevalence of vitamin D deficiency.Expert consensus statements describe detailsof various populations with deficiency as 36% in youngadults aged 18–29 years (Binkley et al., 2007), 42% inBlack women aged 15–49 years, 57% in general medicaloutpatients, and 84% in Black adults living in Boston(Hanley & Davison, 2005). Deficiency can vary in populationsduring seasonal changes. Limited ability exists toreplenish this supply in the winter months when cold,snow, and cloud cover prevent the sun exposure necessaryin northern states ( Holick, 2007). A study of submarinersfound levels of vitamin D to decline within 2 months ofsubmerging beneath the surface of the water (Dlugos,Perrotta, & Horn, 1995).Sunlight Exposure and Vitamin DResearchers have determined that a fine line exists betweenthe amount of sunlight exposure necessary to storeenough vitamin D 3for synthesis and sunburn. The standardrecommended dose of sunshine exposure is 10–15 mindirect contact to face, hand, and arms in the middle of theday (Webb & Engelsen, 2006). Adequate direct sunlightexposure is significantly affected by the angle and latitudeof the physical location as well as atmospheric conditions.Significant differences were demonstrated at high latitudesas well as variable cloud cover. Latitudes above 37°north and below 37° south with reduced sunlight result ininsufficient UVB exposure to stimulate cutaneous vitaminD 3synthesis during winter months (Holick, 2008). Withthe indications that vitamin D may protect against morethan bone disease, the need to supplement in ways otherthan sun exposure is evident.Physical and Biologic Factors Affecting Vitamin DMultiple individual physical and biologic factors influencevitamin D inadequacy (Holick, 2004). Included in theseclassifications are specific physical factors, physiologiccomponents, and medication impedance. Any physicalfactor that reduces the UVB exposure such as sunscreen,clothing, and glass shielding affects production of vitaminD by the skin (Binkley et al., 2007). Biological factorssuch as skin pigmentation, medication use, body fatcontent, and fat malabsorption also affect vitamin Dproduction (Holick, 2006). Increased skin pigmentationhas been demonstrated to reduce cutaneous vitamin D 3production as much as 90% (Holick & Chen, 2008). Specificmedication classes reduce absorption of vitamin Dsuch as anticonvulsants, corticosteroids, rifampin, andcholestyramine (Holick, 2006). Medical conditions that affectintestinal absorption such as sprue, cystic fibrosis, andCrohn’s disease impact the vitamin D level as well (Holick,2006). Increasing age is associated with Vitamin D inadequacy.Holick (2006) demonstrated the difference in productionof cutaneous vitamin D between a 70-year-old anda 20-year-old to be 4 times less in the senior citizen. This hastremendous implications for senior citizens, many of whomultimately become nursing home residents, or whose progressivephysical debilitation results in reduced exposure tosunlight because of inactivity or infirmity (Holick, 2007).These factors—the epidemiological, physical, and biologicfactors—identified are important in the perioperative120 Sullivan

management of patients undergoing thyroid and parathyroidsurgery because hypocalcemia treatment for thispopulation must include Vitamin D supplementationin the active, biologically available form of vitaminD—calcitriol.Research and Vitamin DResearch in relation to vitamin D is proliferative. Thereal impact of vitamin D is yet unknown; it appears weare just beginning to scratch the surface. Currently, morethan 900 studies are registered on ClinicalTrials.govrelated to vitamin D, including topics such as associatedconditions, treatment modalities, and the implication ofvitamin D in various disease states (http://clinicaltrials.gove/results?term=vitamin+d).Practice and Process ChangeThe initial variation in patient symptomology describedin the case example was noted by the doctor of nursingpractice (DNP) student. The observed change stimulateda clinical inquiry in collaboration with other members ofthe endocrine surgical team. A literature review for similarcases brought to the forefront the epidemic proportion ofindividuals who are at risk of vitamin D deficiency in thephysical locale of the institution. The current guideline hasno decision process or method to identify or screen thoseat risk for development of postoperative symptomatichypocalcemia caused by vitamin D deficiency. It becameapparent through this process that the CPG needs tobe updated. The update would necessitate revision thatincludes both a system of evaluation and an algorithm fortreatment of vitamin D deficiency to prevent associatedmorbidity and mortality for this surgical population undergoingunilateral neck exploration.The DNP student led the interprofessional team thatmodified the current CPG. The process was guided by theessentials for the practice doctorate including implementationof knowledge translation, process improvement,and systems thinking (American Association of Collegesof Nursing [AACN], 2006). The DNP student managedthe process that included the development of a systemwideguideline to improve patient outcomes in this surgicalpopulation. A flow chart of the process improvementusing the Carey model is included in Table 2. In addition,during the clinical inquiry process, preoperative monitoringof vitamin D levels in this patient population demonstratedthe seasonal trend toward deficiency describedby Holick (2007). Specifically, the incidence of vitamin Dinadequacy trended downward from October to May andthen would trend upward during summer months. Thisfinding was noted in patients who had previously beentested by their primary care physician to be at a normallevel. This discovery influenced the decision to includeall thyroid and parathyroid surgery patients for vitaminD screening during all seasons. It was noted during theTABLE 2.Process Improvement Flowchart CrosswalkIdentify Problem to ImproveOrganize a teamFlow chart current processIs process standardizedIdentify quality characteristicsSelect key quality characteristic for improvementDevelop an operational definition of the quality characteristicCollect and plot dataAre special causes present?Identify process variablesSelect a key process variable (KPV)Select an action to impactCollect additional data on KPVImpact of Vitamin D Deficiency on Postoperative Symptomatic HypocalcemiaAuthor, chief, residency directorNo evaluation of vitamin D except PTH casesYes but need to changeVitamin D level: when, where, how to look atVitamin D levelSerum 25(OH)DCreated vitamin D chart one surgeon’s patientsIf so, investigate and eliminateNew implementation of telephone pretestingObtain post-op vitamin D and react appropriatelyRewrite guideline to includeAudit all chartsDid action have desired impact on KPV?Make action permanent→ Make change and repeat processStart another improvementNote. PTH 5 parathyroid hormone. Adapted with permission from Carey, R., & Lloyd, R. (2001). Measuring quality improvement in healthcare: A guide tostatistical process control applications. Milwaukee, WI: ASQ Quality Press.Vitamin D 121

evaluation of this patient population that although currentrecommendations suggest baseline surveillance of vitaminD levels as part of the yearly physical exam, many patientshave not had any serum levels drawn. Thus, a secondaryhealth outcome for this population has been the identificationand treatment of vitamin D deficiency in patientswho might not otherwise have been screened.Conclusions and Recommendations for PracticeVitamin D deficiency is epidemic in many populationsworldwide. Untreated hypocalcemia can lead to seriouscomplications such as congestive heart failure, respiratoryarrest, metabolic acidosis, and lethal catatonia. Thepotential for vitamin D deficiency in patients undergoingthyroid and parathyroid surgeries needs to be carefullyconsidered along with unrecognized or untreatedvitamin D deficiency. The consequences of hypocalcemiaand vitamin D deficiency for this patient population areincreased morbidity or mortality leading to higher coststo the health care system from either readmission to thehospital or multiple clinic visits and decreased patient satisfactioncaused by the disruption of quality of life as wellas loss of work time. In the preoperative setting, advancepractice nurses and surgeons need to consider risk factorssuch as location, ethnicity, comorbidities, and other illnessesthat affect intestinal absorption and medicationswhen managing the care of patients considering thyroidand parathyroid surgery. Attention to the potential individualsat risk for vitamin D deficiency and the integrationof evidence-based practice will improve the quality ofcare and health care outcomes or this patient population.ReferencesAbboud, B., Sleilaty, G., Zeineddine, S., Braidy, C., Aouad, R.,Tohme, C., . . . Sarkis, R. (2008). Is therapy with calciumand vitamin D and parathyroid autotransplantation usefulin total thyroidectomy for preventing hypocalcemia? Headand Neck, 30(9), 1148–1154; discussion 1154–1145.American Association of Clinical Endocrinologists. (2006).AACE/AME task force guidelines for clinical practice forthe diagnosis and management of thyroid nodules. EndocrinePractice, 12(1), 63–102. Retrieved from http://www.aace.com/pub/pdf/guidelines/thyroid_nodules.pdfAmerican Association of Clinical Endocrinologist, AmericanAssociation of Endocrine Surgeons. (2005). AACE/AAES task force on primary hyperparathyroidism: Positionstatement on the diagnosis and management of primaryhyperparathyroidism. Endocrine Practice, 11(1), 1–6.Retrieved from http://www.aace.com/pub/pdf/guidelines/HyperparathyroidPS.pdfAmerican Association of Colleges of Nursing. (2006). The essentialsof doctoral education for advanced nursing practice,October 1–28. Retrieved from http://www.acn.nche.edu/DNP/pdf?Essentials.pdfAutier, P., & Gandini, S. (2007). Vitamin D supplementation andtotal mortality: A meta-analysis of randomized controlledtrials. Archives of Internal Medicine, 167(16), 1730–1737.Bellantone, R., Lombardi, C. P., Raffaelli, M., Boscherini, M.,Alesina, P. F., De Crea, C., . . . Princi, P. (2002). Is routinesupplementation therapy (calcium and vitamin D) usefulafter total thyroidectomy? Surgery, 132(6), 1109–1112;discussion 1112–1103.Binkley, N., Novotny, R., Krueger, D., Kawahara, T., Daida, Y. G.,Lensmeyer, G., . . . Drezner, M. K. (2007). Low vitamin Dstatus despite abundant sun exposure. Journal of ClinicalEndocrinology and Metabolism, 92(6), 2130–2135.British Association of Endocrine Surgeons. (2003). Guidelinesfor the surgical management of endocrine disease and trainingrequirements for endocrine surgery. Retrieved from http://www.baes.info/Pages/guidelines.phpCarey, R., & Lloyd, R. (2001). Measuring quality improvementin healthcare: A guide to statistical process control applications.Milwaukee, WI: ASQ Quality Press.Chia, S. H., Weisman, R. A., Tieu, D., Kelly, C., Dillmann, W.H., & Orloff, L. A. (2006). Prospective study of perioperativefactors predicting hypocalcemia after thyroid andparathyroid surgery. Archives of Otolaryngology Head NeckSurgery, 132(1), 41–45.Dlugos, D., Perrotta, P., & Horn, W. (1995). Effects of the submarineenvironment on renal-stone risk factors and vitamin Dmetabolism. Undersea Hyperbaric Medicine, 22(2), 145–152.Erbil, Y., Barbaros, U., Temel, B., Turkoglu, U., Issever, H.,Bozbora, A., . . . Tezelman, S. (2009). The impact of age,vitamin D3 level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy.The American Journal of Surgery, 197, 439–446.Forrest, J., Rehder, K., Cahalan, M., & Goldsmith, C. (1992). Multicenterstudy of general anesthesia. Anesthesiology, 76, 3–15.Glinoer, D., Andry, G., Chantrain, G., & Samil, N. (2000). Clinicalaspects of early and late hypocalcaemia after thyroid surgery.European Journal of Surgical Oncology, 26(6), 571–577.Gupta, K., Smith, R., Gupta, H., Forse, R. A., Fang, X., &Lydiatt, W. (2011). Outcomes after thyroidectomy andparathyroidectomy. Head & Neck, 34(4), 477–484. http://dx.doi.org/10.1002/hed.21757Hanley, D. A., & Davison, K. S. (2005). Vitamin D insufficiencyin North America. Journal of Nutrition, 135(2), 332–337.Holick, M. F. (2004). Sunlight and vitamin D for bone healthand prevention of autoimmune diseases, cancers, and cardiovasculardisease. American Journal of Clinical Nutrition,80(6 Suppl), 1678S–1688S.Holick, M. F. (2006). High prevalence of vitamin D inadequacyand implications for health. Mayo Clinical Proceedings,81(3), 353–373.122 Sullivan

