The Effect of an Advance Practice Nurse-Modulated Computer-Based Education on Nursing Staff Knowledge of Delirium

Juliana M. Mwose, MSN, RN, ACNS-BC, Valparaiso University

Purpose: The purpose of this study will be to assess nurses' basic knowledge about delirium and to determine the effect of a computer-based, educational intervention provided by an advance practice nurse on nurses' knowledge about delirium.

Literature/Evidence Reviewed: Acute delirium is associated with poor patient outcomes such as increased mortality, functional decline, and increased length of hospital stay. Nurses spend the greatest amount of time at the patient's bedside and are therefore a vital component in delirium recognition. Early recognition of delirium provides a greater opportunity to identify causes and potential interventions.

Practice Innovation/Intervention: This project will involve a pretest and posttest of all consenting nurses on a geriatric unit, to measure the effectiveness of a computer-based, advance practice nurse-modulated educational intervention to improve nurse's identification of delirium in an acute geriatric care setting. The pretest will include a 20-item test, followed by a PowerPoint presentation and a posttest using the same 20-item tool.

Implementation Strategies/Key Stakeholders: Prior to the educational intervention, participants will be provided with 1 joint 15-minute session of orientation and explanation about the project. This first session will take place on the unit during a staff meeting. For the nurses who cannot make it to a staff meeting, the doctor of nursing practice student will arrange to meet with them to explain the project objectives and activities. Informed consents will be explained and obtained. At the beginning of the self-study module, participants will be asked to take an online pretest on delirium information. The tool was designed based on information from 4 clinical practice guidelines on delirium accessed through National Guideline Clearinghouse and an agency of the US Department of Health and Human Resources and Quality. The pretest will be used to assist nurses to see their areas of strength and weakness and help them focus their learning using the educational modules provided by the doctor of nursing practice student. A posttest will be given immediately after the study module to assess for increased knowledge about delirium.

Method of Evaluation: Measurement of the impact of the educational intervention on nursing staff knowledge of delirium will consist of analysis and comparisons of the pretest and posttests using the SPSS 14.0 statistical package. Descriptive statistics and frequencies will be used to describe the nurses' demographic characteristics. Paired t tests will provide comparisons of pretest and posttests on the module. Bivariate correlations of certain demographic characteristics and pretests will provide additional data.

Findings: The hypothesis of this project is that providing nurses working in a geriatric acute care setting with structured education about delirium will increase their knowledge about delirium.

Implications: Literature review on nurses' identification of delirium demonstrates that an opportunity exists to educate nurses about delirium. Nursing is a specialty that requires additional knowledge and skills beyond what they learn in nursing school. This project may be significant in contributing to the body of nurse's knowledge and improving patient outcomes.

Development, Implementation, and Management of an Intranet Nursing Portal to Streamline Delivery of Current, New, and Changing Information That Impacts Nursing Practice

Vicky Keys, MSN, RN-BC, PeaceHealth St John Medical Center

Purpose: To streamline delivery and improve accessibility to information impacting nursing practice through the design, implementation, and management of a centralized nursing portal within the hospital intranet.

Significance: To provide evidence-based care, be aware of facility changes and educational opportunities, and to understand the impact of healthcare reform on practice, nurses need centralized information that is accessible, current, and compatible with workflow.

Design/Background Rationale: Three separate unit-based Web pages were used to deliver information to the staff. The responsibility of Web page ownership was ill-defined. The posted information was sporadic, inconsistent, and frequently outdated. There was no centralized location for staff meeting minutes, unit updates, or employee achievements. There was no defined communication plan for hospital-wide committee members to inform staff about issues of concern.

Methods: FOCUS-PDCA Quality Improvement Model was used. The ambiguity of Web page ownership and the inconsistent, delayed, and disorganized delivery of information were identified as the problem. To identify existing processes of communication, a flowchart was created. The process by which nurse liaisons from hospital committees informed staff of decisions related to their units/practice was also evaluated. Communication gaps between committees and staff were identified. Inconsistencies with Web page ownership and how the Web pages were used to inform were also identified. Providing 1 centralized Web page to replace the multiple unit-based Web pages was selected as the project. The goal of the Web page was to provide current information related to policy, equipment, practice changes, health information changes, unit news, patient resources, education/certification information, and staff achievements. The Web page was planned based on interviews with staff and leadership to determine the most relevant topics and sources. A process of providing information to the educator/clinical nurse specialist for posting on the Web page was defined. Staff was notified of the upcoming discontinuation of existing Web pages through the hospital newsletter and staff meetings. The system change eliminating the Web pages was implemented. An electronic scavenger hunt designed to familiarize staff with the layout of the Web page and locate any information gaps was forwarded to staff via hospital e-mail.

