Projects of current and past Certificate students

Nurses' Beliefs about Caring for Patients with Traumatic Brain Injury

Oyesanya TO, Thomas MA, Brown RL, Turkstra LS

Patients with traumatic brain injury (TBI) and their families rely on health care providers, particularly nurses, to provide accurate information, yet inaccurate beliefs about TBI have been found among nurses. Although prior studies have assessed nurses' beliefs about TBI recovery and rehabilitation, none have assessed specific beliefs about the nursing role to care for these patients. The purpose of this study was to investigate nurses' beliefs and learning preferences about caring for patients with moderate-to-severe TBI. A cross-sectional survey was administered to 513 nurses at a Midwestern hospital between October and December 2014 (20.3% response rate). Latent class analysis was used. Findings showed that nurses had inaccurate beliefs about TBI relating to recovery and the nursing role, and had significant differences in learning preferences. These findings have implications for development of educational and training interventions specific to nurses to ensure that they have factual information about TBI and to clarify the nursing role.

Telephone interpreter discrepancies: videotapes of Hmong medication consultations

Maichou Lora and Betty Chewning

Background. Over 25 million people in the USA have limited English proficiency (LEP). Interpreters are often used to facilitate communication with health care providers. Little is currently known about interpreter quality.

Objective. To explore the quality of telephone interpretation during medication consultations between Hmong clients and their pharmacists.

Methods. This descriptive study analyzed transcripts from videos of consultations between six triads of Hmong patients, pharmacy students and interpreters. Analysis was divided into two segments: (1) pharmacy: communication from student pharmacist the interpreter to patient and (2) patient: communication from patient to interpreter to student pharmacist. Researchers coded transcripts separately then compared codes.

Key findings. The six encounters yielded 496 communications with 275 discrepancies including omissions, additions, and word substitutions. Pharmacy to patient communications included, 45% (118/262) of omissions, 27.5% (72/262) of substitutions, and 15.6% (41/262) of additions. The patient to provider communications included, 8.1% (19/234) of omissions, 6.0% (14/234) of substitutions, and 4.2% (10/ 234) of word additions. Some omissions, additions, and substitutions in the pharmacy to patient communications were classified as potentially clinically relevant. Significantly, substantial discrepancies between the student pharmacists’ comments and the interpretation to patients had potential for hindering relationship building between patients and their providers.

Factors associated with the use of appropriate venous thromboembolism prophylaxis

In more than ten percent of deaths among hospitalized patients, venous thromboembolism (VTE) has been implicated as a contributing factor. The Agency for Healthcare Research and Quality (AHRQ) recommended appropriate VTE prophylaxis (AVP) as the single greatest intervention that can improve the safety of hospitalized patients. However, the use of AVP is surprisingly low. In partnership with physicians, pharmacists, and nurses at a community hospital, we analyzed electronic health records to find whether demographic, clinical, admission, and hospital course characteristics might influence the use of AVP interventions.

How nurses decide to ambulate hospitalized older adults: Development of a conceptual model

Adults over the age of 65 years account for 60% of all hospital admissions and experience consequential negative outcomes directly related to hospitalization. Negative outcomes include falls, delirium, loss in ability to perform basic activities of daily living, and new walking dependence. New walking dependence, defined as the loss in ability to walk independently, occurs in 16%--59% of hospitalized older patients. Nurses are pivotal in promoting functional walking independence in hospitalized patients. However, little is known about how nurses make decisions about whether, when, and how to ambulate older patients. A qualitative study using grounded dimensional analysis was conducted to further explore how nurses make decisions about ambulating hospitalized older adults. Twenty-five registered nurses participated in in-depth interviews lasting 30--60 min. Open, axial, and selective coding was used during the analysis. A conceptual model, which is grounded in how nurses experience ambulating patients, was developed. Multiple categories and dimensions interact and produce an action by the nurse to either restrict mobilization to the level of the bed or progress the patient to ambulation in the hallway. Factors that seemed to have a greater impact on nurses' decisions on whether, when, and how to ambulate were the risk/opportunity assessment, preventing complications, and the presence of a unit expectation to ambulate patients.

Protective Factors in American Indian Communities to Reduce Adolescent Violence

With their distinct cultural heritage and rural boundaries, American Indian reservation communities offer a unique opportunity to explore protective factors that help buffer adolescents from potential risk behaviors such as violence. Prior work on Indian communities has not explored three potential protective factors for violence—parental monitoring of adolescents and friends, adolescents’ self-efficacy to avoid fighting, and adolescents’ interest in learning more about their traditional culture. My project explores the relationship between these factors and reduced risk of reported violence by working together with the Indian community. Based on my data from 630 American Indian students, there were significant gender differences both in perceived parental monitoring and in adolescents’ self-efficacy. For female adolescents, parental monitoring had the strongest inverse relationship with female adolescents’ involvement in violence. Female adolescents’ self-efficacy and their interest in learning more about their culture were also inversely associated with violence and therefore potentially important protectors. Male adolescents who reported more interest in learning the tribe’s culture had better self-efficacy to avoid violence. However, self-efficacy did not successfully predict their reported involvement in peer violence. These findings support exploring gender differences, parental monitoring, self-efficacy training as well as cultural elements in future violence intervention studies.