Holick, M. F. (2007). Vitamin D deficiency. New EnglandJournal of Medicine, 357(3), 266–281.Holick, M. F. (2008a). Deficiency of sunlight and vitamin D.British Medical Journal, 336(7657), 1318–1319.Holick, M. F. (2008b). Does vitamin D3 dosing schedule influencetreatment efficacy in nursing home residents withvitamin D deficiency? Nature Clinical Practice Endocrinology& Metabolism, 4(12), 656–657.Holick, M. F. (2008c). Sunlight, UV-radiation, vitamin D andskin cancer: How much sunlight do we need? Advances inExperimental Medicine and Biology, 624, 1–15.Holick, M. F. (2008d). Vitamin D and sunlight: Strategies forcancer prevention and other health benefits. Clinical Journalof the American Society of Nephrology, 3(5), 1548–1554.Holick, M. F. (2008e). The vitamin D deficiency pandemic andconsequences for nonskeletal health: Mechanisms of action.Molecular Aspects of Medicine, 29(6), 361–368.Holick, M. F., & Chen, T. C. (2008). Vitamin D deficiency:A worldwide problem with health consequences. AmericaJournal of Clinical Nutrition, 87(4), 1080S–1086S.Kurukahvecioglu, O., Karamercan, A., Akin, M., Tezel, E., Ege,B., Taneri, F., & Onuk, E. (2007). Potential benefit of oralcalcium/vitamin D administration for prevention of symptomatichypocalcemia after total thyroidectomy. EndocrineRegulation, 41(1), 35–39.Nahas, Z., Farrag, T. Y., Lin, F. R., Belin, R. M., & Tufano,R. P. (2006). A safe and cost-effective short hospital stayprotocol to identify patients at low risk for the developmentof significant hypocalcemia after total thyroidectomy.Laryngoscope, 116(6), 906–910.Payne, R. J., Hier, M. P., Cote, V., Tamilia, M., MacNamara,E., & Black, M. J. (2005). Postoperative parathyroid hormonelevels in conjunction with corrected calcium values asa predictor of post-thyroidectomy hypocalcemia: Review ofoutcomes 1 year after the implementation of a new protocol.Journal of Otolaryngology, 34(5), 323–327.Roh, J. L., & Park, C. I. (2006). Routine oral calcium and vitaminD supplements for prevention of hypocalcemia aftertotal thyroidectomy. American Journal of Surgery, 192(5),675–678.Roh, J. L., Park, J. Y., Rha, K., & Park, C. (2008). Is central neckdissection necessary for the treatment of lateral cervicalnodal recurrence of papillary thyroid carcinoma? Head andNeck, 29(10), 901–906.Serpell, J., & Phan, D. (2007). Safety of total thyroidectomy.ANZ Journal of Surgery, 77(1–2), 15-19.Walker Harris, V., & Jan De Beur, S. (2009). Postoperativehypoparathyroidism: Medical and surgical therapeuticoptions. Thyroid, 19(9), 967–973.Webb, A. R., & Engelsen, O. (2006). Calculated ultraviolet exposurelevels for a healthy vitamin D status. Photochemistryand Photobiology, 82(6), 1697–1703.Yamashita, H., Murakami, T., Noguchi, S., Shiiba, M., Watanabe,S., Uchino, S., & Murakami, N. (1999). Postoperativetetany in Graves disease: Important role of vitamin Dmetabolites. Annals of Surgery, 229(2), 237–245.Acknowledgments. The author wishes to acknowledge Dr. PauletteSeymour-Route, Dr. Giles Whalen, and Dr. Jean Boucherfor guidance during this project.Correspondence regarding this article should be directed to MarySullivan, DNP, ANP-BC, ACNP-BC, University of Massachusetts,Worcester, Graduate School of Nursing, 2 Rosslare Drive, Worcester,MA 01602. E-mail: Mary.Sullivan3@Umassmemorial.orgVitamin D 123

practice managementAdoption of a Pain AssessmentTool in Older Homebound PatientsWith Dementia in a HousecallPractice: A Dissemination StudyJean-Claude K. Provost, APRN, DNP, FNP-CThe University of Portland, School of NursingThis article describes the steps of a pilot dissemination study toward adopting a pain assessment tool forolder homebound adults with dementia. The chosen practice site had not previously used adequate painassessment tools for older adults with dementia. After the selection process by a pain assessment toolcommittee, providers (N 5 20) were asked to choose between three tools: pain assessment in advanceddementia (PAINAD), the Abbey Pain Scale, and DOLOPLUS-2/ DOLOSHORT. Providers voted touse the PAINAD (54%) for the following 2 weeks. A preintervention audit showed that without the useof a pain assessment tool, 97.7% of the charts did not have any documentation of a pain diagnosis nor anintervention. Postintervention using PAINAD, 91.3% of the charts had both (x 2 [1] 5 18.645, p , .001).The feedback obtained from providers (n 5 10) after 2 weeks of testing the tool was unanimously positive.Many providers reported increased confidence in identifying pain and some changed their practiceby placing pain assessment in the forefront of their encounter with their older clients with dementia.PAINAD was adopted as the pain assessment tool for this practice.Keywords: older adult; dementia; pain assessment; dissemination studyThe practice site for this pilot study is a private, notfor-profitorganization located in Portland, Oregon thatdelivers in-home medical services for older homeboundpatients with multiple chronic conditions. Approximately80% of the patients in this practice have a diagnosis ofdementia (Alzheimer’s type or other) and also have concurrentdiagnoses potentially associated with pain (arthritis,diagnoses associated with decreased mobility, cancerhistory, etc.). This organization includes primary care andhospice care.This pilot study emerged from the identification ofa need from the hospice management team working incollaboration with primary care providers to establishminimal standards for pain assessment in patients withsevere cognitive impairment. The primary care team hadnot been using any specific assessment tool and oftenrelied on secondary sources (caregivers, nurses, andfamily) to base their judgment on the presence of pain.Currently, the Wong-Baker scale, originally used for pediatricpatients, is sometimes used, however, inconsistentlyand unreliably, for older adults with more severe cognitiondeficits (Herr, Mobily, Kohout, & Wagenaar, 1998;Kaasalainen & Crook, 2004).Although some primary care providers use scales thatmay not be appropriate for older adults with dementia(e.g., Wong-Baker scale), some treat pain subjectively124 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.124

elying on the caregivers’ or family’s observations of behaviors,such as calling out, withdrawal, depressed mood,striking out, decreased eating, agitation, and restlessness.Approaches in the treatment of pain depend mostly onthe patient’s history and sensitivity to certain drugs aswell as the prescriber’s habits and level of comfort withcertain medications. The lack of use of a pain assessmenttool appropriate for older patients with dementia at thissite does not support best practice. Pain symptoms mightbe confused with depression or delirium with aggressivefeatures and therefore inadequately addressed in the planof care.The Impact of Dementia on Pain RatingIt is estimated that 4.5 million Americans have beendiagnosed with dementia. By 2050, the prevalence is expectedto triple (Herr, Bjoro, & Decker, 2006). Dementiais characterized by a decline in intellectual functionsaffecting abstract thinking, memory, judgment, and languageuse (Kaasalainen & Crook, 2004). It is a commonmisconception that pain decreases with age and that olderpatients with dementia are mostly unaware of pain issues(Harkins, 1996). Although it is true that the number ofpain complaints decreases with the progression of dementiaand pain recall and integration of pain experiencemay be less reliable, pain is still present (Herr et al., 2006).Rather than being less sensitive to pain, older clients withdementia fail to interpret sensations of pain and are unableto verbally communicate those to providers (Horgas,2007). Furthermore, assessing pain in this population canbe challenging because pain is often caused by a complexcombination of physical pain, depression, loss, anger, andloneliness (Leone, Standoli, & Hirth, 2009). Consequently,difficulties in assessing pain via nonverbal cues and lackof patient self-reporting often lead to undertreatment ofpain issues in patients with dementia compared to cognitivelyintact groups (Fuchs-Lacelle, Hadjistavropoulos, &Lix, 2008; Hadjistavropoulos, Fitzgerald, & Marchildon,2010; Husebo et al., 2008).In addition to lack of self-reporting, there is evidencethat providers and caregivers do not recognize nor dothey manage pain adequately (Krulewitch et al., 2000).Families and caregivers of patients with dementia oftendemonstrate poor knowledge of pain treatment. Theyalso tend to have negative attitudes toward pain medicationusage, which, in turn, leads to undertreatment ofpain (Krulewitch et al., 2000). Such beliefs and reluctanceto medicate pain make the work of providers even moredifficult. Pain assessment and treatment then becomea challenge because providers depend on caregivers toobtain subjective data relating to their clients.The need for pain assessment early in the care deliveryof older adults is imperative to maintain well-being(Bachino, Snow, Kunik, Cody, & Wristers, 2001; Barber& Gibson, 2009; Devons, 2002; Hadjistavropoulos et al.,2010; Kovach, Weissman, Griffie, Matson, & Muchka,1999; Tsai & Chang, 2004). Tait and Chibnall (2008)reported that undertreatment of pain in older clients isassociated with a high level of comorbidities and physicaldisabilities. Other factors such as weight loss, sleepdisturbance, and depression caused by uncontrolled paincan seriously affect life satisfaction (Leone et al., 2009;Pautex et al., 2006). Pain is regarded as one of several possiblecauses of delirium in older patients with dementia(Richard, Doucet, Carmichael, & Voyer, 2009). Patientswith two or more pain-related diagnoses, in addition totheir dementia, had higher aggression scores than patientswith one or no pain-related diagnoses (Delac, 2002).In this dissemination study that looked at practicechange, participating providers were asked to answer aquestionnaire regarding their pain assessment practicesand education needs. Participants attended a group educationalsession for 1 hr and were asked to vote on one painassessment tool to use in practice following the educationalsession. They were also asked to use the chosen toolfor 2 weeks. At the end of 2 weeks, providers completeda follow-up questionnaire, sharing their feedback relatedto the experience of using the pain assessment tool. Theproviders’ charts were examined for use of the pain assessmenttool. Each participant signed an informed consentprior to enrolling in the study. The Institutional ReviewBoard of the University of Portland exempted this studyfrom review.Desired Project OutcomesThe purpose of this project was the dissemination andadoption of a pain assessment tool for older clients withdementia that would be used by all practitioners in thispractice setting. Desired outcomes for the project were asfollows:1. Providers would identify and assess pain issuesin older patients with dementia. The outcomemeasure was a documented diagnosis of pain ordiagnosis known to cause pain (e.g., osteoarthritis,osteoporosis) in the provider’s encounter notes.2. Providers would change their prescribing habitsbecause they identified pain more adequately.Adoption of a Pain Assessment Tool 125

MethodsThe outcome measure was a documented review ofpain interventions or a change in the treatment ofpain in the provider’s encounter notes.Implementation Planning and StepsFigure 1 illustrates the outline of this pilot study. Eachstep reflects the different phases leading to the adoptionand dissemination of the assessment tool during this pilotstudy.A pain assessment tool committee was created to (a)examine the criteria that are important to the group andthe practice in selecting pain assessment tools for olderadults with dementia, (b) discuss which tools would beappropriate and which ones would not, (c) discuss othercriteria that would be important in selecting a tool in ahouse call practice setting, and (d) select pain assessmenttools that are appropriate for the practice in order for allproviders in the practice to make the final decision inadopting one tool. The committee was composed of threenurse practitioners, one physician assistant, the hospicenurse manager, and a licensed clinical social worker.Selection criteria for pain assessment tools used anevaluation process designed by Herr et al. (2006), whosestudy aimed at critically evaluating existing tools used forpain assessment in older adults with dementia and providingclinicians with recommendations regarding the use andpotential deficits of these tools. Herr et al. listed five criteria:conceptualization, subjects setting, administration/scoring/feasibility, reliability, and validity. The AmericanGeriatrics Society (2009) guidelines for pain evaluationwere also used to support the committee’s decision process.In addition, ease of teaching the tool (to families andcaregivers) was selected as an additional criterion. Thecommittee then decided which tools best captured all criteriaand selected three tools to be presented to the groupof providers.Twenty surveys were sent out to providers askingthem to examine their practice and the need for a pain assessmenttool. The responses showed no barriers to caringand treating pain. Only one respondent believed that painis a normal consequence of aging, and two believed thataging results in decreased sensitivity to pain. All providers(100%) reported that they base their judgment in assessingpain on the opinion of other health care professionals(home health nurses, hospice nurses, mental health nurses,physical therapists, and caregivers). When not relyingon the opinion of others, they base their assessment onobserving the patients’ facial expressions (such as grimacing)and behaviors. This would indicate that providerswould be likely to use an observational scale rather than aself-report scale.Surprisingly, only one respondent was currently usingan observational scale (pain assessment in advanced dementia[PAINAD]), whereas others were using the FacesPain Scale (n 5 2) and the Pain Analog Scale (n 5 4). Theuse of self-reported scales and other assessment tools callingfor abstract thinking has been shown to be inappropriatewith severe cognitive impairment (Fuchs-Lacelleet al., 2008; Hadjistavropoulos et al., 2010; Husebo et al.,2008). All other providers reported not using any paintool at this time (n 5 11). Eighty-six percent of the providersadmitted they do not currently have the necessarytools for assessing pain in older adults with dementia, yetonly 54% stated they would be more likely to assess painissues if they had an appropriate tool. A majority (n 5 13)wanted to have an easy access to the pain tool. The needfor a pain assessment tool that is appropriate for olderadults with dementia was well demonstrated through thisquestionnaire.Findings from the questionnaire were used to customizeeducation needs to the providers; this includeda literature review of articles discussing pain assessmentpractices in older adults with dementia and the presentationof three pain assessment tools previously selectedby the pain committee. The committee had selectedPAINAD, the Abbey Pain Scale, and DOLOPLUS-2/DOLOSHORT. Poster presentations of these tools werereviewed by the practitioners. After a week, providerselected to use PAINAD as the pain assessment tool ofreference for this practice.AnalysesTo evaluate the outcomes related to using a pain assessmenttool, a comparison group was used. A random sampleof patient charts that did not use any pain assessment toolwith appointments prior to the educational presentationwas selected. The comparison group list of patients wasgenerated from the appointments schedule for all providers,accessible in the electronic health records (EHR).Selection criteria for the charts to be audited were as follows:(a) the patient had to have had an encounter withhis or her provider within the defined time frame, (b) adiagnosis of dementia had to be specifically listed amongthe active diagnoses (those with other diagnoses such asmental retardation or mild cognitive impairment were excluded),and (c) a “pain” diagnosis had to be specifically126 Provost