Outcomes: Initial anecdotal feedback has been positive. Surveys have been sent to nursing staff to evaluate their knowledge of the Web site, frequency in which they review, and their perception of practice relevance. Surveys to leadership included queries about the content and frequency of posting. The results of the surveys are pending.

Conclusions: A clinical nurse specialist is uniquely prepared to oversee the development, implementation, and management of a centralized nursing portal. Providing current patient and nursing resources to improve patient care and leading the system change to create a Web page and eliminate existing Web pages demonstrate influence in all 3 domains.

Implications: A centralized nursing portal streamlines information flow, reduces change to practice gaps, avoids replication of work, and is a better use of resources.

A Heart Failure Cross-setting Handoff Tool

Diane Nanno, BS, RN, College of Nursing, Upstate Medical University

Purpose: The purpose of this project is to optimize outcomes for heart failure (HF) patients across settings.

Significance: According to the American Heart Association, HF affects 5.7 million people in the United States annually and results in approximately 300 000 deaths each year. Heart failure is the most common reason for hospital admission, and HF patients are the most frequent population to be readmitted within 30 days.

Background: Heart failure patients are often discharged from acute care to certified home health agencies. Patients discharged to a certified home health agency have the highest 30-day readmission rate of all discharged patients. This may be due to lack of a clear clinical handoff to the receiving agency, resulting in the flawed assumption that the patient may have deteriorated, putting the patient at risk for unnecessary emergency department visits and readmissions. Beginning in 2012, the Centers for Medicare & Medicaid Services will reduce reimbursement for HF patients readmitted within 30 days of hospital discharge.

Description and Approach: A literature review was performed using several evidenced-based databases to find the best evidence. Poor transition from acute care to homecare puts patients at risk for readmission. An HF handoff tool was developed to communicate crucial clinical information essential to a smooth handoff. The handoff tool was designed to address the gaps in transition of care from hospital to home, "painting a clear clinical picture" of the patient at discharge. Hospital-based and homecare nurses were educated regarding background and use of the handoff tool.

Outcomes: Outcomes pending completion of project, which will occur prior to conference.

Conclusions: Collaboration through use of the HF handoff tool is an effective way to communicate essential clinical information across settings and can reduce 30-day hospital readmissions for patients discharged to homecare.

Implications: Improving the transition across settings will improve care, patient satisfaction, and ultimately reduce 30-day hospital readmissions. The clinical nurse specialist, as clinical leader and change agent, is in a unique position to improve the handoff across settings, influencing improvement across spheres. Future research is needed to develop handoffs to additional settings and diagnoses.

Perioperative Clinical Nurse Specialist Optimizing Outcomes

Rosemary Marshall, BS, RN, CPAN, CNS Student, College of Nursing, Upstate Medical University

Purpose: The purpose of this poster presentation is to demonstrate how a clinical nurse specialist (CNS) can be effectively utilized in the perioperative arena.

Significance: The perioperative continuum begins preoperatively upon admission extending into the operative stage with final transference into the postsurgical period. Within each of these 3 phases, patients have varying degrees of vulnerability. Potential complications include, but are not limited to, wrong-site surgery, pressure ulcer formation, hemodynamic instability, surgical site infection, respiratory decompensation, and death.

Background: This CNS student was within a teaching hospital that was not her established place of employment. Therefore, a need to prove competency was essential. Through the integration of surgical patient care across the continuum through the 3 spheres of influence, she was able to demonstrate her clinical knowledge as a professional leader.

Approach: In the perioperative environment, the CNS student effectively navigated through the complex surgical healthcare system. By means of collaborating, advocating, mentoring, consulting, researching, educating, and role modeling, key stakeholders came to rely on the student.

Outcome: This student performed numerous literature searches to obtain evidence-based practices; one such search was for central line placement. Management recruited the CNS's help with projects assigned to their unit such as with deep vein thrombosis prevention and when is the most efficacious time to administer flu shots to the surgical outpatient. The CNS helped with data collection on hover mats and stretcher usage. Educator competencies were applied on a daily basis. Staff requested information on malignant hyperthermia; therefore, the CNS conducted informal in-services along with a poster board for additional information.

Conclusion: Clinical nurse specialists are not often hired in the perioperative area. However, through evidence-based practices, the CNS has the ability to decrease the occurrence of perioperative complications. Clinical nurse specialists have the skills, judgment, and the knowledge that is required to optimize patient and family outcomes through cost-effective modalities.

