Predictors of patient outcomes following interactions with nurses

A research and theory-based model was used to identify outcome predictors of hospitalized patients' perceptions of caring and support by nurses. The model tested the effects of cogent personal characteristics of patients (general level of self-esteem and need for control while hospitalized) on their perceptions of humanistic caring and support from nurses and, in turn, considered the effect of these variables on situational appraisal, coping strategies, psychological distress, and coping effectiveness. The 120 hospitalized adult patients indicated that the moderate amount of humanistic caring they received was beneficial. Several factors influenced caring ratings. Higher positive ratings were received from younger patients; however, people with low self-esteem and those desiring more control over their care or reporting a high degree of pain tended to perceive more threat and psychological distress as a results of their encounters with nurses. Following positive caring experiences with nurses, patients with higher self-esteem levels reported effective coping. Overall, positive caring experiences, along with coping strategies and decreased psychological distress levels, explained 40% of the variance of hospitalized patients' ability to cope effectively following their encounters with nurses.     

Do clinical and formal assessments of the capacity of patients in the intensive care unit to make decisions agree?

BACKGROUND: The complex environment and technology of intensive care unit (ICU) care may impair the ability of patients to participate in medical decision making or give informed consent. We studied the agreement of the intuitive assessments of residents and nurses of ICU patients' cognition, judgment, and decision-making capacity, and whether those assessments agreed with abbreviated formal mental status testing. METHODS: Using a prospective survey case study, we assessed 200 English-speaking patients within 24 hours of their ICU admission. Formal assessment of cognition, judgment, and insight was performed by a research assistant. We obtained independent intuitive ratings by nurses and residents of patient cognition, judgment, and ability to participate in medical decision making or give informed consent. RESULTS: Residents' and nurses' assessment of cognition and judgment showed a high degree of agreement with weighted ks of greater than 0.76. Assessments of cognition by residents and nurses agreed with Folstein Mini-Mental State Examination in 70% and 73.6% of cases, respectively. Forty percent of the population had an unimpaired Mini-Mental State Examination score of greater than 23, and an additional 12% of the subjects were mildly impaired with scores of 20 to 23. When asked whether they would approach patient or family for consent for an invasive procedure, nurses and physicians said they would request informed consent from 66% and 62% of the patients, respectively. CONCLUSIONS: Residents and nurses caring for patients newly admitted to the ICU agree in their assessment of cognition, judgment, and capacity to participate in medical decision making, and are not unduly influenced by ventilator status. Their assessments correlate highly with abbreviated formal mental status testing.     

Residual cognitive dysfunctioning at 6 months following coronary artery bypass graft surgery

Neuropsychological testing is a sensitive method for quantitative assessment of cognitive dysfunctioning following cardiopulmonary bypass (CPB). However, the methodological problems associated with this method, such as learning effects due to repeated testing and the effects of distress on test performance, have often been underestimated. In this study, these confounding effects were controlled for by including the spouses of patients, exposed to the same potential stress effects associated with the operation, as a nonsurgical control group. The experimental group consisted of 63 patients (40-75 years) undergoing elective coronary artery bypass graft (CABG) surgery. A battery of standardized neuropsychological tests was administered to both groups 2 weeks preoperatively and 1 week, 1 month, and 6 months postoperatively. Statistical testing of inter-group differences in preoperative to postoperative changes in test performance revealed the following results: (1) For immediate memory and learning, in general test scores showed the same time course for both groups. (2) For recent memory, patients' scores showed a significant deterioration at 1 month after CABG surgery compared with the scores of spouses. This effect had not completely disappeared at 6 months postoperatively. (3) For attention and psychomotor speed as well as verbal fluency, patients' scores had deteriorated significantly at 1 week after surgery, with incomplete recovery at 6 months. These negative cognitive effects were not related to the patients' ages or CPB parameters (duration of CPB, aortic cross-clamp time, mean flow and arterial pressure during CPB and aortic cross-clamping, and minimum nasopharyngeal temperature). No differences in self-ratings of mood over time were found between the patients and spouses. The results indicate that, when adequately controlling for the effects of learning and distress, some cognitive functions are still impaired at 6 months after CABG surgery.     