Problem identification: Providers in thispractice do not assess older adults withdementia with appropriate pain toolsPersonal experience and observation: Faces Pain Scaleis currently used for older adults with dementia.Short audit showing that pain is not formally assessedReview of literature- Incidence of pain issues in older adults- Impact of dementia on pain rating.The more advanced the dementia,the more difficult to self-report pain- Providers’ knowledge deficits(older adults do not have pain; ifnot stated, pain does not exist; etc.)- Review of pain assessment toolsavailable for this populationPainAssessmentToolCommitteecreationAdoptionof toolinto practiceReview/selection of criteriafor adopting a pain tool usingHerr et al. (2006) template- Conceptualization- Subjects settings- Administration/scoring/feasibility- Reliability- Validity- Easy to teachDisseminationGroup meeting/discussion oftools, scoring/eliminationFeedback review:ObstaclesIdentification/ObjectivesReadjustmentsSuccessful outcomesdefined by the following:- Use of tool- Increased documentationof pain-related diagnoses- Interventiondocumentation relating topain managementSelection of THREE painassessments toolsPoster presentation ofselected pain toolsEvaluation of tool usefeedback via short writtenproviders’ surveyData analysis from chartreviewAdoption of ONE pain tool bygroup/dissemination of paper formtool to providers2-week tool usetrialFigure 1. Dissemination study implementation process: Descriptive outline and steps.Creation of a questionnaire to evaluatepractitioners’ knowledge, practice, andbeliefs.Feedback and corrections.Testing ofquestionnaireAdministration toprovidersData analysis ofquestionnaireEducation delivery toproviders viaPowerPoint presentationComparison group:Chart audit looking forpain diagnoses andinterventions when nopain tool was usedAdoption of a Pain Assessment Tool 127

TABLE 1.Comparison Group Audit (No Pain Assessment Tool Used)Pain DiagnosisNo (%) Yes (%) Total Chi-squarePain intervention No (%) 42 (97.7) 12 (52.2) 54 3.792Note. df (1).*p , .001.Yes (%) 1 (2.3) 11 (47.8) 12 17.063Total 43 (100) 23 (100) 66 20.854listed among the active diagnoses (including cancer pain,fibromyalgia, osteoporosis, arthritis of any joints, degenerativejoint disease, and irritable bowels syndrome).Attempts were made to create a sampling for thecomparison group that was representative of each providerand reflected his or her patient caseload. Providerswith a caseload of less than 20 patients were not subjectedto the chart audit because they represented less than 1%of the total patient census. In addition, this investigator’spatient caseload was excluded, and his patients werededucted from the total patient census.The Preimplementation Chart AuditData from the chart audit were arranged in an Exceltable, and the EZAnalyze software was used for statisticalcalculations.There was a significant association between the absenceof a documented pain diagnosis and the absenceof a pain-related intervention (x 2 [1] 5 20.854, p , .001).Of individuals who did not have a documented pain diagnosis,97.7% did not receive a pain-related intervention,whereas 52.2% of patients who did have a pain diagnosisdid not receive a pain intervention. A lesser percentageof individuals with a documented pain diagnosis in theirchart note received a pain intervention (47.8%) as comparedto individuals without a documented pain diagnosis(2.3%; see Table 1).The Postimplementation Chart AuditCompleted PAINAD tools were collected after a 2-weektesting period by the providers. Five copies of the toolwere given to each of the 20 providers (100 total). Fortyfourtools were returned completed. Seven tools did notmeet the inclusion criteria because they were used incorrectlyor incompletely.There was a significant association between the presenceof a pain diagnosis and the presence of a pain-relatedintervention when providers used the pain assessmenttool (x 2 [1] 5 18.645, p , .001). This indicated that whenPAINAD was used, a significantly higher percentage ofindividuals with a documented pain diagnosis received apain intervention (91.3%) as compared to individuals withouta documented pain diagnosis (21.4%). Alternatively,78.6% of individuals who did not have a documented paindiagnosis also did not receive a pain-related intervention.Only 8.7% of patients who did have a pain diagnosis didnot receive a pain intervention (see Table 2).Comparing both groups, the data show that whethera pain tool is used or not, progress notes are much lesslikely to have a pain intervention without the presenceof a pain diagnosis (97.7% in the comparison group asopposed to 83.3% in the postintervention group). This issupported by the fact that in the current EHR system, itis difficult to document an intervention that is not linkedto a diagnosis. Consequently, charts with a documentedTABLE 2. Postintervention Group Audit (Pain Assessment in AdvancedDementia Used)Pain DiagnosisNo (%) Yes (%) Total Chi-square*Pain intervention No (%) 11 (78.6) 2 (8.7) 13 12.094Note. df (1).*p , .001.Yes (%) 3 (21.4) 21 (91.3) 24 6.551Total 14 (100) 23 (100) 37 18.645128 Provost

pain intervention and without a diagnosis were lower inboth preintervention and postintervention groups (2.3%and 21.4%, respectively).Although in the absence of a pain tool in the comparisongroup, providers were assessing and treating their olderclients for pain 47.8% of the time; this number was significantlyhigher when they were asked to use PAINAD(91.3%). Alternatively, with the use of PAINAD, the numberof patients who had a pain diagnosis in their assessmentbut no intervention fell dramatically from 52.2% toonly 8.7%. The correlation between the use of a pain assessmenttool and the presence of a diagnosis and therefore anintervention appears to be strong in this pilot study.Providers’ FeedbackAfter 2 weeks of using the PAINAD tool, providers weregiven a chance to share their feedback related to the useof the tool in their daily practice. Feedback was veryconsistent and enthusiastic regarding integrating a newtool in their daily practice because it was “easy to use” formost, “quick,” “simple,” and “straightforward, using a familiartemplate (0–10).” Using PAINAD raised the levelof awareness of pain in the older adult with dementia and“contributed to formulating a better differential [diagnosis]for assessing agitation in dementia.” For others, havinga pain assessment tool supported their “intuition” andquantified pain levels in nonverbal patients.Providers felt a greater satisfaction with assessing pain.As a result, six providers felt they were more aware of potentialpain-related problems and made a conscious effortassessing pain earlier in the encounter. One provider alsofavored analgesic treatment, as opposed to psychotropicmedications. Another provider stated, “I added scheduledacetaminophen in one patient and increased the oxycodonedose in another.” The collective feedback from the providerstended to support the idea that the adoption of a painassessment tool does offer good potential to change theprescription habits of providers. Another provider statedthat she “stopped worrying about undertreating pain” inthis population now that she has an assessment tool.Finally, most providers (n 5 7) stated that havingPAINAD integrated into the EHR would make it readilyaccessible and would facilitate its use. Using PAINAD inits paper format was reported to be inconvenient by mostproviders.Barriers IdentifiedSeveral barriers were identified in this pilot study. A lackof participation from some providers might be attributedto (a) refusal to participate in any experiment, (b) difficultiesrelating to changing their daily practice, (c) resistanceto recognizing that the current state of pain assessment isnot adequate, (d) possible resistance to participating in anacademic project, and (e) possible lack of time or omissionto take the paper form of the tools with them.Another barrier identified related to the provider’slevel of proficiency in using the EHR. Although mostproviders responding to the feedback survey wished thetools had been integrated into the EHR, most providershad not reached a level of proficiency allowing retrievingand using this tool within the software. Previous attemptsto integrate psychometric tests in the EHR had provenunsuccessful.Lessons LearnedThis pilot study was effective, and the practice voted toadopt the PAINAD tool. The study generated enthusiasm,caused practitioners to reexamine their practice, andprovided them with a new tool to assess pain in the olderadult with dementia. A few lessons were learned alongthe process.The study might have benefited from allowing greatertime periods for responding to questionnaires. Providerswere given 2 weeks to return the first questionnaire, resultingin a 75% return rate. For reasons related to duedates and completion requirements for data collection,providers had only 1 week to return the second questionnaire,resulting in a 50% return rate. Extending deadlinescould have meant a larger sample, consequently strengtheningthe data and findings.In addition, the integration of the PAINAD tool inthe EHR was delayed because of varying degrees of proficiencyamong providers. Feedback received indicated thatthe paper form of the tool was actually a barrier to use.In the future, informatics support might be sought prior tostarting a pilot project to maximize the use of the EHR andfamiliarize providers in the early phases of the project.ConclusionThe implementation of a pain assessment tool for olderhomebound adults with dementia in this house callpractice was successful. This pilot project responded to aneed for improved identification of pain in this population.In addition, in a health care system now orientedtoward the concept of medical homes, primary care providerswill have to demonstrate that care provided in thehome setting is cost-effective with improved outcomes.The adoption of a pain assessment tool in this house callAdoption of a Pain Assessment Tool 129

practice contributed to improved quality of life for the patientsand cost containment through gradual changes inthe prescribers’ practice. Throughout the implementationprocess, providers realized the benefits of adopting a painassessment tool appropriate for older clients with dementia.Most providers embraced this change and looked forwardto integrating the use of PAINAD to their practice,which will be made more readily accessible in the nearfuture with its integration into the EHR.Future StepsThis practice site is expanding rapidly with the addition ofa hospice agency. This study is intended to expand beyondprimary care to hospice services in order for providers andhospice workers to refer to the same tool and better treatpain in the older adult with dementia at the end of hisor her life. The next phase of this project is to facilitatechanges within the hospice team, then bridge the use ofPAINAD between primary care and hospice.Although this project intended to integrate PAINADinto the EHR template within the next 6 months, it appearsthat providers would rather have it integrated soonerthan later. The next step will be to seek assistance from thecurrent EHR supplier and order software changes to meetthe providers’ request.Further education is also required regarding treatmentof pain with high scoring PAINAD. In a few instances,high-scoring assessment did not lead to any changes inthe plan of care and did not generate any documentationsupporting a lack of intervention. Although well educatedon pain in the older adult with dementia, the providershave to obtain buy-in from patients’ caregivers and familyto be able to treat pain adequately. Provider educationwill not only focus on documentation requirements butalso the negotiating skills needed to meet the needs ofour clients and obtain the agreement of their caregivers.Future practice change will focus on shifting providers’prescription habits from psychotropic drugs to moreanalgesic drugs.ReferencesAmerican Geriatrics Society. (2009). AGS clinical practice guideline:Pharmaceutical management of persistent pain in olderpersons. Retrieved from http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2009/Bachino, C., Snow, L. A., Kunik, M. E., Cody, M., & Wristers, K.(2001). Principles of pain assessment and treatment in noncommunicativedemented patients. Clinical Gerontologist,23(3/4), 97–115.Barber, J. B., & Gibson, S. J. (2009). Treatment of chronic nonmalignantpain in the elderly. Drug Safety, 32(6), 457–474.http://dx.doi.org/0114-5516/09/0006-045Delac, K. (2002). Pain assessment in patients with cognitive impairmentis possible. Advanced Emergency Nursing Journal,24(1), 52–54.Devons, C. A. J. (2002). Comprehensive geriatric assessment:Making the most of the aging years. Current Opinion inClinical and Metabolic Care, 5, 19–24.Fuchs-Lacelle, S., Hadjistavropoulos, T., & Lix, L. (2008). Painassessment as intervention: A study of older adults withsevere dementia. Clinical Journal of Pain, 24(8), 697–707.Hadjistavropoulos, T., Fitzgerald, T. D., & Marchildon, G.P. (2010). Practice guidelines for assessing pain in olderpersons with dementia residing in long-term care facilities.Physiotherapy Canada, 62(2), 104–113. http://dx.doi.org/10.3138/physio.62.2.104Harkins, S. W. (1996). Geriatric pain: Pain perception in theold. Clinics in Geriatric Medicine, 12(3), 435–459.Herr, K., Bjoro, K., & Decker, S. (2006). Tools for assessmentof pain in nonverbal older adults with dementia: A state-of-the-sciencereview. Journal of Pain and SymptomManagement, 31(2), 170–192. http://dx.doi.org/10.1016/j.jpainsymman.2005.07.001Herr, K. A., Mobily, P. R., Kohout, F. J., & Wagenaar, D. (1998).Evaluation of the Faces pain scale for use with elderly.Clinical Journal of Pain, 14(1), 29–38.Horgas, A. L. (2007). Assessing pain in older adults with dementia.Try This: Best Practices in Nursing Care to Adults withDementia, D2. Retrieved from http://www.interiorhealth.ca/uploadedFiles/Health_Services/Senior_and_Adult_Care/Dementia_Care/Professional_Resources/trythis_issue_d22007.pdfHusebo, B. S., Strand, L. I., Moe-Nilssen, R., Borgel-Husebo,S., Aarsland, D., & Ljunggren, A. E. (2008). Who suffersmost? Dementia and pain in nursing home patients: Across-sectional study. Journal of the American Medical DirectorsAssociation, 9(6), 427–433. http://dx.doi.org/10.1016/j.jmda.2008.03.001Kaasalainen, S., & Crook, J. (2004). An exploration of seniors’ability to report pain. Clinical Nursing Research, 13(3), 199–215. http://dx.doi.org/10.1177/1054773804265692Kovach, C. R., Weissman, D. E., Griffie, J., Matson, S., &Muchka, S. (1999). Assessment and treatment of discomfortfor people with late-stage dementia. Journal ofPain and Symptom Management, 18(6), 412–419.Krulewitch, H., London, M. R., Skakel, V. J., Lundstedt, G. J.,Thomason, H., & Brummel-Smith, K. (2000). Assessmentof pain in cognitively impaired older adults: A comparisonof pain assessment tools and their use by nonprofessionalcaregivers. Journal of the American Geriatrics Society, 48(12),1607–1611.Leone, A. F., Standoli, F., & Hirth, V. (2009). Implementinga pain management program in a long-term care facility130 Provost