Implication: Working within the 3 spheres, the perioperative CNS can improve surgical patient outcomes. A CNS who practices in the surgery specialty area plays a significant role in improving patient safety and welfare. Because technology is a major component of the surgical arena, the perioperative CNS can influence resource utilization in order to promote cost-effective innovations.

Effect of Heart Failure Education on Intermediate Care Unit Nursing Staff's Knowledge of Heart Failure and Best Practice Guidelines

Carol Budgin, MS, RN, CCNS, Valparaiso University

Objective: This evidence-based practice project was designed to determine if disease-specific education would improve nurses' knowledge levels with regard to heart failure (HF) self-care education principles and best practice guidelines.

Significance: Numerous studies have demonstrated that there are 3 types of barriers (patient-level, provider-level, and system-level) that can lead to variances in HF management and suboptimal patient outcomes (McEntee, 2009). The participants for this project will benefit from increasing their knowledge of HF and best practice guidelines. Increased knowledge improves self-esteem and self-confidence when caring for patients with HF, positively impacting provider-level barriers. The anticipated improvements in discharge planning and patient education may lead to improvements in patients' self-care, positively impacting patient-level barriers.

Design: This evidence-based-practice project is exploratory and descriptive using a convenience sample of nurses who care for patients with HF on an intermediate care unit of a small, urban-centered community hospital.

Background: The current national readmission rate for patients with HF is 17%. At the clinical agency where the project is taking place, the HF readmission rate is 27%. Nurses play a key role in HF management. If they are inadequately prepared to care for and/or educate patients with HF, nursing care will be suboptimal, and hospital readmission rates with the subsequent increased costs for care will continue to soar (Reilly et al, 2009).

Method: Four in-services on HF education that is essential for patient self-care will be presented. A 20-item, true-or-false survey developed by Albert et al (2002) will be administered both before and after intervention. The outcome measures will include overall and detailed perceptions of HF management that is necessary for patients' self-care. Such details include signs and symptoms of decompensation, diet and fluid restrictions, pharmacological management, exercise, invasive interventions, and best practice guidelines.

Outcomes: The anticipated outcomes of educating nurses on disease-specific HF education will improve their knowledge of HF, the principles of self-care, and HF best practice guidelines.

Conclusions: The preintervention surveys have been done, and the results are in the process of being analyzed. The project will be completed by January 15, 2012.

Implications: If the postsurvey results demonstrate improvements in HF and best practice guidelines knowledge acquisition, then that method of improving knowledge in other disease entities can be utilized in this organization and in other healthcare systems, positively impacting system-level barriers. Nursing education in hospitals may need to be changed to periodically include a series of specific disease-focused seminars. Further research can then be done to assess if knowledge improvement has any effect on disease-specific patient hospital readmission rates, patient lengths of stay, and overall cost.

Cardiac Observation/Emergency Department Collaborative (COED)

Christine Townsend, BS, RN, CEN, EMT-P; and Elizabeth Janke, BSN, RN, PCCN, Orlando Health

Significance: Emergency department (ED) overcrowding is a safety threat and can lead to reduced quality of care. Prolonged holding of admitted patients has reached epidemic proportions. Ineffective throughput can negatively impact patient safety and hospital finances. Prolonged ED stays can cause nursing intervention delays. In keeping with the organization's Synergy nursing model, placing the patient on the right unit with the right nurse at the right time can improve outcomes.

Design: A collaborative process improvement project was initiated between the ED and the cardiac observation unit (COU). We began with a multidisciplinary meeting of key personnel, including 2 clinical nurse specialist (CNS) students, with common goals: increasing patient safety, increasing COU census, and decreasing ED length of stay. Cardiac observation unit admission criteria include complaint of chest pain, negative electrocardiogram and cardiac enzymes, and no comorbid conditions.

Methods: Development of an improved throughput process was guided by the CNS students with departmental leadership and staff. Episodic rounding and hourly electronic medical record surveillance are conducted by the charge nurses and CNS students to identify patients who meet COU admission criteria. Traditional patient placement by the administrative supervisor was bypassed for a more time-efficient RN-to-RN communication. This method facilitated report, bed assignment, and accountability for delays. After physician-to-physician admission decisions are made, the ED RN contacts the COU to initiate admission. The patient arrives on the unit within 20 minutes of bed assignment. The history and physical examination are conducted on COU. Education was provided by CNS students and unit leadership via team huddles, e-mails, and one-on-one education. Physicians received education from the director of medical quality. Updates and education are ongoing.

