Antibiotic‐resistant bacteria, especially multidrug‐resistant strains, play a key role in impeding critical patients from survival and recovery. The effectiveness of the empiric use of antibiotics in the circling manner in intensive care units (ICUs) has not been analyzed in detail and remains controversial. Therefore, this systematic review and meta‐analysis were conducted to evaluate antibiotic‐cycling effect on the incidence of antibiotic‐resistant bacteria.
We searched PubMed, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science for studies focusing on whether a cycling strategy of empiric use of antibiotics could curb the prevalence of antibiotic‐resistant bacteria in ICUs. The major outcomes were risk ratios (RRs) of antibiotic‐resistant infections or colonization per 1,000 patient days before and after the implementation of antibiotic cycling. A random‐effects model was adopted to estimate results in consideration of clinical heterogeneity among studies. The registration number of the meta‐analysis is CRD42018094464.
Twelve studies, involving 2,261 episodes of resistant infections or colonization and 160,129 patient days, were included in the final analysis. Based on the available evidence, the antibiotic‐cycling strategy did not reduce the overall incidence of infections or colonization with resistant bacteria (RR = 0.823, 95% CI 0.655–1.035, p = .095). In subgroup analyses, the cycling strategy cut down the incidence of resistant bacteria more significantly than baseline period (p = .028) but showed no difference in comparison with mixing strategy (p = .758).
Although the cycling strategy performed better than relatively free usage of antibiotics in the baseline period on reducing resistant bacteria, the cycling strategy did not show advantage when compared with the mixing strategy in subgroup analyses. In addition, these viewpoints still need more evidence to confirm.
Implementation of evidence‐based practice (EBP) is necessary for healthcare systems to improve quality, safety, patient outcomes, and costs. Yet, EBP competency is lacking in many nurses and clinicians across the country.
The purpose of this initiative was to determine whether nursing teams (Executive Leader, Clinical/Mid‐level Leader, and Direct Care Nurse) attending a 5‐day EBP continuing education skill‐building program (immersion) was an effective strategy to build EBP competence, practice, and culture sustainability over time. The Advancing Research and Clinical Practice Through Close Collaboration Model was used to guide this initiative.
A project team was assembled, including leaders with EBP expertise from the Air Force Medical Service and The Helene Fuld Health Trust National Institute for EBP in Nursing and Healthcare at The Ohio State University. Five survey instruments were used to evaluate outcomes, including Organizational Culture and Readiness for System‐Wide Implementation of Evidence‐Based Practice, Evidence‐Based Practice Beliefs, Evidence‐Based Practice Implementation, and Evidence‐Based Practice Competencies, as well as the Knowledge Assessment Questionnaire test. Nursing teams were invited to participate and complete the program with the implementation of EBP projects over the following year.
Participants’ EBP knowledge, skills, competencies, and beliefs were significantly improved and sustained over 12 months.
A team‐based EBP skill‐building program was an effective strategy for building EBP competence, practice, and culture. This initiative demonstrated that the direct involvement of leadership and infrastructure to support EBP were crucial factors for building and sustaining an EBP culture.
Critical care nurses are in the best position to detect and monitor delirium in critically ill patients. Therefore, an optimum delirium assessment tool with strong evidence should be identified with critical care nurses to perform in the daily assessment.
To evaluate and compare the diagnostic performance of delirium assessment tools in diagnosing delirium in critically ill patients.
We searched five electronic databases including the Cochrane Library, PubMed, Embase, CINAHL, and a Chinese database for eligible diagnostic studies published in English or Mandarin up to December 2018. This diagnostic test accuracy meta‐analysis was limited to studies in intensive care unit (ICU) settings, using the Diagnostic and Statistical Manual of Mental Disorders (DSM) as a standard reference to test the accuracy of delirium assessment tools. Eligible studies were critically appraised by two investigators independently. The summary of evidence was conducted for pooling and comparing diagnostic accuracy by a bivariate random effects meta‐analysis model. The pooled sensitivities and specificities, summary receiver operating characteristic curve (sROC), the area under the curve (AUC), and diagnostic odds ratio (DOR) were calculated and plotted. The possibility of publication bias was assessed by Deeks’ funnel plot.