using a quality improvement approach. Journal of the AmericanMedical Directors Association, 10, 67–73. http://dx.doi.org/10.1016/j.amda.2008.08.003Pautex, S., Michon, A., Guedira, M., Emond, H., Le Lous, P.,Samaras, D., . . . Gold, G. (2006). Pain in severe dementia:Self-assessment or observational scales? Journal of theAmerican Geriatrics Society, 54(7), 1040–1045. http://dx.doi.org/10.111/j.1532-5415.2006.00766.xRichard, S., Doucet, L., Carmichael, P.-H., & Voyer, P. (2009).Predisposing factors associated with delirium among dementedlong-term care residents. Clinical Nursing Research,18(2), 153–171.Tait, R. C., & Chibnall, J. T. (2008). Under-treatment of painin dementia: Assessment is key. Journal of the AmericanMedical Directors Association, 9(6), 372–374. http://dx.doi.org/10.1016/j.jmda.2008.04.001Tsai, P.-F., & Chang, J. Y. (2004). Assessment of pain in elderswith dementia. Medsurg Nursing, 13(6), 364–370.Acknowledgments. The author would like to thank MarieNapolitano, PhD, ARNP, FNP-C, FAAN at the University ofPortland and Casey Shillam, PhD, RN at UC Davis for theirvaluable feedback and support throughout this study.Correspondence regarding this article should be directed toJean-Claude K. Provost, APRN, DNP, FNP-C, The Universityof Portland, School of Nursing. E-mail: provostj@up.eduAdoption of a Pain Assessment Tool 131

PRACTICE MANAGEMENTAnesthesia Handoff:A Root Cause AnalysisBased on a Near-Miss ScenarioEileen Y. Evanina, RN, MS, CRNANicole L. Monceaux, RN, BSN, SRNAColumbia University School of NursingThe Joint Commission on Accreditation of Hospital Organization ( JCAHO) has handoff requirementsto create the safe and effective transfer of patient information between providers. Multiple studies haveinvestigated standardized nurse-to-nurse handoffs and nurse-to-physician handoffs. However, very fewstudies have examined handoff communication between anesthesia providers. A near-miss scenarioduring a sitting craniotomy procedure is reviewed, and a root cause analysis conducted to demonstratethe importance of communication and how a standardized anesthesia handoff tool can facilitate patientsafety.Keywords: handoff; anesthesia; root cause analysis; near missHandoff communication occurs in all health care specialtiesat the end of shift, change in clinician providingcare, or during consultation. The Joint Commissionon Accreditation of Hospital Organization ( JCAHO)defines handoffs as the real-time process of passingpatient-specific information from one caregiver toanother for the purpose of ensuring the continuityand safety of patient’s care ( Joint Commission, 2007).Handoff communication is often viewed as simply thetransfer of information. Its impact on patient safety isfrequently lost. In 2006, JCAHO created specific handoffcommunication requirements to standardize theprocess to create safe transfer of patient information.JCAHO also found that ineffective communication isthe greatest contributing factor to near-miss scenariosand sentinel events. To demonstrate the importanceof communication during the provision of anesthesia,a near-miss scenario that occurred during a sittingcraniotomy and the root cause analysis that was conductedare presented.Background Information About PosteriorCraniotomy SurgeryDuring posterior craniotomy surgeries, patients are placedin the sitting position for ease of access to the surgicalsite. The sitting position is significant because the surgicalsite is above the heart (Figure 1). Because of elevation ofthe surgical field above the heart and lack of valves in thecerebral venous circulation, the risk for venous air embolismis constant (Stoelting & Miller, 2007, p. 298). Thevolume of air that becomes trapped within the circulationand the site in which the air becomes lodged maycause the patient to develop cardiac, pulmonary, cerebraldamage, or death. A change of vital signs, a sudden decreasein expired end-tidal carbon dioxide (ETCO 2), orthe sudden appearance of end-tidal nitrogen (ETN2)notifies the anesthesia provider and the surgical teamof air embolism occurrence. Upon recognition of an airembolus, the appropriate intervention is to communicateto the surgeon to irrigate the operative site with fluid;deliver 100% oxygen; increase intravascular volume132 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.132

infusion; place the patient in Trendelenburg position; andif present, aspirate air from the central venous catheter( Morgan, Mikhail, & Murray, 2006).Case PresentationA certified registered nurse anesthetist (CRNA) and astudent registered nurse anesthetist (SRNA) initiatedanesthesia on a 35-year-old male for posterior craniotomysurgery. Two hours into the case, it was time for changeof shift, a relieving CRNA arrived. Handoff report wasgiven verbally while the relieving CRNA and the SRNAcontinued to manage the case. Included in the handoffreport were the following:• The name of the procedure• Patient allergies• Past medical history• Past surgical history• Intravenous and intra-arterial line placements• Volume status and hemodynamic stabilityDuring the first 2 hr of the case, the ETCO 2hadbeen trending at approximately 25 mmHg, which wasnot reported during the handoff report. Normal ETCO 2is 35–45 mmHg; however, during craniotomy surgeries,ETCO 2is kept at the lower end (between 25 and35 mmHg) to facilitate cerebral autoregulation (Morganet al., 2006).Approximately 5 min after the handoff, the SRNAwho had been in the room since the beginning of the casenoticed a 10 mmHg decrease in the ETCO 2. The SRNAalerted the CRNA who had just assumed care, and thesurgeon of the possibility of an air embolism. The CRNAbelieved that the patient was being hyperventilated anddecreased the tidal volume, which would consequently increasethe ETCO 2. The student was adamant that therewas a significant change in status and alerted the surgeonagain. The surgeon did not respond so the SRNA andleft the operating room to get both the CRNA and theattending anesthesiologist who had been involved in thecase for the previous 2 hr.Upon return of all three anesthesia providers, thesurgeon was queried regarding the possibility of an airembolism. With this inquiry, the surgeon stated that anopen venous sinus was noticed and flooded with saline.The necessary window of time to intervene was now inexcess of 10 min; meanwhile, the ETCO 2had returnedto baseline, and no immediate intervention was necessary.Upon completion of the case, the patient was awakenedwith no sequelae noted. The patient did not have anyFigure 1. Sitting position for posterior craniotomy.complications postoperatively, and the incident was considereda near-miss scenario.Anesthesia HandoffThere has been a significant growth in the number ofarticles published that addressed communication and perioperativehandoff during the last 10 years. Most studieshave focused on effective perioperative communication,emphasizing its importance in achieving safe, high- qualityperformance in a high-risk environment. Qualitativestudies and surveys on handoff communication betweenanesthesia providers and recovery room nurses revealedwidespread dissatisfaction with the current handoff process,describing it as “informal, unstructured, and inconsistentwith often incomplete information” (Nagpal et al.,2010). A 2008 study found that handoffs were frequentlyin verbal form and took place in a hurried environmentwith considerable distractions (Smith, Pope, Goodwin, &Mort, 2008).In 2006, JCAHO made the standardized approach tohandoff communication a National Patient Safety Goal.JCAHO requirement 2E addresses the essential componentsof handoff communication as (a) being interactive,(b) up to date, (c) having a verification process by repeatingback information, and (d) having minimal interruptions.Adapted from the military, many organizations currentlyuse the Situation, Background, Assessment, and Request(SBAR) tool to standardize handoff and communicate keypoints of patient care (Mascioli, Laskowski-Jones, Urban,Anesthesia Handoff 133

& Moran, 2009). Although SBAR is the most popular,other standardized handoff tools have been createdincluding Demographic, Assessments, Tests, Alerts, Status(DATAS); Identify, Diagnosis, Events, Anticipated,Leave (IDEAL); Problem list, Expected tasks, Diagnosis,If/then, Administrative data, Therapeutics, Results, IVaccess, Custody and consents (PEDIATRIC); and InformationTransfer Aid Memoir (ITAM).In 2008, JCAHO recognized through a root causeanalysis that the breakdown in communication resulted in65% of sentinel events. It was also found that near misseshappen with greater frequency than sentinel events.A near miss is defined as any process variation that didnot affect an outcome but for which a recurrence carriesa significant change in a serious adverse outcome. In theliterature, the terms “near miss,” “close call,” and “potentialadverse event” are used synonymously. The U.S. Departmentof Veterans Affairs defines close call as an event orsituation that could have resulted in an adverse event butdid not, either by chance or through timely intervention.A root cause analysis is required by JCAHO and VeteransHealth Administration (VHA) for sentinel events and isrecommended for near misses.Root Cause AnalysisA root cause analysis team was formed to review the nearmissscenario that had occurred. The team consisted ofthe two CRNAs and SRNA involved in the posteriorcraniotomy case. A root cause analysis is a process for identifyingthe basic or causal factors underlying variations inperformance ( JCAHO, 2010). The tools that were usedto perform root cause analyses include brainstorming,flowcharts, fishbone diagrams, and relations diagrams.Root cause analyses focus on the what (the event) andthe why (the system), not the who (health care provider;Williams, 2001). The event was reviewed thoroughly bythe team members, and through brainstorming, six potentialcontributing factors to the near miss were identified:incomplete handoff information, absence of standardizedanesthesia handoff, environmental factors (noise,distractions), possible equipment error, fatigue causedby scheduling, and hierarchy and communication issuesacross professions. To further illustrate the contributingfactors and their causal relationship, a fishbone diagramwas created (Figure 2). The fishbone diagram, also knownas the cause-and-effect diagram or Ishikawa diagram,CommunicationPersonnelHandoff• Incomplete information given• No standardized handoffHierarchy and communicationacross professions• Perceptor/student relationshipScheduling• Fatigue with 8-hr shifts vs. 12-hr shiftsNear miss/Air embolismEquipment• Possible equipment errorBarriers• Continuous distractions• Time pressure• NoisyPolicy• No standardized anesthesiahandoff in placeEnvironmental factorsPolicy and proceduresFigure 2. Fishbone diagram—Contributing factors of a near-miss scenario.134 Evanina and Monceaux