Outcomes: Since implementation of this revised process, the ED arrival to bed placement time decreased by 11 minutes, and ED length of stay decreased by 2 hours for COU patients. A 2% decrease in patients leaving without treatment was also achieved. The COU census is running at 78% of capacity, and productivity is greater than 100%, demonstrating that the goals for the project were achieved. In addition, the percentage of COU patients with a primary admitting diagnosis of chest pain increased to more than 50%. The CNS students will continue to collect and evaluate the data to determine whether the positive outcomes are maintained.

Conclusions: Limitations include lack of centralized data collection, short time frame of implementation, and difficulty in retrieving comparative data prior to starting the new process. Data collection must continue to see the full effect. This multidisciplinary approach has demonstrated a positive impact on throughput. Improvements were seen in the areas of ED waiting and boarding times, patients leaving without treatment, and appropriate placement of cardiac observation patients.

Implications: By increasing throughput, the ED is able to treat more patients, and the COU has been able to improve cardiac patient census and productivity. Decreased ED length of stay has enhanced the care and safety of patients. Improved throughput generates increased revenue for the organization. Once the process is fine tuned, the goal is to implement this practice with other patient populations.

Establishing a Central New York Perinatal and Infant Bereavement Network

Janet Press, BS, RN-C, CT, College of Nursing, Upstate Medical University

Purpose: The purpose of this project is to provide perinatal bereavement support in a community setting using collaborative efforts of a multidisciplinary group.

Significance: The perinatal mortality rate in New York State, excluding New York City is 9.0 per 1000, which is approximately 180 families in the Central New York (CNY) region affected by neonatal death and deaths of babies older than 20 weeks' gestation annually. Less than 20-week losses also leave families needing emotional, spiritual, and physical support. There are no established norms that acknowledge perinatal death.

Background/Rationale: The CNY-Perinatal and Infant Bereavement Network (PIBN) was modeled after the Resolve Through Sharing bereavement program, a national perinatal bereavement organization. Without these supports, perinatal loss often leaves parents feeling isolated and marginalized. Holding events and creating opportunities to network relieve some of the isolation and promote concrete ways to honor their babies.

Method: Clinical nurse specialist (CNS) student, as a perinatal nurse, led this group to establish a standard of care for perinatal bereavement in CNY. Events and resources were developed. Events are held every season. They include a Walk to Remember, a candle-lighting service, a Celebration of Life, and a family picnic. Resources include the resource listing, a newsletter, and a Web page. Current projects include development of a Facebook page, parent-to-parent support training, and a community awareness campaign for 2013.

Conclusions: The CNS role facilitates patient and family support by developing and maintaining a community-based, multidisciplinary program for care of grieving patients and their families. Parents' involvement is necessary to inform the direction and fuel the efforts of the CNY-PIBN. Feedback and increasing participation by families support the efforts of the CNY-PIBN. It is important to use new technology, such as Facebook, as a social networking tool.

Implications: Client involvement should inform our practice to keep it energized and relevant. Ongoing community-wide bereavement support is necessary for families after hospital discharge. Other bereavement networks exist, and the model can be implemented in other areas, but must be molded by the local resources and needs. The CNS role optimized outcomes by incorporating patient, community, organizations, best practice knowledge, and the skills to orchestrate effective programs for bereaved families.

Transitional Care: Improving Outcomes for the Adult Patient With Cystic Fibrosis

Toni Heer, MS, RN, College of Nursing, Upstate Medical University

Purpose: To promote effective coordination of care and avoid preventable detrimental outcomes for the adult cystic fibrosis patients as they transition from hospital to home, using a model that promotes the role of the clinical nurse specialist (CNS) as integral in care transitions.

Significance: Research has shown that care coordination programs with strong transitional care components improve outcomes of beneficiaries from the inpatient setting, to home and primary care provider. Transitional care ensures patient-centered approach and promotes education and follow-up care and ongoing reassessment of patient goals. An initiative of the Centers for Medicare & Medicaid suggests integrating care transitions in healthcare delivery models.

Background/Rationale: Cystic fibrosis (CF) is an inherited, terminal illness that requires a lifelong commitment to choose, monitor, and adjust treatment requirements in order to promote life quality and longevity. Thirty thousand children and adults have CF in the United States and more than 40% of the population are 18 years or older. Patients with CF suffer chronic inflammation and infection resulting in pulmonary exacerbations and rigorous care interventions: hospitalizations, outpatient visits to pulmonologists and primary care providers, and home-based therapies. It has been recognized that this population may benefit from care coordination, bridging gaps that exist between disciplines and various healthcare settings.