We identified and evaluated 23 and 8 articles focused on CAM‐ICU and ICDSC, respectively. The summary sensitivities of 0.85 and 0.87, and summary specificities of 0.95 and 0.91 were found for CAM‐ICU and ICDSC, respectively. The AUC of the CAM‐ICU was 0.96 (95% CI, 0.94–0.98), with DOR at 99 (95% CI, 55–177). The AUC of the ICDSC was 0.95 (95% CI, 0.92–0.96), and the DOR was 65 (95% CI, 27–153).
CAM‐ICU demonstrated higher diagnostic test accuracy and is recommended as the optimal delirium assessment tool. However, the results should be interpreted with caution due to the between‐study heterogeneity of this diagnostic test accuracy meta‐analysis.
eHealth educational programs have proven to be an effective means for health promotion, yet limited studies have been conducted for coronary heart disease (CHD) patients to improve their total physical exercise, self‐efficacy for exercise, and cardiovascular risk factor profile.
A prospective randomized controlled trial (RCT) was conducted in two cardiac clinics in Hong Kong. Four hundred thirty‐eight eligible CHD clients were randomly assigned to either the control or the intervention group. All of the participants received standard care, which consisted of regular medical and nursing care in the cardiac clinic. The intervention group received an additional web‐based educational support intervention (eHES), which consisted of a 20‐minute individual educational session on the use of the eHES web link. The eHES web link contains a health information platform related to CHD care and an individual member area with records of health measures and physical exercise data for six months. Data were collected at baseline, at three‐month and six‐month intervals at the cardiac clinic. The primary outcome was the total amount of physical exercise, measured by the Godin–Shephard Leisure‐Time Physical Activity Questionnaire. The secondary outcomes were self‐efficacy for exercise and cardiovascular disease (CVD) risk markers (body weight, blood pressure, lipid profile). The data were analyzed using a generalized estimating equations model.
The intervention group reported a statistically higher amount of physical exercise and a higher HDL‐C at 3 and 6 months, respectively. There were no statistical differences between the groups in self‐efficacy for exercise and other CVD risk markers.
The study demonstrated the effectiveness of the eHES in meeting the challenge of boosting the amount of physical exercise and increase HDL‐C among CHD patients who engaged for over three months. The results provide insight for eHealth development to support and promote exercise among CHD patients in the community.
Apathy is one of the behavioral and psychological symptoms of dementia (BPSD), which is the most frequent and can accelerate the progress of dementia.
To systematically review the evidence of effectiveness of non‐pharmacological interventions on apathy in patients with dementia.
Databases including the Cochrane Library, Joanna Briggs Institute (JBI) Library, PubMed, EMBASE, CINAHL, PsycINFO, Psychology and Behavioral Sciences Collection, CNKI, and Wan Fang Data were searched for systematic reviews of the effectiveness of non‐pharmacological interventions on apathy in patients with dementia. AMSTAR 2 was applied to assess the methodological quality of reviews.
Nine systematic reviews were included. The average level of overall confidence for included systematic reviews was low. Among all the non‐pharmacological interventions involved in this review, the effectiveness of multisensory stimulation, music therapy, cognitive stimulation, and pet therapy was relatively robust. The effects of reminiscence therapy, therapeutic conversation, progressive muscle relaxation, art therapy, exercise therapy, occupational therapy, dementia special care units, nursing staff education, and comprehensive interventions need to be validated further. Meanwhile, the current evidence failed to support the effects of psychomotor therapy and validation therapy on apathy.
Non‐pharmacological interventions for apathy in patients with dementia are acceptable. In spite of requirements for adequate and high‐quality original studies and quantitative systematic reviews to validate the efficacy of non‐pharmacological interventions, multisensory stimulation, music therapy, cognitive stimulation, and pet therapy are deemed the most helpful according to evidences available.
The capacity for self‐care and positive mental health (PMH) has an influence on well‐being and on one’s approach to chronic illness.
The aim was to determine the level of PMH and self‐care agency as well as the relations among sociodemographic variables, PMH, and the level of self‐care among patients with chronic physical health problems. We also examined correlations between PMH and self‐care agency.
A descriptive, cross‐sectional correlational study was conducted with a sample of 209 patients at a primary care center. The instruments used were the Positive Mental Health Questionnaire and the Appraisal of Self‐Care Agency scale. The STROBE statement was used.