Increasing the reliability and validity of pain intensity measurement in chronic pain patients

This study examined the effects of increasing the number of assessments on the reliability and validity of measures of average pain intensity. Two hundred chronic pain patients completed 2 weeks of hourly pain ratings. A series of regression analyses were performed, and test-retest stability, internal consistency and validity coefficients were computed to address 4 questions. (1) Are chronic pain patients' reports of pain similar from one day to another? (2) What is the reliability and validity of a single rating of pain intensity when used as an indicant of average pain? (3) How many assessments (data points) are required to obtain estimates of average pain intensity with adequate to excellent psychometric properties? (4) How important is it to sample pain from different days? The results were consistent with predictions based on patients' self-reports of their pain and on psychometric theory. First, the majority of patients did not report similar levels of pain from one day to another, and average pain scores calculated from ratings obtained from a single day were less stable than those calculated from ratings obtained from multiple days. Also, and as expected, the results indicate that a single rating of pain intensity is not adequately reliable or valid as a measure of average pain. However, a composite pain intensity score calculated from an average of 12 ratings across 4 days demonstrated adequate reliability and excellent validity as a measure of the average pain in this sample of chronic pain patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Staff perceptions of emotional distress in paitents with burn trauma.

Objective: To compare staff and patient perceptions of patients' emotional distress after acute burn trauma. Design: Staff ratings of patients' psychological states on 6 dimensions of emotional functioning were compared with patient self-report. Results: Staff as a whole and by discipline tended to overestimate depression and underestimate optimism in patients. Moreover, the more experienced (more than 2 years of burn care experience) nurses and occupational/physical therapists were less accurate in estimating depression and optimism than their less experienced counterparts. Conclusion: Consistent with results from spinal cord injury research, findings from the current study indicate a distinct tendency on the part of burn care staff to overestimate their patients' emotional distress and underestimate their positive outlook, supporting the notion that staff may be imposing a "requirement for mourning" on their patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A team approach to geriatric case management

Monash Medical Centre, a large major hospital in Melbourne Australia, recently opened a high dependency unit (HDU) at its Moorabbin campus. The present study was designed to examine two patient groups admitted to the unit after major and non-major surgical procedures. Another aim in the study was to describe the services required by these patients and to compare the two groups with regard to length of stay in the HDU, severity of illness, and pain control. The results of this study indicate that the HDU provided a valuable and needed service to a population of patients who have been identified as at risk of postoperative complications. The findings appear to agree with other research which suggests that nurses consistently rate patients' pain as less severe than patients' own ratings of pain indicate. Thus nurses appear to overestimate patients' perception of pain control. This study again indicates that even though it is generally recognised by nurses that patients are in pain the management of it is such that pain continues to be inadequately controlled.     

Perceptions of symptom distress in lung cancer patients: I. Congruence between patients and primary family caregivers

Part I of this two-part paper employs a comparative design to compare primary family caregivers' assessments of lung cancer patients' symptom distress with patients' own perceptions of symptom distress in the home setting. Part II describes the results of the qualitative component of this research. A convenience sample of 37 patient-family caregiver dyads completed the McCorkle and Young Symptom Distress Scale (SDS). Family caregivers' global scores were moderately correlated with patients' global scores (r = 0.71; P < 0.001). No significant differences in ratings were found for ten of the 13 symptoms assessed. Therefore, when the patient is unable to provide a self-report of symptom distress, health-care professionals may seriously consider family caregivers' assessments of patients' symptom distress to be reasonable estimates for at least ten of the 13 symptoms on the SDS.     

Presurgery Distress and Specific Response Expectancies Predict Postsurgery Outcomes in Surgery Patients Confronting Breast Cancer.

Prior to scheduled surgery, patients frequently experience particularly high levels of distress and expect a variety of postsurgery symptoms. Surgery patients who confront breast cancer are no exception. It has been suggested that such presurgery distress and response expectancies are predictive of postsurgery outcomes. To test the contribution of presurgery distress and expectancies to common postsurgery symptom outcomes (pain, nausea, fatigue, and discomfort), 63 female patients undergoing breast cancer surgery were recruited to a prospective study. Results indicated that presurgery distress uniquely contributed to patients' postsurgery nausea, fatigue, and discomfort; specific expectancies uniquely contributed to pain intensity, pain unpleasantness, and fatigue (ps     

Categorizing pain in patients seen in a veterans health administration hospital: Pain as the fifth vital sign.