Description of Approach: Review of the literature including CINAHL, MEDLINE, and Cochrane Library reveals evidence that supports the need for care transitions initiatives. Based the review of existing transitional care models, the CNS student will institute the use of Naylor's transitional care model to meet the complex needs of the CF patient.

Outcomes: The project is currently underway and will be completed by conference.

Interpretation: It has been clearly identified that the accelerated pace of care, growing complexity of patient care needs, and fragmentation across the care continuum support the need for care transitions initiatives. It is expected that the addition of a transitional care model will optimize outcomes for CF patients and result in fewer hospitalizations.

Implications: The CNS is in a unique position to promote improved patient outcomes by utilizing advanced knowledge and skills and promoting transitional care models in identified populations. This project affords the CNS to influence all spheres and to be full partners in direct patient care and patient safety and satisfaction and to promote quality outcomes.

Clinical Nurse Specialist Intervention to Decrease Central Catheter-Related Bloodstream Infections

Barbara Daley, BS, RN, College of Nursing, Upstate Medical University

Purpose: To determine whether daily bathing with chlorhexidine gluconate (CHG) in intensive care unit (ICU) patients is effective in decreasing central catheter-related bloodstream infections (CRBSIs).

Significance: There are approximately 250 000 CRBSIs each year resulting in 30 000 deaths annually. They are the fifth leading cause of death in acute care hospitals, cost 9 billion excess healthcare dollars, and will no longer be reimbursed by the Centers for Medicare & Medicaid. A central line infection is a significant cause of increased morbidity and mortality. The clinical nurse specialist (CNS) can be instrumental in reducing line infections, thereby improving outcomes.

Background/Rationale: At a university hospital, central line infections have been a significant problem. This results not only in increased expense and extended hospital stays but also poor patient outcomes. The Centers for Disease Control recommends daily bathing with CHG in ICU patients in an attempt to decrease line infections, which the literature supports.

Approach: The CNS student met with the interdisciplinary team and performed a literature review using several databases (Cochrane, CINAHL, PubMed, and Google Scholar) to find the best evidence. Additionally, other university hospitals were contacted to see what bathing products they use, and if they were effective in reducing CRBSIs. Key players (infectious disease physician, infection control, CNS, ICU trainers, nurse educators) were gathered to form a committee, and a 6-month trial in the ICU began to evaluate line infections and potential complications from CHG bathing. The CNS monitored central line infection rates before and after implementation of CHG bathing.

Outcomes: Outcomes are pending completion of the project, which will occur prior to the conference.

Conclusions: Central catheter-related bloodstream infections are a devastating complication in patients with central lines. One way to decrease these infections is by daily bathing with CHG.

Implications for Practice: Clinical nurse specialists are in a good position to decrease line infections, thereby decreasing mortality, improving patient outcomes, and decreasing hospital expenditure.

Spirituality and Blood Pressure Measurements in Caucasian and African American Women: A Comparative Study

Tracy Thornton, RN, MHA, University of the Incarnate Word

Purpose: The purpose of this study is to compare levels of spirituality and blood pressure (BP) among a sample of Caucasian (CAU) and African American (AA) women, 55 years or older with hypertension in the Private Family Medicine Clinic.

Research Question: Does a relationship exist between levels of spirituality and BP among CAUs and AA women 55 years or older, with hypertension who attend the Private Family Medicine Clinic in Live Oak, Texas?

Significance: It is estimated that almost half of AA women (45%) have some type of cardiovascular disease, compared with CAU women with about 32%. In the AA population, higher levels of spirituality are associated with increased frequency of health-related self-care practices and favorable physiological outcomes; however, little information is found in the literature that relates to AA women.

Background: Psychological and medical stress often happens at the end of life, so developing a sense of spiritual well-being before that stage occurs might be an aspect of coping with illness. Large bodies of research document a relationship between spirituality and physical and mental health outcomes. It is estimated that 480 000 women in the United States die of heart disease each year. Our knowledge base regarding cardiovascular disease in AA women has not kept pace with the accumulation of data on CAU women.

Methods: A comparative descriptive design was used to examine the levels of spirituality and BP in 30 women with mean age of 73 (SD, 8.5) years (range, 59-88 years). The data collection instrument used was the Spirituality Perspective Scale (SPS), with a Cronbach [alpha] of P = .904. Data were analyzed using descriptive statistics, t test, and Mann-Whitney test.