Significant differences were found in the PMH factors in relation to sociodemographic variables and health conditions. Suffering one or more chronic diseases was associated negatively, and significantly, with the capacity for self‐care. The four most prevalent chronic health problems in the sample were hypertension, hypercholesterolemia, obesity, and diabetes mellitus.
In people with chronic physical health problems, there is a positive relationship between PMH and self‐care capacity. An increase in the possibility of caring for oneself saw an increase in PMH; conversely, an increase in PMH brought with it an increased capacity for self‐care as well. Therefore, if actions are taken to increase PMH, the capacity for self‐care will also increase.
Obesity is an important public health problem, particularly among middle‐aged women. Type D personality, characterized by negative affectivity and social inhibition, is prevalent among obese and overweight middle‐aged women and has been linked to maladaptive health‐related behaviors and unhealthy lifestyle. Lifestyle interventions based on type D personality could be a first step in combatting obesity in middle‐aged women.
To identify the effects of a lifestyle intervention based on type D personality on health‐promoting lifestyle behaviors, psychological distress, type D personality, and body composition in overweight and obese middle‐aged women.
A total of 36 overweight and obese middle‐aged women participated in a quasi‐experimental design using a non‐equivalent control group pretest‐posttest. The experimental group received a total of eight sessions of a lifestyle intervention program based on type D personality over the course of four weeks. Outcomes were measured health‐promoting lifestyle behaviors, psychological distress, type D personality, and body composition (body weight, body mass index, body fat, and abdominal fat).
Following the intervention, the experimental group scored significantly higher than the control group for health‐promoting lifestyle behaviors, and significantly lower than the control group for psychological distress and type D personality. Body weight and body mass index decreased significantly in the experimental group compared to the control group.
Further research on various intervention programs for overweight and obese middle‐aged women is warranted, including lifestyle interventions based on type D personality.
Datum from electronic sources has accumulated and resulted in the establishment of big data and data science. Big data consists of data sets that are larger than traditional data processing applications can manage. Data science is the research method used to analyze big data. Researchers are applying research methods to harness large and complex data sets to increase our understanding of population health by creating predictive models of patients using a variety of key variables or characteristics. Evidence‐based practice relies on the appraisal of research to ensure rigor prior to implementation in clinical settings. Consistent with other research methods, papers based on data science should be subject to appraisal for determination of best evidence. The purpose of this paper is to present a tool that can be used to appraise research papers based on large data sets and data science research methods.
The following approach was used to develop the Data Science Appraisal Tool (DSAT). Despite an exhaustive search, we were unable to locate an appraisal tool for papers based on data science research methods. We then synthesized the extant literature to form the tool. The tool is based on the common characteristics of big data: (a) verification that the data set is representative of big data; (b) preparation of the data for analysis; (c) methodology used for data analysis; (d) results; and (e) theoretically based.
Appraisal tools currently exist for traditional and well‐known research methods. The DSAT provides a method to appraise papers based in data science for best evidence.
Nurses are in key positions in the healthcare system to provide, monitor, and manage the care delivered to their patients. In 2005, the Quality and Safety Education for Nurses (QSEN) initiative was launched to redefine quality and safety competencies for pre‐licensure nursing education. It is imperative that nurses are graduating with the full spectrum of the QSEN competencies to practice in today’s healthcare environments.
The purpose of this systematic review was to evaluate the research about student nurses’ perceptions of their abilities to perform the six QSEN competencies and to determine the effect of integrating the QSEN content in their courses, clinical placements, or simulation experiences.
A systematic review of the literature was conducted to retrieve published studies from CINAHL, PubMed, Web of Science, and ERIC using the search terms of Quality and Safety Education for Nurses, QSEN, QSEN competencies, nursing student, and student nurse. The studies that were included in this review were assessed by both authors independently using standardized critical appraisal tools.
Seven studies met the inclusion criteria: four descriptive, one quasi‐experimental, and two mixed‐methods designs. Overall, pre‐licensure nursing students perceived patient‐centered care as the most discussed and quality improvement as the competency least reviewed in their curricula. Students reported to be most prepared to perform patient‐centered care skills and least prepared to perform quality improvement skills.