was used to identify the causal relationships between theoutcomes and the contributing factors of those outcomes( JCAHO, 2010).ResultsThe root cause analysis team deemed two contributingfactors as root causes: absence of standardized anesthesiahandoff and communication issues across professions.The six contributing factors were ranked based on theirpatient safety impact. Each factor was given a numberbetween 1 and 4; 1 (no impact on patient safety), 2 (mildimpact on patient safety), 3 (moderate impact on patientsafety), and 4 (strong impact on patient safety). Althoughthe system was subjective, consistent patterns were found.“Incomplete handoff information” and “hierarchy andcommunication issues across professions” were rankedthe highest. “Environmental factors” and “fatigue causedby scheduling” were ranked the lowest and therefore hadthe lowest impact on patient safety. After further discussionof the results, it was concluded that the incompletehandoff information was directly related to the absenceof a standardized anesthesia handoff and therefore wasconsidered a root cause. These findings resulted in the followingrecommendations:• Develop, validate, and implement a standardizedsystem for anesthesia handoff.• Educate anesthesia providers on the importance ofstandardizing anesthesia handoff.• Instruct anesthesia providers to use the proposedanesthesia handoff tool for any change in anesthesiaprovider such as breaks, lunches, and changes ofshift.• During departmental meetings, follow up on thehandoff tool use and encourage feedback fromanesthesia staff.• Reevaluate the tools’ benefits, consistency, andshortcomings at consistent intervals.DiscussionThe fundamental causes of the near-miss scenario werecommunication barriers and the lack of a standardizedanesthesia handoff. Hierarchy and the status of theSRNA involved in the case were particularly relevant issuesin this near-miss scenario. Sutcliffe, Lewton, andRosenthal (2004) suggest that communication failuresoften arise from status differences as well as concernswith hierarchy and with interpersonal power and conflict.The near-miss scenario occurred in part to the SRNA’svigilance and tenacity regarding an important clinicalwarning sign: the lowering of ETCO 2. The SRNA couldhave complied with the relieving CRNA’s determinationof lowering the tidal volume to increase the ETCO 2reading but opted to advocate in the patient’s care. Thesurgeon should have also communicated to the anesthesiateam about the open venous sinus that was discoveredand flooded with saline after the SRNA’s initial inquiry.The interchanges between residents, attending physicians,fellows, residents from other specialties, and other professionalstaff such as nurses each have a high potential for reinforcingdifferences in status and power of those involvedin communication and handoffs (Sutcliffe et al., 2004).Anesthesia is regarded as one of the leading specialtiesin terms of safety and might be expected to yield relevantinsights into handover practice (Gaba, 2000, p. 785).During handoff in the posterior craniotomy case, incompleteinformation was conveyed to the incoming anesthesiaprovider. Information regarding the patient must beconveyed adequately, precisely, and interactively. In addition,important information regarding case specifics suchas the ETCO 2trend, insertion of a central venous catheterin the operating room, the follow-up of a chest X-ray inthe recovery room, or problems with equipment must beconveyed during handoff communication.The importance of a standardized handoff method isparamount in patient safety. Studies involving anesthesiologists,CRNAs, SRNAs, and anesthesia departmentchairs are needed to investigate handoff communication.The diversity of handoff measurement approaches suggestsa lack of consensus about the primary purpose of ahandoff as well as the interventions that are most promisingfor improving the processes. “Recognizing there aresimultaneously multiple purposes for handoffs is a criticalprecursor to quality improvement” (Patterson & Wears,2010, p. 52).ReferencesAnwari, J. S. (2002). Forum: Quality of handover to the postanesthesiacare unit nurse. Anaesthesia, 57, 488–493.Gaba, D. (2000). Anaesthesiology as a model for patient safetyin health care. British Journal of Medicine, 91, 785–788.Joint Commission Resources. (2007). Improving hand-off communication.Oakbrook Terrace, IL: Author.Joint Commission on Accreditation of Hospital Organizations.(2007). Improving America’s hospitals: The Joint Commission’sannual report on quality and safety—2007. Retrieved fromhttp://www.jointcommission.org/Improving_Americas_Hospitals_The_Joint_Commissions_Annual_Report_on_Quality_and_Safety_-_2007/Anesthesia Handoff 135

Joint Commission on Accreditation of Hospital Organizations.(2008). The Joint Commission. Sentinel event statistics: September30, 2008. Retrieved from http://www. jointcommission.org/SentinelEvents/Statistics/Joint Commission on Accreditation of Hospital Organizations.(2010). Root cause analysis in healthcare: Tools and techniques(4th ed.). Oakbrook, IL: Joint Commission Resources.Mascioli, S., Laskowski-Jones, L., Urban, S., & Moran, S.(2009). Improving handoff communication: By improvingour process, we enhanced patient care and made handoffcommunication more effective. Nursing, 39, 52–55.Morgan, G. E., Mikhail, M. S., & Murray, M. J. (2006). Clinicalanesthesiology (4th ed.). New York, NY: McGraw-Hill.Nagpal, K., Vats, A., Lamb, B., Ashrafian, H., Sevdalis, N.,Vincent, C., & Moorthy, K. (2010). Information transferand communication in surgery: A systematic review. Annalsof Surgery, 252, 225–239.Patterson, E. S., & Wears, R. L. (2010). Patient handoffs: Standardizedand reliable measurement tools remain elusive. The JointCommission Journal on Quality and Patient Safety, 36(2), 52–61.Smith, A. F., Pope, C., Goodwin, D., & Mort, M. (2008). Interprofessionalhandover and patient safety in anaesthesia:Observational study of handovers in the recovery room.British Journal of Anaesthesia, 101, 332–337.Solet, D. J., Norvell, J. M., Rutan, G. H., & Frankel, R. M.(2005). Lost in translation: Challenges and opportunitiesin physician-to-physician communication during patienthandoffs. Academic Medicine, 8, 1094–1099.Stoelting, R. K., & Miller, R. D. (2007). Basics of anesthesia(5th ed.). Philadelphia, PA: Churchill Livingstone Elsevier.Sutcliffe, K. M., Lewton, E., & Rosenthal, M. M. (2004). Communicationfailures: An insidious contributor to medicalmishaps. Academic Medicine, 79, 186–194.Williams, P. M. (2001). Techniques for root cause analysis.BUMC Proceedings 2001, 14, 154–157.Correspondence regarding this article should be directed to NicoleL. Monceaux, RN, BSN, SRNA, Columbia University School ofNursing, 630 West 168 th Street, Suite 315, New York, NY 10032.E-mail: nm2502@columbia.edu136 Evanina and Monceaux

ETHICAL AND LEGAL ISSUESResearch Participation:A Moral Obligation?Susan Doyle-Lindrud, DNPGallo Prostate Cancer Center, New Brunswick, NJWe as a society have all benefited from past research. These benefits include immunizations, antibiotics,antihypertensive, diabetic medication, and many more. Clinical research is ongoing, looking forbetter treatments, improved technologies, and cures for diseases. Unfortunately, enrollment into theseresearch studies is often low and can become the barrier to completing the study. Why do so few peopleparticipate in trials and yet expect researchers to find cures? Should the public benefit from the latesttreatments without ever having to participate in the process? Do we have a moral obligation to participatein research or should it be left to the altruistic members of society alone? Differing views of thisargument are explored.Keywords: clinical research; moral; obligation; ethicsClinical research is our hope in finding cures for the manydiseases that exist; diseases that we may not have now butmay develop in the future. We as a society are comfortedby the fact that scientists are actively pursuing treatmentsfor these diseases, and we are aware that we personally maybenefit from research findings one day. We have alreadybenefited from previous research, which resulted in thedevelopment of vaccines and antibiotics. The question is,do we as a society feel compelled to help the scientists oftoday come up with the answers of tomorrow by participatingin a clinical study?The only way researchers can conduct a study is if theyhave willing participants. Harris (2005), in his article “ScientificResearch is a Moral Duty,” states that “We shouldnot, however, forget the powerful obligation there is toundertake, support, and participate in scientific research,particularly biomedical research, and the powerful moralimperative that underpins these obligations” (p. 242).He goes on to say that we all benefit from living in a societyand in a world in which serious scientific research iscarried out and which utilizes the benefits of past research.We have a moral obligation to participate in medicalresearch in certain specific circumstances (Harris, 2005).Barriers to Patient EnrollmentWhy do so few people actually participate in clinical trials?The Atrial Fibrillation Follow-up Investigation of RhythmManagement (AFFIRM) study sponsored by the NationalHeart, Lung and Blood Institute compared the two leadingtherapies for chronic atrial fibrillation to assess whichone offered a better outcome and less adverse events. Only55% of patients invited to enroll in the study chose to enroll(Wyse et al., 2002). A Web-based survey conducted by theCoalition of Cancer Cooperative Groups and NorthwesternUniversity among 40,000 adult cancer survivors foundthat only 10% were aware that cancer clinical trials were anoption (Comis, Colaizzi, & Miller, 2006). A second surveyconducted by Harris Interactive Inc. and cosponsored byseveral groups including the Coalition of National CancerCooperative Groups, The Cancer Research Foundationof America, and The Cancer Leadership Council and theOncology Nursing Society revealed that 75% of patientswith cancer were unaware of clinical trial opportunities, and10% of patients with cancer said they were unsure aboutclinical trials (Finn, 2000). Clearly, the public is unaware ofthe clinical trial opportunities that are available to them.Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Company 137http://dx.doi.org/10.1891/1939-2095.5.2.137

Findings from a systematic review exploring thebarriers to participation in randomized controlled trialsrevealed that preferences for a particular treatment,worry about treatment toxicity, additional procedures andappointments, inconvenience, additional expense, travel,and the issues of uncertainty kept patients from signingthe consent form. People who withdrew from one studyindicated that they felt the participants should be paid(Madsen et al., 2002; Ross et al., 1999). Additional barriersto participation in clinical trials include a low level ofunderstanding about the process of random assignmentand about the meaning of the standard treatment (Comis,Miller, Aldige, Krebs, & Stoval, 2003).Suspicions About Clinical Trial ParticipationIn addition, there are people who are suspicious of themotives of the researchers. History reveals there have beeninstances of unethical research practices that have left anindelible mark on societal attitudes. Examples includethe Nuremberg trials. Twenty-three Nazi physicians werecharged with conducting experiments on German civiliansand nationals of other countries without their consent.The experiments ranged from studying the effects ofhigh altitude, freezing, burning, or severing healthy limbsto test surgical techniques (Burt, 1996).Another example that has further increased suspicionof clinical research is the Tuskegee study of untreatedpatients with syphilis followed from 1932 to 1972, mostof whom were African Americans. This study monitoredthe natural history of syphilis, leaving the patients untreatedfor their disease even though a cure was available( Reverby, 2001). A more recent example of a clinicalstudy that created suspicion about participation in clinicaltrials was a trial of HIV-therapy during pregnancy thatincluded a placebo as the control arm conducted in developingcountries (Orentlicher, 2005).Role of Ethics ReviewIn 1964, the World Medical Association Declaration ofHelsinki developed ethical principles for medical researchinvolving human subjects. It states that it is the mission ofa physician to safeguard the health of the people. His orher knowledge and conscience are dedicated to the fulfillmentof this mission. The Declaration of Geneva of theWorld Medical Association binds the physician with thewords, “The health of my patient will be my first consideration,”and the International Code of Medical Ethicsdeclares that “a physician shall act only in the patient’sinterest when providing medical care which might havethe effect of weakening the physical and mental conditionof the patient” (The Helsinki Declaration of the WorldMedical Association, 2001).The Federal Policy for the Protection of Human Subjectsor the “Common Rule” was published in 1991 andcodified in separate regulations by fifteen federal departmentsand agencies and requires protections on humansubjects and places responsibility for protections on theInstitutional Review Board. It mandates that all researchersobtain informed consent from human subjects prior toparticipation in research. In addition, the Department ofHealth and Human Services has added additional regulationsor subparts that include protections for vulnerablepopulations defined as the mentally ill, mentally handicapped,pregnant women, fetuses, children and prisoners(US Department of Health and Human Services, 2012).The intent is to protect human research subjects from coercivepressures or harm, especially “vulnerable” populations.Vulnerable groups include the mentally ill, mentallyhandicapped, pregnant women, fetuses, children, and theprisoners. Patients should review an informed consentand sign it if they agree to participate in the study. Inaddition, the participant is free to stop participating atanytime because participation is voluntary.Informed ConsentHealth care providers conducting research need to communicateeffectively with the potential study candidateand answer all questions thoroughly so that any suspicionsmay be eliminated, and the participant is fully informed.A study by Albrecht, Blanchard, Ruckdeschel, Coovert,and Strongbow (1999) looking at physician–patient communicationfound that patients who felt that their physicianshad communicated clearly about a prospectivestudy were more likely to enroll (Albrecht et al., 1999).The ethical guidelines of the Council for InternationalOrganizations of Medical Sciences (CIOMS) state,“The physician/investigator must assure the patient thattheir decision on whether to participate will not affect thetherapeutic relationship or other benefits to which theyare entitled” (Orentlicher, 2005).Informed consent and the decision to sign one followsthe common morality principle of autonomy. Thisis a norm of respecting the decision-making capacity ofautonomous persons and is one of the principles thatguides professional ethics (Beauchamp & Childress,2001). Informed consent does not represent one momentin time. It requires a constant, ongoing exchangeof information between the researcher and the subject.138 Doyle-Lindrud