Findings and Outcomes: A convenience sample of 30 women from a private physician practice was queried. The majority of participants were CAU (22; 73%), widowed (17; 57%), and has income of less than $40 000 (17; 57%). The mean systolic BP for AA women was 132 (SD 11.8) mm Hg, and in CAUs was 120 (SD, 28) mm Hg. The mean diastolic BP for AAs was 74 (SD, 9.6) mm Hg, and in CAUs was 72 (SD 8.8) mm Hg. The mean for the SPS scale for CAU was 57 (SD, 3.4), and in AAs was 54 (SD, 9.1). A significant correlation exist between education and systolic/diastolic BP at P = .04 and P = .02 respectively. Correlation is also significant between education and income at P = .02.

Conclusions: Scores on the SPS showed no significant differences between AA and CAU women in relationship to spirituality; both groups scored high. The scores for BP did not show a significant difference between the 2 groups. There was also no significant correlation between age, income, length of hypertension, marital status, and education, although significant correlation was noted between education, systolic, and diastolic BP. Even though the SPS scores were very close, these finding are significant when compared with the disparity of the number of AAs in the study at 27%. These finding are limited because of the small sample size, and we are unable to generalize because of the size.

Implications: Findings may have implications for further research with larger samples to determine if a relationship exists between spirituality and BP.

Getting to the Core of Heart Failure: Core Measures and Get With the Guidelines-Heart Failure

Lorrie M. Langdon, BS, RN, CCRN-CSC, SUNY Upstate Medical University

Purpose: The purpose of this project is to improve the care of HF patients by educating nurses in the 6 components of the discharge instructions.

Significance: Over 5 million adults in the United States have HF, and more than 550 000 are diagnosed annually. Direct costs in the United States are over $30 billion a year. Approximately half of all HF patients are rehospitalized within 6 months.

Background: Standardized performance measures are recommended by regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations and the Centers for Medicare & Medicaid Services. Similar performance measures are recommended by the American College of Cardiology/American Heart Association in their quality improvement program, Get With the Guidelines-Heart Failure. Improved compliance with performance measures leads to decreased hospitalizations for heart failure (HF) patients. Patients who received educational interventions for discharge instructions had a 35% lower risk of hospital readmission or mortality. The 6 areas to be addressed during discharge for HF patients are activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen.

Approach: A literature review was conducted using several evidence-based databases (Cochrane, OVID, and CINAHL) to find the best evidence. Additionally, the Web sites of the Centers for Medicare & Medicaid Services, the Joint Commission on Accreditation of Healthcare Organizations, and the American Heart Association were searched for the most current recommended quality performance measures. The clinical nurse specialist student used several different teaching methods to educate nurses about the HF core measures. These included presenting at nursing grand rounds, a poster presentation on a mobile education cart that was displayed and rotated through all nursing units for several days per unit, and in-services for nurses on their units. Baseline data on the HF core measures from January through October 2011 have been obtained from the Clinical Practice Analysis department. The effectiveness of the education for nurses will be evaluated based on data collection of compliance with the HF core measures from November 2011 through February 2012 and will be completed by March 2012.

Outcomes: Pending. Will be completed by conference time.

Interpretation/Conclusions: Compliance with standardized quality measures, specifically discharge instruction, will decrease mortality and readmission rates for HF patients.

Implications: The clinical nurse specialist drives quality outcomes and promotes change to ensure that patients' needs are being met utilizing within the 3 spheres of influence. Education of nursing staff and reinforcement of each of the 6 areas of discharge instruction lead to improved care of HF patients.

The Impact of Education to Caregivers on Optimizing Stroke Recovery and Outcomes

Darcy DeFruscio, MS, College of Nursing, Upstate Medical University

Purpose: To ensure optimal stroke outcome by educating patient caregivers so they may participate in the recovery of the patient.

Significance: Each year, 700 000 people suffer a stroke. Every 45 seconds in the United States, someone suffers from a stroke, which often leaves the patient with residual cognitive and motor deficits. The American Stroke Association estimates that more than 50 million people provide care for chronically ill or disabled people per year in the United States. The literature suggests that caregivers generally have a positive effect on outcome in chronically ill or disabled patients.

Background: Evidence suggests that educating and supporting caregivers of stroke patients have an overall positive effect on stroke recovery. Additionally, teaching family caregivers to cope with the events that occur following a stroke is imperative in relieving their own stress and improves stroke recovery. The literature suggests that stroke knowledge among caregivers is insufficient and requires improvement among healthcare providers.