Revisiting the integration of the quality improvement competency into nursing curricula can increase nursing students’ understanding of this QSEN competency. More research with sufficiently powered sample sizes, valid and reliable tools measuring outcomes of interventional studies, and attention to quality and rigor is needed to assess graduating students’ understanding of the QSEN competencies.
Safe health care of good quality depends on structured and unceasing efforts to progress, promoting strategies tailored to the context, including elements such as patients’ preferences. Although patient participation is a common concept in health care, there is yet limited understanding of the factors that facilitate and hinder it in a healthcare context.
This paper identifies what patients and health professionals depict in terms of enablers and barriers for patient participation in dialysis care.
An explorative qualitative design was applied with seven focus group discussions with patients, staff, and managers across different types of hospitals, with the texts analyzed with content analysis.
The dialysis context represents three key elements—people, resources, and interactions—that can both enable and hinder patient participation. Both barriers and facilitators for patient participation were found to reside at individual, team, and organizational levels, with a greater number of enabling factors implied by both patients and staff.
While the dialysis context comprises opportunities for progress in favor of patient participation, a shared understanding of the concept is needed, along with how contextual factors can facilitate conditions for participation by patient preferences. In addition, the most favorable strategy for implementing person‐centered care is not yet known, but to facilitate patient participation from a patient perspective, creating opportunities to enable staff and patients to share a common understanding is needed, along with tools to facilitate a dialogue on patient participation.
The uptake of evidence‐based knowledge in practice is influenced by context. Observations are suggested as a valuable but under‐used approach in implementation research for gaining a holistic understanding of contexts.
The aim of this paper is to demonstrate how data from observations can provide insights about context and evidence use in implementation research.
Data were collected over 24 months in a randomised trial with an embedded realist evaluation in 24 nursing homes across four European countries; notes from 183 observations (representing 335 hours) were triangulated with interview transcripts and context survey data (from 357 staff interviews and 725 questionnaire responses, respectively).
Although there were similarities in several elements of context within survey, interview and observation data, the observations provided additional features of the implementation context. In particular, observations demonstrated if and how the resources (staffing and supplies) and leadership (formal and informal, teamwork, and professional autonomy) affected knowledge use and implementation. Further, the observations illuminated the influence of standards and the physical nursing environment on evidence‐based practice, and the dynamic interaction between different aspects of context.
Although qualitative observations are resource‐intensive, they add value when used with other data collection methods, further enlightening the understanding of the implementation context and how evidence use and sharing are influenced by context elements. Observations can enhance an understanding of the context, evidence use and knowledge‐sharing triad in implementation research.
New registered nurses (RNs) are at risk of developing symptoms of stress‐related ill health.
To evaluate the effect of a 3 × 3 hour group intervention aiming to prevent symptoms of stress‐related ill health among new RNs by increasing engagement in proactive behaviors. The intervention involves discussions and models of newcomer experiences and stress and the behavior change techniques reinforcing approach behaviors, systematic exposure, and action planning.
A randomized parallel group trial with an active control condition.
The study sample consisted of 239 new RNs participating in a transition‐to‐practice program for new RNs in a large county in Sweden.
Participants were randomized to either the experimental intervention or a control intervention. Data on experiences of stress, avoidance of proactive behaviors, engagement in leisure activities, role clarity, task mastery, and social acceptance were collected before and after the intervention. Effects were evaluated using multilevel model analysis and regression analysis. Missing data were imputed using multiple imputation.
The control group experienced a statistically significant increase in experiences of stress during the period of the study (t(194.13) = 1.98, p = .049), whereas the level in the experimental group remained stable. Greater adherence to the intervention predicted a greater effect on experiences of stress (β = −0.15, p = .039) and social acceptance (β = 0.16, p = .027).
Transition‐to‐practice programs may benefit from adding an intervention that specifically addresses new RNs’ experiences of stress to further support them as they adjust to their new professional role. However, replication studies with larger samples, more reliable measures, and longer periods of follow‐up are needed.
Burnout is a substantial phenomenon across healthcare settings, affecting more than half of healthcare professionals and leading to negative patient and health system outcomes. Infusion center professionals (ICPs) are at increased risk of burnout attributed to high patient volume and acuity levels. Strategies to address burnout have been developed and prioritized by the American Medical Association (AMA), the World Health Organization, and other organizations.