The research study and informed consent form must bereviewed by an oversight committee, the institutional reviewboard (IRB), which has reviewed the study with theaim to protect the participants. Issues addressed includewhether the study is set up to enroll a fair representationof all eligible participants, including women, minorities,and so forth, and have the risks, benefits, and costs beenadequately assessed (Beauchamp & Childress, 2001).Accrual and RetentionThe public should be aware that cures for cancer, lupus, multiplesclerosis, and the many other progressive or terminalailments cannot be achieved without society’s participation.There are countless quality research studies that have beenabandoned because of lack of accrual. With approximately3%–5% of the adult patients with cancer in the UnitedStates participating in clinical trials, individual clinical trialsstruggle to achieve the necessary patient enrollment(Murthy, Krumholz, & Gross, 2004). Approximately 38%of Cancer Therapy Evaluation Program (CTEP)–supportedoncology trials fail to attain the specified minimum accrualgoal and therefore are unable to evaluate the proposed scientifichypotheses of the study and, at the same time, consumesvaluable resources (Cheng, Dietrich, & Dilts, 2010).Moral ArgumentSociety demands that scientists find cures. If societyexpects cures, should they not agree to be a part of theprocess? John Rawls describes the principle of fairness as,when a number of persons engage in a mutuallyadvantageous cooperative venture according to rules,and this restricts their liberty in ways necessary toyield advantages for all, those who have submitted tothese restrictions have a right to similar acquiescenceon the part of those who have benefited from theirsubmission. We are not to gain from the cooperativelabors of others without doing our fair share.(Rawls, 1971, p. 96)Rosamond Rhodes in “Rethinking Research Ethics,”makes the argument that because we all may benefit fromthe research, there should be no free riders. Free riders arethose who benefit from the mutually cooperative schemeswithout contributing to the process (Allhoff, 2005; Rhodes,2005). When people volunteer to participate in researchwhere the risks and dangers are minimal, they are doingwhat any reasonable and decent person should be willing todo, both because of the overwhelming use of the researchand because they wish and expect to receive the benefits ofthe research in return (Harris, 1999). Hans Jonas describedthe benefits which one derives from society generate anobligation to contribute to the general social good. In hissocial contract, he states “We concede, as a matter of course,to the common good some pragmatically determined measureof precedence over the individual good” ( Jonas, 1969).The Belmont Report describes the protection of individualhuman subjects. On July 12, 1974, the National ResearchAct (Pub. L. No. 93-348) was signed into law, thereby creatingthe National Commission for the Protection of HumanSubjects of Biomedical and Behavioral Research. One of thecharges to the Commission was to identify the basic ethicalprinciples that should underlie the conduct of biomedicaland behavioral research involving human subjects andto develop guidelines, which should be followed to assurethat such research is conducted in accordance with thoseprinciples. The three ethical principles developed includethe following (“ Protection of Human Subjects; BelmontReport: Notice of Report for Public Comment,” 1979):1. Respect for persons: Individuals should be treatedwith respect. They should be treated as autonomousagents, and if they have diminished autonomy, theyrequire protection.2. Beneficence: Persons are treated in an ethical manner.The two general rules include (a) “do no harm”and (b) maximize possible benefits and minimizepossible harm.3. Justice: “Fairness in distribution” or “what isdeserved.”The do no harm or principle of nonmaleficence is integralto physicians’ hippocratic oath, asserting an obligationnot to inflict harm on others (Beauchamp & Childress,2001) but may be in conflict with a clinical researcherconducting a trial. The objective of the researcher is tofind a better treatment or technology. Medical researchinvolves patients accepting some risk to their own healthfor the benefit of future patients, but it is important toassure patients that the risk will be minimized is possible(Orentlicher, 2005). This may create a moral conflict forthe researcher and give rise to concerns and trust issuesfor the patient.Jonas (1969), in Philosophical Reflections on Experimentingwith Human Subjects, wrote “let us not forget thatprogress is an optional goal, not a conditional commitment.”He also wrote,Let us also remember that a slower progress in a conquestof disease would not threaten society, grievousas it is to those who have to deplore that theirparticular disease be not conquered, but that societyResearch Participation: A Moral Obligation? 139

would indeed be threatened by the erosion of thosemoral values whose loss, possibly caused by too ruthlessa pursuit of scientific progress, would make it mostdazzling triumphs not worth having.( Jonas, 1969)The question “Is research participation a moral obligation?”should initiate discussion. Wachbroit and Wasserman(2005) states, “Research participation should be seen as acivic activity, like volunteer fire fighting and neighborhoodpatrolling. Like those activities, it is a way for individuals toserve a community from which they derive benefits” (p. 49).This question should be raised in a public forum with theintent to elevate the public’s level of consciousness aboutthe topic. Methods to bring public attention to this mattermight include a large-scale campaign that would involveeducation through the media, health care providers, nonprofitadvocacy groups, patients who had participated inclinical trials, government agencies, and pharmaceuticalcompanies. To decrease barriers to participation, the demandsof the study should be kept to a minimum, consistentwith the scientific purpose of the study, and patientsshould be supported with knowledgeable staff (AmericanSociety of Clinical Oncology, 2009; Ross et al., 1999). Thiscampaign should include a discussion of the benefits thattheir participation will bring to society and potentially tothemselves. With an increased awareness of the benefits ofresearch, people may be guided by the moral principle ofbeneficence; the obligation to help those in need when thetime comes that it is possible to do so (Callahan, 2003). “Agood society is one interested in the full welfare of its citizens,supportive of all those conditions conducive to individualand communal well-being” (Callahan, 2003, p. 63).ReferencesAlbrecht, T. L., Blanchard, C., Ruckdeschel, J. C., Coovert, M.,& Strongbow, R. (1999). Strategic physician communicationand oncology clinical trials. Journal of Clinical Oncology,17(10), 3324–3332.Allhoff, F. (2005). Free-riding and research ethics. The AmericanJournal of Bioethics, 5(1), 50–51; author reply W15–58.American Society of Clinical Oncology. (2009). Enhancingclinical trial awareness and outreach. [jop.ascopubs.org]. Journal of Oncology Practice, 5(4), 206. http://dx.doi.org/10.1200/JOP.0944603Beauchamp, T. L., Childress, J. F. (2001). Principles of biomedicalethics. New York, NY: Oxford University Press.Burt, R. A. (1996). The suppressed legacy of Nuremberg.The Hastings Center Report, 26(5), 30–33.Callahan, D. (2003). What price better health? Hazards of the researchimperative. Berkeley, CA: University of California Press.Cheng, S. K., Dietrich, M. S., & Dilts, D. M. (2010). A senseof urgency: Evaluating the link between clinical trial developmenttime and the accrual performance of cancer therapyevaluation program (NCI-CTEP) sponsored studies.Clinical Cancer Research, 16(22), 5557–5563. http://dx.doi.org/10.1158/1078-0432.CCR-10-0133Comis, R. L., Colaizzi, D., & Miller, J. D. (2006). Cancer clinicaltrials (CCT) awareness and attitudes in cancer survivors[2006 ASCO Annual Meeting Proceedings Part I]. Journalof Clinical Oncology, 24(18S, Supp.), 6061.Comis, R. L., Miller, J. D., Aldige, C. R., Krebs, L., & Stoval,E. (2003). Public attitudes toward participation in cancerclinical trials. Journal of Clinical Oncology, 21(5), 830–835.Finn, R. (2000). Surveys identify barriers to participation in clinicaltrials. Journal of the National Cancer Institute, 92(19),1556–1558.Harris, J. (1999). Ethical genetic research on human subjects.Jurimetrics, 40, 77–91.Harris, J. (2005). Scientific research is a moral duty. Journal ofMedical Ethics, 31(4), 242–248.[The Helsinki Declaration of the World Medical Association].(2001). Gaceta médica de México, 137(4), 387–390.Jonas, H. (1969). Philosophical reflections on experimentingwith human subjects. Daedalus, 98, 219–247.Madsen, S. M., Mirza, M. R., Holm, S., Hilsted, K. L.,Kampmann, K., & Riis, P. (2002). Attitudes towards clinicalresearch amongst participants and nonparticipants. Journalof Internal Medicine, 251(2), 156–168.Murthy, V. H., Krumholz, H. M., & Gross, C. P. (2004).Participation in cancer clinical trials: Race-, sex-, andage-based disparities. The Journal of the American MedicalAssociation, 291(22), 2720–2726. http://dx.doi.org/10.1001/jama.291.22.2720Orentlicher, D. (2005). Making research a requirement oftreatment: Why we should sometimes let doctors pressurepatients to participate in research. The Hastings CenterReport, 35(5), 20–28.Protection of human subjects; Belmont Report: Notice ofreport for public comment. (1979). Federal Register, 44(76),23191–23197.Rawls, J. (1971). A theory of justice. Cambridge, MA: HarvardUniversity Press.Reverby, S. M. (2001). Tuskegee: Could it happen again? PostgraduateMedical Journal, 77(911), 553–554.Rhodes, R. (2005). Rethinking research ethics. The AmericanJournal of Bioetchics, 5(1), 7–28.Ross, S., Grant, A., Counsell, C., Gillespie, W., Russell, I., &Prescott, R. (1999). Barriers to participation in randomisedcontrolled trials: a systematic review. Journal of ClinicalEpidemiology, 52(12), 1143–1156.US Department of Health and Human Services, (2012). FederalPolicy for the Protection of Human Subjects (CommonRule). Retrieved from http://www.hhs.gov/ohrp/humansubjects/commonrule/index.html)140 Doyle-Lindrud

Wachbroit, R., & Wasserman, D. (2005). Research participation:Are we subject to a duty? The American Journal of Bioethics,5(1), 48–49; author reply W15–48.Wyse, D. G., Waldo, A. L., DiMarco, J. P., Domanski, M. J.,Rosenberg, Y., Schron, E. B., . . . Corley, S. D. (2002). Acomparison of rate control and rhythm control in patientswith atrial fibrillation. The New England Journal of Medicine,347(23), 1825–1833.Correspondence regarding this article should be directed to SusanDoyle-Lindrud, DNP, 617 West 168th St, New York, NY 10032.E-mail: Smd9@columbia.eduResearch Participation: A Moral Obligation? 141

GLOBAL PERSPECTIVESFrom the EditorJennifer A. Smith, MBA, MPH, DNPColumbia University School of NursingThe North American Region 14 of Sigma Theta TauInternational (STTI) Honor Society of Nursing hosteda symposium at the United Nations (UN) during Nurses’Week in May 2012. The purpose of the program was toprovide an update on the developing relationship betweenthe UN, STTI, and the nongovernmental organization(NGO) community. In particular, identification of nursingstrategies to promote the UN Millennium DevelopmentGoals (MDG) and global health initiatives wasstressed. Nurse and student members of STTI from theNew York, Connecticut and New Jersey areas participatedas a way to support the mission of the Society, which isto support the learning, knowledge, and professional developmentof nurses committed to making a difference inhealth worldwide.One of the day’s sessions was devoted to the roleof nurses in global humanitarian efforts, in particular,human trafficking. According to the UN (2000) Protocolto Prevent, Suppress and Punish Trafficking in Persons,Especially Women and Children, Supplementing the UnitedNations Convention Against Transnational OrganizedCrime (Palermo Protocol), Article 3:(a) “Trafficking in persons shall mean the recruitment,transportation, transfer, harbouring or receipt of persons,by means of the threat or use of force or otherforms of coercion, or abduction, or fraud, or deception,or the abuse of power or a position of vulnerabilityor of the giving or receiving of payments or benefitsto achieve the consent of a person having controlover another person, for the purpose of exploitation.Exploitation shall include, at a minimum, the exploitationof the prostitution of others or other forms ofsexual exploitation, forced labour or services, slaveryor practices similar to slavery, servitude or the removalof organs;(c) The recruitment, transportation, transfer,harbouring or receipt of a child for the purpose ofexploitation shall be considered ‘trafficking in persons’even if this does not involve any of the means set forthin subparagraph (a) of this article;(d) Child shall mean any person under eighteenyears of age.”The Palermo Protocol focused the global communityon this issue and stressed the need for nations to worktogether to stop human trafficking. National governmentresponses are to use prevention, prosecution, and victimprotection. According to the 2010 Trafficking in Persons(TIP) compiled by the U.S. Department of State,• “12.3 million adults and children in forced labor,bonded labor, and forced prostitution around theworld; 56% of these victims are women and girls• $32 billion annual trade for the traffickers• 4,166 successful trafficking prosecutions in 2009, a40% increase over 2008• More people are trafficked for forced labor thanfor commercial sex, which is less about duping andkidnapping people than it is about coercion of peoplewho entered a forma of service voluntarily ormigrated willingly.• Traffickers often use sexual violence as a weaponagainst women to keep them in compelled service,whether in a field, a factory, a brothel, a home, or awar zone.• Countries that have yet to convict a trafficker underlaws in compliance with the Palermo Protocol: 62• Countries without laws, policies, or regulations toprevent victims’ deportation: 104”The American Nurses Association Position Statementon the Nurse’s Role in Ethics and Human Rights: Protectingand Promoting Individual Worth, Dignity, and HumanRights in Practice Settings of June 14, 2010 states that“Human trafficking is an often hidden example ofviolating human rights. It occurs when vulnerable142 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.142