Description of Approach: A literature review utilizing a combination of the following search terms was conducted: "caregiver support," "caregiver education," "stroke patients," and "stroke recovery." The literature search encompassed the following databases: OVID, MEDLINE, CINAHL, and PsychInfo and suggested inclusion of the caregiver in education. The designated caregiver will receive an educational pamphlet once a stroke patient is admitted to the hospital. A family meeting with a clinical nurse specialist (CNS) will be arranged within 24 hours to educate the caregiver on the content in the pamphlet. The CNS will again meet with the caregiver prior to the patient's discharge to discuss his/her perception of the stroke education he/she received. This will occur specifically prior to discharge to ensure that any areas that need reinforcement may be addressed in real time. The CNS will ask the caregivers for feedback about the education. This will be a way to self-inventory the educational process. Additionally, 2 weeks after discharge, the caregiver will receive a 4-point Likert scale survey, which rates perceived satisfaction of the caregiver education.

Outcomes: To be determined.

Conclusions: The evidence suggests that educating caregivers of stroke patients has a positive effect on stroke recovery. For this project, the caregiver was educated, in addition to the patient, as often the stroke survivor is left with long-term cognitive and physical deficits that may make learning more of a challenge. This project used both prospective and retrospective data, which should strengthen the results.

Implications: Caregivers are key players for optimizing the stroke survivor's recovery. Yet all too often these caregivers are not educated about the complex management for this population. This project will rectify this gap in knowledge.

The Effectiveness of a Culture-Tailored Diabetes Education Program on Post-HgbA_1c Levels

Evelyn Peralta, BSN, RN; and Kathleen Canty, BSN, RN, CCRC, University of the Incarnate Word

Objectives: To learn about the significance of diabetes in the Hispanic culture and to understand the importance of education in preventing the complications associated with diabetes.

Significance and Background: Diabetes is widespread in the Hispanic population. According to the Centers for Disease Control and Prevention (2011), diabetes is the seventh leading cause of death in the United States and the major cause of heart disease and stroke. Diabetes is the leading cause of kidney failure, amputation (nontraumatic), and blindness in the United States. Estimated total direct and indirect medical cost in 2008 for diabetics was $174 billion. In 2008, the estimated number of adults diagnosed with diabetes and living in Bexar county was 90 390 (Centers for Disease Control and Prevention, 2011). There are numerous guidelines and standardized protocols in addressing diabetes. The guidelines recommend using HgbA_1c levels, which measures glucose levels over the previous 3 months. However, there is still a need for a standardized culturally oriented/culture-tailored clinical care, education, outreach, and research programs.

Methods: The study will use a convenience sample using a retrospective chart review of electronic medical records with a continuous nominal measure of pre- and post-HgbA_1c. The study will be conducted at a local Bexar county hospital. A convenience sample of 50 patients will be drawn from the list of all Hispanic patients who participated in the diabetic education program from August 01, 2010, to August 31, 2011.

Research Questions: (1) What are the differences in pre and post HgbA_1c of Hispanic patients who have undergone a culture tailored diabetes program at a local hospital? (2) What is the relationship of the number of attended sessions and post-HgbA_1c at baseline and at 6 months?

Outcomes: After the protocol received university institutional review board approval, data were collected.

Demographics: The 53 participants in this study were primarily female (53; 66%) with a mean age of 48 (SD, 13) years (range, 18-71 years). Thirty-eight percent were married, 42% were single, 13% were divorced, and 4% were unknown marital status. The majority of patients had private insurance (59%), whereas 25% had Medicaid, and 17% had Medicare.

Results: Question 1: Preintervention and postintervention mean scores for the HgbA_1c were 8.99 and 8.20, respectively. Using the paired-samples t test with a 95% confidence interval, the difference between the groups was statistically significant with t = 2.805; P = .0007, df = 48, indicating improved control of glucose levels after the education program. Question 2: According to the Pearson correlations, there was no relationship between the number of sessions and post-HgbA_1c levels.

Conclusion/Implication: The implications of the study indicate that a culturally tailored diabetic education program significantly increases the likelihood of better A_1c levels in the Hispanic culture. This indicates that education directly impacts the health promotion of patients with diabetes living in Texas. The limitations of the study are small sample size, use of a convenience sample, and lack of consistency in the number of sessions attended by the participates.

Development of an Evidence-Based Systemwide Laser Safety Education Program and Competency

Kimberly M. Mitchell, BSN, RN, NC, Aurora Health Care

Purpose: Lasers are commonly used in healthcare today, and ensuring competence is critical for both patient and caregiver safety. Providing effective, consistent, evidence-based education is critical with the necessity to provide cost-effective, high-quality patient care.