Predictors of colorectal cancer screening variation among primary care providers and clinics

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths for both men and women in the United States, claiming nearly 50,000 lives each year. If optimally employed, available CRC screening modalities have the potential to significantly reduce CRC mortality. Screening is underutilized despite the variety of screening tools available, existing evidence on the effectiveness of these tools, and recommendations from multiple professional societies supporting CRC screening. To effect change, we must understand reasons for underuse at multiple levels of the healthcare system. We evaluated patient, provider, and clinic factors that predict variation in CRC screening among primary care clinics and primary care providers (PCPs).

We analyzed electronic medical record (EMR) data for 34,319 adults eligible for CRC screening, 19 clinics, and 97 PCPs in UW Health. Detailed data on potential patient, provider, and clinic predictors of CRC screening were obtained from the EMR. PCP perceptions of CRC screening barriers was measured via survey. The outcome was completion of CRC screening at the patient level. Logistic regression with clustering on clinics obtained adjusted odds ratios and 95% confidence intervals for potential predictors of CRC screening at each level. Seventy-one percent of patients completed CRC screening. Variation in screening rates was seen among clinics (51-80%) and between PCPs (51-82%). Significant predictors of incomplete screening were identified at all levels: patient (younger age, non-white race, being single, non-English primary language, Medicare or Medicaid insurance coverage versus commercial plans, and presence of congestive heart failure and diabetes), provider (smaller panel size of patients eligible for CRC screening), and clinic (physician-owned, greater distance from nearest optical colonoscopy center).

In conclusion, we found that variation in CRC screening exists among primary care clinics and providers within a single clinic and that predictors of variation can be identified at the patient, provider, and clinic levels. Quality improvement interventions addressing CRC screening need to be directed at multiple levels of the healthcare system.

Translating Nonpharmacologic Interventions for Behavioral Symptoms into Practice: Expert Opinions on Barriers, Facilitators and New Approaches for Long-Term Care

Behavioral symptoms affect nearly all people with dementia. They cause enormous patient suffering and include actions that disrupt care and safety, such as wandering, physical and verbal aggression, and refusing treatment. Long-term care (LTC) residents with dementia are at increased risk for experiencing behavioral symptoms as a result of prolonged under-stimulation, isolation and loneliness. Best practice recommendations highlight the utilization of nonpharmacologic approaches as the first line therapy for responding to BSD. Most nonpharmacologic interventions (NPI) for behavioral symptoms are carried out by providers and hinge on the capacity of an intervention to motivate change in provider behavior. Several unique needs and limitations of LTC settings (e.g. inadequate staffing, high turnover rates that often exceed 100% annually, low reimbursement rates, heavy staff workloads, low levels of advanced-degree nurses and other staff) limit providers’ capacity to implement effective NPI for behavioral symptoms, exacerbating an already substantial gap between best evidence and actual practice. Research also suggests that LTC settings are slow to innovate and may require different incentives to motivate adoption of evidence-based practice.

There is a growing body of evidence on faciltiators and barriers to provider behavior change. Yet , the relevance of these factors for facilitating provider implementation of NPI in LTC has not been examined. To inform future translational research efforts, we conducted a review of barriers to NPI in LTC. Based on critical appraisal of reseach-based strategies for changing provider behavior, we generated a list of barriers and potential facilitators to translation of NPI into practice. A Delphi survey was conducted with LTC clinicians to establish agreement on barriers/facilitators to translation. Our paper (forthcoming) will report findings from the Delphi survey and proposes research, practice and policy recommendations for accelerating the adoption of effective NPI into LTC practice.

These findings have also guided the development of a local research-practice-policy collaborative, the South-Central Wisconsin Long Term Care Partnership. The goal of the Partnership is to effect local change in long-term care quality by engaging policy partners, practitioners, researchers and educators in a collaborative networking community that sets the stage for successful research and practice improvement initiatives.

Pending microbiology cultures at hospital discharge and post-hospital outcomes in patients discharged to sub-acute care

Each year, more than 20% of Medicare patients are re-hospitalized within 30 days, costing over $17 billion. Pneumonia, septicemia, and urinary tract infections are common healthcare-associated infections, and are in the top 10 reasons for re-hospitalizations in these patients. Microbiology cultures are key tools used to detect infections, and >27% of general medicine and sub-acute care patients are discharged from the hospital with a pending blood, urine, or sputum culture. Whether there is a link between pending microbiology cultures at hospital discharge and re-hospitalization, emergency department (ED) visits, or death within 30 days, remains unknown.

We retrospectively analyzed electronic medical record and laboratory information system data for 773 stroke, hip fracture, and cancer patients discharged from a single large academic medical center to sub-acute care in 2003-2008. Multinomial logistic regression models were used to examine the relationship between pending cultures and death, re-hospitalization, or ED visit. ll models controlled for patient sociodemographics and patient medical history, allowing for adjusted odds ratios and 95% confidence intervals to be presented.

Patients with preliminary results available at discharge for their pending culture had greater odds (1.8) of being re-hospitalized or visiting the ED for an infection within 30 days as compared to those with no pending culture. Patients with normal final culture results returning after discharge had greater odds (2.0) of dying within 30 days as compared to those with no pending culture.

In conclusion, pending microbiology cultures at hospital discharge may be related to poor post-hospital patient outcomes, and represent a targeted area for improvement in communication and follow-up.

An educational module on advance directives for nurses

My Type 2 Translational Research Certificate project is the development of an educational module on advance directives for nurses. This project was the result of research I had done on advance directives with an ethicist at a hospital in Milwaukee. While presenting our findings of the research to a nursing committee at the hospital, the committee requested education for nurses on advance directives. This module will be developed collaboratively and will provide a direct benefit to the hospital.