persons are exploited in sex industries or labor markets.Nurses are in a perfect position to intervene andadvocate for these victims when they encounter themin clinics, emergency rooms or community healthcenters.”Trafficking is a global health issue that all nurses mustbe aware of. The New York State Nurses Association(NYSNA; 2010), in particular, states that“Educational efforts at multiple levels of the professionbeginning with entry level programs must bedirected at increasing awareness among colleagues;advocating for the continuation of research in traffickingimpact from the local to global levels; disseminatingthe information regarding recognition cues andflags that can help identify a victim, and advocatingfor the application of these standards throughout thehealthcare environment. The Federal and State lawsadvocate for the reporting of a reasonably potentialvictim of trafficking. Access to reporting at the Nationallevel includes the National Human TraffickingResource Center (NHTRC). The NHTRC is a national,toll free hotline that operates 24 hours a dayseven days a week, 365 days a year. The NHTRC canbe reached by calling 1-888-3737-888 or emailingNHTRC@PolarisProject.org”NYSNA’s (2010) position also outlines roles for theprofessional nurse and the employer regarding trafficking.“The RN has the responsibility to:• Advocate for patients, families and significantothers who may be inadvertently involved withtraffickers;• Advocate for the rights of the patient to receiveadequate healthcare free of coercion from thetrafficker;• Advocate for the recovery and release of the traffickingvictim through the available resources;• Active participation in state and national initiativesthat research, disseminate and demonstratestandards and codes that impact governmentswho do little or nothing to prevent and prohibittrafficking;• Know the available resources or where to findsuch resources in the event of reasonable suspicionof a victim of trafficking;• Document the subjective and objective assessmentof the potential victim according to policyto ensure adequate information in collection ofevidence;• Seek continued education and competency inareas of forensic nursing and certification inareas of violence towards women, such as SexualAssault Nurses Examination.In addition to the nurse’s responsibilities, the employeris obliged to promote and establish conditionsof employment that provides nurses with the abilityto practice within acceptable standards and guidelinesassuring quality care to the public. The employer hasthe responsibility to:• Utilize existing multidisciplinary policy groupsto examine, establish or review current languagein policy and procedures related to identificationguidelines, methods for referral, access toresources, and management of information of apotential victim of trafficking to ensure the safetyof the healthcare worker, and of the patient;• Encourage collaborative efforts with local agenciesand resources to ensure proper methods forreporting suspicion of a victim, which ensurecomplete transfer of information and safety measuresfor the healthcare worker and the victim;• Provide adequate access to information regardingtrafficking to healthcare workers, and the public;• Support and promote ongoing research opportunitiesthat focus on the development of standardsfor nursing’s impact on trafficking.”As doctors of nursing practice (DNPs) in the roles ofclinicians and leaders, we must be keenly aware aboutthe pervasiveness of human trafficking in both local andglobal arenas and about our responsibilities to our profession,our collaborators and team, and our patients.ReferencesAmerican Nurses Association. (2010). The nurse’s role in ethicsand human rights: Protecting and promoting individual worth,dignity, and human rights in practice settings. Retrieved fromgm6.nursingworld.org/gm-node/337771.aspxNew York State Nurses Association. (2010). Human traffickingposition statement. Retrieved from http://www.nysna.org/practice/positions/human_trafficking.htmUnited Nations. (2000). Protocol to prevent, suppress and punishtrafficking in persons, especially women and children, supplementingthe United Nations Convention Against TransnationalOrganized Crime. Retrieved from www.uncjin.org/Documents/.../final.../convention_%20traff_eng.pdfU.S. Department of State. (2010). Fact sheet: Trafficking in persons:Ten years of partnering to combat modern slavery. Retrievedfrom http://www.state.gov/r/pa/scp/fs/2010/143115.htmFrom the Editor 143

GLOBAL PERSPECTIVESMary Johnson, DNP, ACNP-BC,Visits Norway as Fulbright Specialistin Simulation PedagogyMary P. Johnson, DNP, ACNP-BCJennifer A. Smith, DNP, MPH, MBA, NP-CColumbia University School of NursingAssistant Professor of Clinical Nursing at Columbia University School of Nursing (CUSON) MaryJohnson, DNP, ACNP-BC, was selected as a Fulbright Specialist in the host institution of Oslo andAkershus University College of Applied Sciences (HiOA). The main purpose of the project was tostrengthen and enhance collaboration between HiOA and CUSON related to simulation pedagogyand acute care practice. Falling within the mission of Columbia’s WHO Collaborating Center forAdvanced Practice Nursing, the two universities signed a Memorandum of Understanding in 2009 andhave collaborated in several areas: master’s students exchanges; faculty visits; presentations at academicconferences; and development of a multicountry network, IRIS, which focuses on opportunities forpostbaccalaureate students and faculty between the United States and Europe. The specific goal forDr. Johnson was to move beyond the level of “visits” to focus on areas of acute care nursing, simulationpedagogy, and development of common cases that can be used to compare student work and teachingmethods in both institutions. This Fulbright program also provided Dr. Johnson with a better understandingof the Norwegian health care system, hospitals, and the role of the acute care practitioner—essential information for future advisement of visiting HiOA students to the United States.Assistant Professor of Clinical Nursing at ColumbiaUniversity School of Nursing (CUSON) Mary Johnson,DNP, ACNP-BC, was selected as a Fulbright Specialistin the host institution of Oslo and Akershus UniversityCollege of Applied Sciences (HiOA). The main purposeof the project was to strengthen and enhance collaborationbetween HiOA and CUSON in the field of simulationpedagogy and acute care practice. Falling within themission of Columbia’s WHO Collaborating Center forAdvanced Practice Nursing, the two universities signeda Memorandum of Understanding in 2009 and have collaboratedin several areas: master’s students exchanges;faculty visits; presentations at academic conferences; andthe development of a multicountry network, IRIS, whichis focused on opportunities for postbaccalaureate studentsand faculty between the United States and Europe.The specific goal for Dr. Johnson was to move beyondthe level of “visits” to begin focusing on the specific areasof acute care nursing and simulation pedagogy and the developmentof common cases that can be used to comparestudent work and teaching methods in both institutions.This Fulbright program also provided Dr. Johnson with abetter understanding of the Norwegian health care system,hospitals, and the role of the acute care practitioner—essential information for future advisement of visitingHiOA students to the United States.The following is a brief description of Dr. Johnson’svisit in Oslo. During the first week in Oslo, Dr. Johnsonmet with students in the critical care specialty program atHiOA. Students entering this program must have a bachelor’sdegree in nursing and a minimum of 24 months ofrelevant work as a general nurse in an intensive care unit.144 Clinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Companyhttp://dx.doi.org/10.1891/1939-2095.5.2.144

This program is in the process of obtaining accreditationas a master’s degree program. Discussion was ongoingabout the differences in the United States and Norwegianhealth care systems as well as some of the commonissues, such as the cost of education in both countries.In Norway, students typically take time off from work togo back to school, and the cost is covered by a scholarshipfrom their place of employment. They return to their jobsafter graduating—presumably to their same department.Some supplement their income by working on weekendswhile attending school.Norwegian students were curious about malpracticelawsuits in the United States. This does not occur inNorway, so the concept of being sued by a patient and,in some cases, making health care decisions based on thepossibility of a malpractice suit, was new to them. The roleof the advanced practice registered nurse (APRN) in theUnited States was also a topic of interest for the HiOAstudents. In the United States, acute care nurse practitioners(ACNPs) have a distinctly different role from registerednurses (RNs). This is different from the Norwegiancritical care specialty program that prepares students to becritical care specialists within the traditional nursing role.One of the students attending these discussions spent2 weeks as an exchange student at CUSON in April 2012,observing nursing roles in a cardiothoracic surgical intensivecare unit and a medical intensive care unit (becauseof U.S. regulations, non–U.S. licensed students are onlypermitted to observe patient care). This student sharedher experience and her impression that the ACNPs sheobserved in the United States “write the orders, makedecisions about patient treatment and do everything aphysician does”—a truly different role than in Norway.The amount of time spent in clinical education was comparedwith the Norwegian group spending up to 40 hrper week and the CUSON students spending 2–3 daysper week (24–36 hr) in each clinical rotation and 1–2 daysof didactic classes.Dr. Johnson also met with master’s program facultymembers because an important goal of her visit was toshare information about CUSON’s ACNP curriculumand how it has developed. She explained about the overallprogram plan and the rationale for how much clinicaltime was required, core courses, and acute/critical carespecialty courses. Key to the discussion was the recentIOM report about the future of nursing and its recommendationthat the bachelor’s degree should be the entrylevel and that nurse leaders and nurses at all levels shouldwork to the full extent of their particular scope of practice.Although these Norwegian students will graduate ascritical care specialists, their role as a nurse does not fundamentallychange as it does from RN to APRN in theUnited States.A visit to Oslo Legevakt, a freestanding emergencydepartment (ED), was part of Dr. Johnson’s trip, whereshe met several graduates of HiOA’s graduate nursingprogram. The ED serves 500,000 Oslo residents and seesapproximately 300 patients per day. They now have a significantnumber of alcohol and drug intoxication cases,domestic abuse, and suicide attempts in addition to themore routine emergency room cases. There is also a large“call center,” which includes four nurses taking calls. Thenurses receive special training to triage calls and counselpatients as needed. The center received 175,000 calls in2011. Physicians were involved in only 20% of those callsbecause the nurses handle most patient calls. Telemedicineis integrated in the ED also. For example, patientscan have an EKG done, and it is sent electronically to beinterpreted by a cardiologist. As in many EDs, there is ashortage of space and staff resulting in long wait times,but the staff here is devoted to teaching the students andnew nurses and there is emphasis on discussions with thenursing students to review their clinical experiences andhow they can learn from it. There are potential collaborationpossibilities for students here.During Dr. Johnson’s second week in Oslo, she touredUllevål Hospital, where a CUSON ACNP exchange studentspent several months last year. Ullevål has a largesimulation training center with three fully equippedsimulation rooms with video and separate control rooms.They also have three separate debriefing rooms withvideo screens and white boards. There are several trainedsimulation instructors representing different hospitaldepartments, including nursing education, anesthesia,obstetrics, and critical care. All clinical instructors takethe simulation facilitators course, which is provided onsite at the hospital. Also discussed were the different rolesof the ACNP as compared with the critical care nurse.The CUSON ACNP student spent time with the intensivecare physicians and consulted and collaboratedwith them. This was a crucial component in the student’slearning of diagnosis and management skills. It was proposedthat select critical care nurses be sent from Ullevålto Columbia for a 2-week observational experience.Dr. Johnson met with a group of HiOA doctoral facultyand presented the results from her study concerningsimulation education, “Manikin versus Web-basedsimulation training for acute care nurse practitioner students.”She also explained in detail the role of the APRNin the United States. The reaction from the group wasDNP Visits Norway 145

very positive, and they were excited about the possibilityof initiating this role in Norway. It was suggested thatan NP program be started at HiOA as a research project,which would not require approval as a new program. Mostimportantly, all felt there is a need in Norway for APRNsas alternative providers. The politics of APRN practiceand potential physician resistance was broached, but Dr.Johnson stressed that her overwhelming experience withphysicians in the United States is that they are supportiveof her role and a great resource.Dr. Johnson ended her program with a visit to thesimulation manufacturer, Laerdal Medical and theStavanger Acute Medicine Foundation for Education andResearch (SAFER) simulation center where she discussedher research, including plans for continued simulationresearch by following ACNP students after graduationinto the workplace to examine the difference betweenstudents who spent a larger part of their “clinical” time insimulation versus a “live” experience and look at outcomesincluding job performance and turnover rates and lengthof orientation or mentorship needed during the first yearon the job.The simulation experts at SAFER spoke about thecircle of learning—the nucleus representing learningneeds. Circle 5 knowledge acquisition, skills proficiency,computer simulation, simulation in teams, clinical experiences,and this circle continues. They also discussed realismversus relevance: Relevance is always important butfor newer participants, realism may be more important.They may not really know what is or isn’t relevant as novices.More experienced participants may not care if theroom is set up perfectly realistically, but they will be judgingthe relevance of the content. Other topics covered includedmultidisciplinary training and the development ofa new handover protocol for emergency medical technicians(EMTs) and ED nurses. A protocol was developedthat was found to provide improved communication onan interdisciplinary level. Follow up from the study foundthat the EMTs used the protocol regularly and the nursesdid not (Aase, Søyland, & Hansen, 2010).Health care reform is occurring also in Norway, andthere are now requirements that providers follow certainprotocols to lessen preventable errors and complications.General practitioners in Norway have required simulationtraining every 5 years and includes team communication,closed loop communication, speaking up (thisinvolves training providers on how to speak up when theysee something wrong even when it is their superior whois wrong). Part of this communication is training peoplehow to use all available resources.ReferenceAase, K., Søyland E., & Hansen B. S. (2010). A standardizedpatient handover process: Perceptions and functioning. Workingon Safety, Røros SAFER (Stavanger Acute MedicineFoundation for Education and Research), University ofStavanger, Stavanger University Hospital.Correspondence regarding this article should be directed toMary P. Johnson, DNP, ACNP-BC, 617 West 168th Street,New York, NY 10032. E-mail: mpd20@mail.cumc.columbia.edu146 Johnson and Smith