Previous research has supported the concept of classifying pain intensity into distinct categories (of mild, moderate, and severe) based on the effects of pain on functioning. Such categories, however, have not been studied in samples of veterans. The current study sought to validate the concept of pain intensity classification in a sample of veterans with mixed types of chronic pain. There were 632 veterans referred to a pain program and asked to complete a packet of questionnaires that included a 0 to 10 measure of pain intensity and measures of pain-related interference, depressive symptomatology, and disability. The results indicated that the veterans' ratings of pain at its worst could be classified into the categories of mild, moderate, and severe, with cutpoints of a maximum rating of 3 for mild and 7 for moderate pain. The findings suggest that pain treatment studies of veterans with diverse types of chronic pain should include ratings of pain intensity at its worst that can be reliably classified as mild, moderate, or severe and related to other important outcomes such as daily function and mood. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychosocial predictors of children's postoperative pain

The purpose of this study was to investigate the influence of psychosocial variables in the prediction of children's pain intensity following surgery. Forty-two children, ages 7 to 17 years (M = 12.26, SD = 3.06), completed an interview 1 week prior to surgery assessing anticipatory distress related to their forthcoming surgery and history of coping strategy use. Following surgery, children reported the intensity of their pain using visual analog scales. Findings demonstrated that the majority of children experienced moderate to severe postoperative pain. Hierarchical multiple regression analyses revealed that psychosocial variables added to the prediction of children's postoperative pain after controlling for the influence of surgery-related and demographic variables. These findings lend initial support for the inclusion of psychosocial assessment measures (e.g., anticipatory surgery distress) in the preoperative assessment of pediatric patients who may be at risk for excessive postsurgical pain.     

Patient education for discharge after coronary bypass surgery in the 1990s: are patients adequately prepared?

Short hospitalizations for patients undergoing coronary artery bypass grafting (CABG) require continuous nursing evaluation of patients' discharge education. Six institutions collaborated in surveying 300 postoperative patients with CABG to identify learning priorities and patients' perceptions of the effectiveness of discharge education. Data analysis from the self-administered questionnaire demonstrated consistent patient priorities across institutions. Differences in teaching methods and content did not affect perceived preparedness or importance scores. Regional experience demonstrates that variable teaching efforts meet patients' priorities and provide high overall patient preparedness for discharge. Patients with the shortest hospitalizations had higher preparedness scores.     

Effectiveness of structured nursing assessment of symptom distress in advanced lung cancer

PURPOSE/OBJECTIVES: To test the efficacy of structured symptom assessment on level and rate of change in symptom distress over time. DESIGN: Prospective six-month randomized control trial. SETTING: Outpatient oncology offices and clinics in California. SAMPLE: 48 subjects newly diagnosed with advanced lung cancer, predominantly non-small cell. Most subjects received chemotherapy, 50% were women, and their average age was 62 years. 190 observations were analyzed. METHODS: Subjects were assigned randomly to structured assessment or usual care. Both groups completed the Symptom Distress Scale (SDS) monthly. After bivariate screening of potential predictors, a multivariate regression model for level and rate of change in SDS scores was created. MAIN RESEARCH VARIABLES: Symptom distress, functional status, and emotional distress. FINDINGS: Fatigue was the most common severely distressing symptom. In a multivariate model, chemotherapy and systematic assessment were associated with less symptom distress over time. Higher scores in depression and more functional limitations were related to higher levels of overall distress. Weight loss had a small impact. CONCLUSIONS: Systematic use of structured symptom assessment forestalled increased symptom distress over time. Chemotherapy lessened symptom distress, but the impact diminished with time. Subjects with more depression and greater functional limitations had greater symptom distress. IMPLICATIONS FOR NURSING PRACTICE: During the course of advanced lung cancer, systematic ongoing nursing assessment of symptoms may be the first step in enhancing interventions to decrease distress. Patients at highest risk for symptom distress are those who experience emotional distress and functional limitations.     

Psychological recovery from coronary artery bypass graft surgery: the use of complementary therapies

This study explored the use of complementary therapies that patients pursued after coronary artery bypass graft (CABG) surgery and its relation to psychological recovery, particularly postoperative distress. Information about post-CABG Surgery depression and general distress, health-care practice thereafter, perceived social support, and chronic conditions other than cardiac disease was gathered from a sample of 151 patients through two questionnaires. Additional cardiac, surgical, and demographic data were obtained from medical records. Structural equation modeling (LISREL 8) was used to test the hypothesis that patients' health-care practices improved psychological adjustment after CABG. Of the sample, 85% practiced complementary approaches, especially prayer, exercise, and lifestyle-diet modification. The number of the other chronic illnesses strongly predicted post-CABG depression and general distress. CABG patients who pursued complementary approaches, particularly exercise and prayer, had better psychological recovery.     

Cognitive-behavioral and pharmacologic interventions for childrens' distress during painful medical procedures.