This quality improvement project aimed to address perceived burnout, job‐related stress, and job satisfaction among nurses, physician assistants, and medical assistants at a large pediatric hospital through integration of two infusion center (IC)‐based staff engagement interventions.
A pre‐ and post‐test study design was used. Existing team huddles in the IC were modified based on the AMA STEPS Forward program recommendations to incorporate appreciative inquiry and recognition into team and department events. Peer recognition was tailored toward institutional core values. The Mini‐Z Burnout survey was administered before and 3 months after implementation of both interventions.
Pre‐ to post‐intervention responses revealed a higher percentage of staff reporting no burnout (57.7% vs. 75%), low levels of job‐related stress (58.8% vs. 65.5%), and satisfaction with current job (70.6% vs. 82.8%). Most participants agreed or strongly agreed that structured huddles (69%) and recognition events (82.8%) were beneficial and recommended continuation (65.5% and 82.8%, respectively). Open‐ended responses regarding workplace stressors focused heavily on staffing and patient acuity.
Project outcomes support the integration of tailored interventions to reduce burnout among pediatric ICPs. Organizational commitment to addressing burnout can provide incentive to scale up institution‐wide staff engagement interventions. Further study is needed to assess the efficiency and effectiveness of such tailored interventions across diverse settings.
There is increased acknowledgment of the importance of knowledge translation (KT) in the role of graduate‐prepared healthcare practitioners, such as nurses, as change agents in the mobilization of evidence‐based knowledge. The offering of flexible educational programming online and hybrid course delivery in higher education is a response to insufficient didactic methods for providing graduate students with the competencies to facilitate KT.
To describe the development, implementation, and evaluation of a cohort‐based, online, innovative KT curriculum using a theoretical approach to KT called the Knowledge‐As‐Action Framework, which focuses on the knower, knowledge, and context as being inseparable. This process strategically engages with stakeholders to link practice concerns with existing realities, thus providing the best available knowledge to inform KT action in complex healthcare contexts.
The Model of Evidence‐Informed, Context‐Relevant, Unified Curriculum Development in Nursing Education guided the cohort‐based online KT course process. The development, implementation, and evaluation involved (a) an environmental scan, (b) a literature review, (c) faculty development, (d) curriculum design of two 10‐week courses, and (e) a summation of the concurrent participatory evaluation of the two courses, including faculty and student responses. The Knowledge‐As‐Action Framework is comprised of six interrelated dimensions as part of a “kite” metaphor, with the underlying premise that if any one of the dimensions results in an imbalance, the KT process may be grounded.
Evaluation revealed (a) intentionality of the core processes of curriculum work; (b) effectiveness of indicators for evaluating the KT courses; (c) leadership should be added as a learning domain for KT; (d) the Knowledge‐As‐Action Framework provided an integrated, philosophical, and evidence‐based approach to KT; (e) cohort model facilitated a community of inquiry; and (f) the formalized structured approach of the courses with ongoing supervision and mentoring allowed for timely completion.
Teaching and learning in an online cohort model created a community of inquiry and facilitated experiential learning. The active engagement of students with their practice‐based stakeholders promoted change in clinical settings and enhanced students’ professional development to lead change.
Reflective practice affects all levels of nursing, including students, as well as practicing nurses. Self‐reflective practice is a widespread concept in nursing; however, few empirical studies have demonstrated the possible effects of such a practice. The purpose of this integrative literature review was to identify evidence of the effects of self‐reflective practice on baccalaureate‐level nursing students, especially stress.
The literature search was conducted utilizing CINAHL and PubMed databases. The inclusion criteria were studies published between 2013 and 2018, articles that were peer‐reviewed, written in English, and focused on nursing education of baccalaureate programs only. A total of 15 articles were reviewed.
There is limited but growing evidence to suggest self‐reflective practices have positive effects on baccalaureate‐level nursing students. The self‐reflective practices decreased stress and anxiety and increased learning, competency, and self‐awareness of nursing practice. While written reflections were most commonly used in the studies, other forms of reflection, such as verbal and photography, were effective as well.
Nursing students can benefit from incorporating reflection into the didactic and clinical settings. Nursing faculty are encouraged to integrate reflection into the nursing curriculum. Nurses within the first year of practice could benefit from using reflective practice as well. Experienced nurses and nurse managers can encourage and mentor novice nurses on the use and benefits of reflective practice.