COMMUNITIES OF INTERESTRAND Health Research Highlights:Malpractice Risk, byPhysician SpecialtyRAND Health is the nation’s most trusted source of publichealth policy research, with an international reputation forconducting policy-relevant research of the highest quality. Atany given time, Health’s more than 200 professionals workin more than 300 projects across the policy spectrum. Healthreveals short, user-friendly research highlights, which are intendedto disseminate research to professionals both inside andoutside the health arena.Dr. Robert Brook, the distinguished chair in health careservices at the RAND Corporation has encouraged us to includeResearch Highlights of particular relevance in our journal. Thisissue of Clinical Scholars Review features discussion of highdeductiblehealth plans. All RAND health publications andresearch highlights are available at www.rand.org/health.Despite intense interest, there have been few comprehensivestudies characterizing differences in malpractice risk,by physician specialty. This prompted researchers to analyzenational malpractice data on more than 40,000 physiciansin 24 specialties. They found large variation acrossspecialties in the frequency of claims and the amount paidon claims. The data suggest that most physicians face atleast one claim during an extended career, although mostclaims do not result in a payment to the plaintiff.IntroductionData are lacking, by medical specialty, on the share ofphysicians who face malpractice claims and the size ofpayments and cumulative incidence of such claims. Previousstudies used older data with limited geographiccoverage, relied on self-reports from limited samples withlow response rates, or lacked information on physicianspecialty or payment size.To understand malpractice risk by specialty, AnupamB. Jena, Seth Seabury, Darius Lakdawalla, and AmitabhChandra analyzed data from 1991 through 2005 for nearly41,000 physicians covered by a large nationwide liabilityinsurer. The data included at least 200 physicians in each of24 specialties, allowing analysis of malpractice risk, by specialty.(Those in a specialty with fewer than 200 physicianswere grouped in a 25th, “other specialties,” category.)Malpractice ClaimsAcross specialties, 7.4% of physicians annually had aclaim, and 1.6% made an indemnity payment. Amongphysicians in neurosurgery, 19.1% annually faced a claimbut just 2.6% in psychiatry did (Figure 1). Physician’s age,year, and state of practice did not affect these estimates.Specialties with higher proportions of claims do notalways incur higher proportions of payments. For example,gynecology had the 12th highest average annual shareof physicians with a claim but the highest share with apayment.Indemnity PaymentsAcross specialties, the mean indemnity payment was$274,887, and the median was $111,749 (Figure 2). Specialtiesmost likely to face indemnity claims were notalways those with the highest average payments. Thedifference between mean and median reflects a skeweddistribution toward large payments in some specialties.Obstetrics and gynecology accounted for the most paymentsof at least $1 million, followed by pathology, anesthesiology,and pediatrics.Career Malpractice RiskMost physicians can expect to face at least one malpracticeclaim over a 30-year career. By 45 years of age, 36% ofphysicians in low-risk specialties are likely to have had atleast one malpractice claim, compared to 88% of those inhigh-risk categories. By this same age, just 5% in low-riskspecialties and 33% in high-risk ones are likely to haveClinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Company 147http://dx.doi.org/10.1891/1939-2095.5.2.147

NeurosurgeryThoracic-cardiovascular surgeryGeneral surgeryOrthopedic surgeryPlastic surgeryGastroenterologyObstetrics and gynecologyUrologyPulmonary medicineOncologyCardiologyGynecologyNeurologyInternal medicineEmergency medicineAll PhysiciansAnesthesiologyDiagnostic radiologyOpthalmologyNephrologyPathologyDermatologyFamily general practiceOther specialtiesPediatricsClaim with payment to a plaintiffAny claimPsychiatry0 5 10 15 20Physicians with a malpractice claim annually (%)Figure 1. Proportion of physicians facing a malpractice claim annually according to specialty. Copyright Massachusetts Medical Society.Reprinted with permission.148 RAND Health Research Highlights

NeurosurgeryNeurologyInternal medicinePulmonary medicineGeneral surgeryPathologyPediatricsObstetrics and gynecologyThoracic-cardiovascular surgeryCardiologyFamily general practiceAll PhysiciansOrthopedic surgeryOpthalmologyDiagnostic radiologyGastroenterologyAnesthesiologyGynecologyEmergency medicineUrologyPlastic surgeryPsychiatryOther specialtiesMedianMeanDermatology0 100 200 300 400 500 600Payments to plaintiff ($ in thousands)Figure 2. Amount of malpractice payments according to specialty. Payments are shown in 2008 dollars. Specialties that had fewer than30 payments (i.e., oncology and nephrology) are not listed. Copyright Massachusetts Medical Society. Reprinted with permission.RAND Health Research Highlights 149

made at least one indemnity payment. By 65 years of age,75% of physicians in low-risk specialties and 99% of thosein high-risk ones are likely to have had at least one malpracticeclaim, and 19% of those in low-risk specialtiesand 71% of those in high-risk ones are likely to have hadat least one indemnity payment.Findings and ImplicationsThese results confirm malpractice rates in many highriskspecialties found in earlier research based on selfreporting.The results indicate higher malpractice ratesthan previously reported in low-risk specialties, possiblybecause of the stigma of a claim in these fields. The resultsalso indicate that many will never have to make anindemnity payment. Nevertheless, the risk of a claim, thepossibility of a claim leading to a payment, and the size ofa payment contribute to high levels of perceived malpracticerisk among U.S. physicians.Acknowledgments. This research brief describes work supportedby the RAND Institute for Civil Justice and RAND Healthdocumented in “Malpractice Risk According to Physician Specialty”by Anupam B. Jena, Seth Seabury, Darius Lakdawalla,and Amitabh Chandra, The New England Journal of Medicine,Vol. 365, No. 7, August 18, 2011, pp. 629–636 (available athttp://www.nejm.org/doi/full/10.1056/NEJMsa1012370).This research brief was written by Clifford Grammich.RAND Health, a division of the RAND Corporation, isthe nation’s largest independent health policy research program,with a broad research portfolio that focuses on quality, costs, andhealth services delivery among other topics.Abstracts of all RAND Health publications and full text ofmany research documents can be found on the RAND HealthWebsite at www.rand.org/health. The RAND Corporation isa nonprofit research organization providing objectives analysisand effective solutions that address the challenges facing thepublic and private sectors around the world. RAND Publicationsdo not necessarily reflect the opinion of its research clientsand sponsors. RAND is a registered trademark.150 RAND Health Research Highlights

COMMUNITIES OF INTERESTReflective Response: MalpracticeRisk, by Physician SpecialtyCourtney Reinisch, DNP, FNP-BC, DCCRutgers University College of Nursing, New JerseyThe RAND brief on malpractice risk for physiciansadvises that most physicians will face one claim in anextended career (Grammich, 2011). Although, mostclaims do not result in payment to a plaintiff, the risk ofa claim, the possibility of a claim leading to a payment,and the size of a payment contribute to high levels of perceivedmalpractice risk among U.S. physicians (Anupam,Seabury, Lakdawalla, & Chandra, 2011).Although the RAND brief focuses on physicians byspeciality, concern regarding risk is not unique to physicians.Health care providers in various settings and specialtiesassume risk on a daily basis while providing careto patients. Health care institutions, hospitals, long-termcare facilities, nurses, dentists, and therapists take on riskto provide care. Data collection of claims is compiled fromgovernment, military, private, and public institutions.Information regarding the numbers and types ofclaims are recorded in the National Practitioner DataBank (NPDB). The NPDB was created by the HealthCare Quality Improvement Act of 1986 (HCQIA), TitleIV of Pub. L. No. 99-660. It was amended and implementedin 1990. The NPDB is overseen by the HealthResources and Services Administration (HRSA), Bureauof Health Professions (BHPr), Division of PractitionerData Banks (DPDB; U.S. Department of Health andHuman Services [USDHHS], 2010).The Data Bank’s original purpose was to collect anddisseminate information about physicians and dentists toprevent incompetent or unprofessional practitioners frommoving from one jurisdiction to another without disclosureor discovery of the physician’s or dentist’s previousdamaging or incompetent performance. The Data Bankwas to promote professional peer review activities. Theoverall goal was to improve patient safety and quality ofcare (USDHHS, 2010).In 2010, Section 1921 of the Social Security Act, asamended by Section 5(b) of the Medicare and MedicaidPatient and Program Protection Act of 1987 and asamended by the Omnibus Budget Reconciliation Actof 1990 (Section 1921) was enacted. This resulted inexpanded reporting on adverse licensing actions takenagainst all health care practitioners, not just physiciansand dentists. Any negative action or finding that a statelicensing authority, a peer review organization, or a privateaccreditation entity finalized against a health carepractitioner or entity must be reported. Licensing reportsfrom 1996 forward are to be migrated from the HealthcareIntegrity and Protection Data Bank (HIPDB) to theNPDB ( USDHHS, 2010).With the implementation of Section 1921, the NPDBprotects beneficiaries participating in the Social SecurityAct’s health care programs from unfit health carepractitioners. In addition, the NPDB sought to improve theanti fraud provisions of these programs. The NPDB annualreports are published on the Data Bank Website at http://www.npdb-hipdb.hrsa.gov/AnnualReport. The reports areavailable to the general public (USDHHS, 2010).The reports provide the numbers and types of claimslevied against a provider, institution, or organization.Reports are separated into malpractice and adverse actions.Adverse actions include effects on state licensure,clinical privileges, and professional society membership,exclusion from Medicare or Medicaid and DEA.The adverse actions reporting increased to 85% of allthe reports in 2010, whereas malpractice claims decreasedto 15% of claims. More than 75,000 adverse actions werereported in 2010, with a little more than 40,000 actuallytaking place in that year. More than 24,000 of thosereported adverse actions were made against nurses orparaprofessional nurses. Seven thousand five hundredClinical Scholars Review, Volume 5, Number 2, 2012 © Springer Publishing Company 151http://dx.doi.org/10.1891/1939-2095.5.2.151

adverse actions were reported against physicians anddentists (USDHHS, 2010).In 2010, there were more than 10,100 malpracticereports filed against physicians. Dentists accounted foralmost 1,600 malpractice reports, and other practitionersaccounted for approximately 1,500 malpractice reportsin 2010 (USDHHS, 2010). Other practitioners are notclearly defined. Advance practice nurses, nurse midwives,nurse anesthetists, and others may be included in the1,500 reports. This number accounts for 11% of the totalmalpractice reports for the year 2010.The CNA Healthpro survey reveals an increase ofclaims against CNA-insured nurse practitioners during1998–2008. CNA reports 1,799 claims brought againstover the 10-year period with 707 being open or closedcases with payment. The specialties with the most frequentlyreported claims are adult/geriatrics, family, andneonatal, respectively. Neonatal claims have the highestpayout although for a low number of closed cases. The outpatientoffice is the most frequent location for claims tobe made. Wrongful death is the most frequently claimedinjury. The most frequent diagnosis for a wrongful deathcause is infection, sepsis, and abscess. Diagnosis-relatedcomplaints account for almost 40% of all claims (CAN& NSO, 2009). Some of the data from this report arenot surprising. It would make sense to have the greatestnumber of claims against adult/geriatric nurse practitioners(NPs) as they account for the largest number of NPs.In addition, the outpatient medical office is the most typicalplace of employment for NPs.Risk is a concern for all health care providers. Whatthese reports fail to explain is the personal cost to theindividual provider. When a claim is brought, unfortunately,a patient or family has experienced an adverseoutcome for which they seek justice. There has been painand suffering. In the case of the provider, the pain andsuffering may just begin. Depositions, time loss from work,time away from friends and family, legal consultation feesare all sources of stress. As providers in all areas of healthcare, we must work to minimize risk by maintaining clearcommunication with patients, clear documentation, peerreview, and acknowledgement when something does notgo as planned. The empathetic, ethical, and prudent providerwill help minimize risk and costs to patients andthe health care system as a whole. Preparation of advancepractice nurses with the doctor of nursing practice degreeand an emphasis on culturally competent, ethical, andprudent care may control risk faced by these providers.ReferencesAnupam, B. J., Seabury, S., Lakdawalla, D., & Chandra, A.(2011). Malpractice risk according to physician specialty.The New England Journal of Medicine, 365(7), 629–636.Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1012370CNA & Nurses Service Organization. (2009). Understanding nursepractitioner liability: CNA Healthpro nurse practitioner claimsanalysis 1998–2008. Risk management strategies and highlightsof the 2009 NSO survey. Retrieved form http://www.nso.com/pdfs/db/Nurse_Practitioner_Claim_Study_02-12-10.pdf?fileName5Nurse_Practitioner_Claim_Study_02-12-10.pdf&folder5pdfs/db&isLiveStr5YGrammich, C. (2011). Malpractice risk, by physician specialty[RAND Institute for Civil Justice and RAND HealthResearch]. Retrieved from http://www.rand.org/content/dam/rand/pubs/research_briefs/2011/RAND_RB9610.pdfU.S. Department of Health and Human Services. (2010).National practitioner data bank annual report. Retrieved fromhttp://www.npdb-hipdb.hrsa.govCorrespondence regarding this article should be directed toCourtney Reinisch, DNP, FNP-BC, DCC, Rutgers University,College of Nursing, 180 University Ave., Newark, NJ 07102.E-mail: courtney.reinisch@rutgers.edu152 Reinisch