This study evaluated the efficacy of a cognitive–behavioral intervention package and a low-risk pharmacologic intervention (oral Valium), as compared with a minimal treatment-attention control condition, in reducing children's distress during bone marrow aspirations. The subjects were 56 leukemia patients who ranged in age from 3 years to 13 years. The three intervention conditions were delivered in a randomized sequence within a repeated-measures counterbalanced design. Dependent outcome measures included observed behavioral distress scores, self-reported pain scores, pulse rate, and blood pressure scores. Repeated-measures analyses of variance indicated that children in the cognitive-behavior therapy condition had significantly lower behavioral distress, lower pain ratings, and lower pulse rates than when they were in the attention-control condition. When children were in the Valium condition, they exhibited no significant differences from the attention control condition except that they had lower diastolic blood pressure scores. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nutrition, tissue oxygenation, and healing of venous leg ulcers

Little research has examined the healing and pain associated with saphenous vein (SV) harvest incisions, and no literature has addressed the associated distress and cosmetic result. The purpose of this study was to determine whether dry sterile gauze dressings, transparent film dressings or no dressings were more effective in hospitalized patients undergoing coronary artery bypass graft (CABG), in terms of minimizing leg incisional pain, minimizing the distress of a leg scar and improving the cosmetic appearance of the leg incision scar. Patients were randomized to dressing type on postoperative day (POD) 1, completed a pain and distress visual analogue scale (VAS) on PODs 1, 3 and 5, and a cosmetic result VAS upon discharge. Overall, leg incisional pain decreased over time (p < 0.05). Females reported decreasing pain between PODs 1 and 3, while males reported increasing pain between PODs 1 and 3 (p < 0.05). The film-dressing group reported decreasing pain from PODs 1 to 3, while the no-dressing and gauze-dressing groups reported increasing pain from PODs 1 to 3 (p < 0.05). Pain on POD 5 was positively correlated with an unfavorable cosmetic result (r = 0.42, p < 0.05), and distress on POD 5 was positively correlated with an unfavorable cosmetic result (r = 0.44, p < 0.05). The results of this study are encouraging and support the continued testing of dressings to minimize pain and distress, as well as enhancing cosmetic result.     

Effects of relationship maintenance on psychological distress and dyadic adjustment among couples coping with lung cancer.

Objective: Relationship maintenance strategies help to ensure the continuation of valued relationships by keeping them at a certain level of intimacy. This study evaluated how lung cancer patients' and spouses' efforts to maintain their relationships affected their psychological and marital adjustment over time. Design: Psychosocial questionnaires were administered within 1 month of lung cancer treatment initiation (baseline) and 3 and 6 months later to 158 lung cancer patients and their spouses. Main Outcome Measures: Study outcomes were global severity index scores on the Brief Symptom Inventory, and total scores on the Dyadic Adjustment Scale. Results: Multilevel modeling analyses using the Actor-Partner Interdependence Model showed that, regardless of gender or social role (i.e., patient or spouse), individuals who engaged in the strategies of positivity, networks, and shared tasks reported less distress at baseline than other participants. Over time, the effects of providing more assurances and experiencing a partner's increased reliance on social networks differed: patient distress was exacerbated, and spouse distress was alleviated. Couples where both partners engaged in more frequent maintenance behaviors reported greater dyadic adjustment at baseline and over time. Conclusion: For couples coping with lung cancer, the initial treatment period may be an important time that sets the tone for future spousal interactions. Engaging in relationship maintenance during this stressful time may help mold more resilient relationships and facilitate adjustment as the disease progresses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Perception of causes of omissions in the assessment of patients with chest pain

There is growing evidence that errors and omissions often occur in the nursing assessment and care of patients. As yet, the impact of audit has been insufficient to correct these deficiencies, possibly because audit does not primarily focus on the causes of deficiencies. The purpose of this study was to examine the perceived causes of omissions in the assessment of patients with chest pain and to compare these with omissions detected in an audit of the assessment records. The type of attributions nurses used to explain the causes of the omissions was also investigated. Following an audit of the assessment records of patients with chest pain, 88 nurses were invited to answer a 51-item questionnaire relating to the types of omissions which occurred in the assessment of patients with chest pain. The results showed a marked discrepancy between the frequency of reported omissions and those found in the assessment records. The most common causes of omissions reported by the nurses were patients' condition, work overload, lack of time, poor assessment documentation, not realizing that the assessment had not been fully carried out and different nurses being involved in the assessment of patients. Nurses overwhelmingly attributed the causes of omissions to external or environmental factors rather than internal ones such as lack of knowledge or fatigue, which have implications for the types of strategies that might be used to improve care.