Significance: Lasers can be very effective tools but are also dangerous to both patients and caregivers if not used safely. The Joint Commission requires documentation of both the education and competency of care providers to ensure patient safety. Demonstration of education and competency is especially critical when dealing with high-risk equipment or care situations such as laser procedures.

Design: A review of the laser education available at Aurora Health Care along with a review of best practices in laser safety education and online learning management was conducted. From this review, the following essential components were identified: (a) basic history of laser development; (b) basic laser physics (Ball, 2004); (c) laser tissue interaction and how it relates to laser usage (Absten, 2009, June); (d) potential safety hazards, identify critical safety precautions that must be taken for both patients and caregivers; and (e) critical actions to take in the case of a laser fire, laser malfunction, or laser injury (OSH Answers, 2003). The laser safety components and best practices for online education were used in the development of a new evidence-based laser education program. The laser module was implemented on the Aurora learning management system on October 10, 2011.

Methods: Approval was obtained through the Aurora Nursing Research Center to conduct an anonymous survey of all caregivers who completed the module to assess the module's effectiveness in January 2012. The survey will be used to evaluate the effectiveness of the evidence-based design utilizing several interactive activities.

Outcomes: Ninety-five care providers completed the module within the first month of its availability. A total of at least 200 caregivers are expected to have completed the module by December 31, 2011.

Conclusions: Results of the survey will be analyzed and used to update the module if needed as well as to share with other clinical nurse specialists to enhance future online educational offerings.

Implications: Current economic demands mandate that healthcare become more cost-effective and provide the best possible quality of care. Utilizing the best available evidence-based methods to educate caregivers is necessary to achieve this mandate. Online education has become increasingly popular and offers the benefits of efficiency and consistency. The availability of an online evidence-based laser safety educational module with a competency tool provides a consistent educational foundation for Aurora caregivers who participate in procedures utilizing lasers and a way to meet the current economic and regulatory demands.

Internet Patient Teaching Program: A Pilot Study of a Preoperative Patient Education Intervention

Barbara Webber, MS, RN, CNS, Aurora St Luke's South Shore

Significance: Nurses are challenged to find innovative ways of preoperative education within the context of budget constraints, patient cultural expectations, and increasing workload while still advocating for quality outcomes.

Background: Lack of patient preparation for surgery may lead to safety issues and complications, delayed or cancelled surgery, and patient/family dissatisfaction. Using the Internet as a tool to enhance preoperative patient education in the ambulatory surgical population may help bridge communication gaps in a fast-paced and consumer-driven market. This project evaluated the impact of an Internet Patient Teaching Program on patient satisfaction in a pilot study.

Methods: This study used a targeted patient-centered intervention within the framework of partnering with patients. The study population included adult ambulatory surgical patients discharged home the same day from a Midwestern urban hospital-based ambulatory surgical setting. A random sample (N = 25) of patients was assigned to control and intervention groups based on access and comfort level with e-mail and Internet. Subjects in the control group (n = 14) received usual preoperative teaching, whereas subjects in the intervention group (n = 11) received usual preoperative teaching plus tailored individual instructions by e-mail with a link to online instructions. Subjects rated the helpfulness of the information received on a 1- to 10-point Likert Scale.

Outcomes: Although patients receiving Internet Patient Teaching Program intervention rated the information more helpful, there was no significant difference between the mean ratings of helpfulness for the intervention group (mean, 9.409 [SD, 1.02]) and control group (mean, 8.392 [SD, 2.35]); t₂₃ = 1.332, P = .196 (2-tailed).

Conclusions: Patients were more positive about the preoperative education when caregivers viewed instructions online. Partnering with patients means asking the patient how they prefer to receive information.

Implications: Use of the Internet in preoperative education requires further investigation of patient, caregiver, and nurse satisfaction.

Understanding Current Access and Utilization of Hospital-Based Palliative Care and Staff Education Needs Across a System

Katherine May, BSN, RN, East Carolina University

Purpose: The purpose of this project was to assess effective interventions to evaluate access and utilization of hospital-based palliative care services across a system and to demonstrate the role of the clinical nurse specialist in leading a systemwide effort to improve palliative care.

Significance: Palliative care is a growing specialty across the United States and has proven to provide extraordinary benefits to patients and families facing serious illness. Despite this, early access and utilization of hospital-based palliative care services remain challenging for various reasons. Understanding the current access and utilization of palliative care services as well as the palliative care educational needs of staff is of utmost importance to implement the most effective systemwide efforts to improve palliative care access for patients and families.

Background: In discussion with quality management leaders, it was identified that there was little known about the current access and utilization of palliative care services throughout the system and what efforts were necessary, if any, to improve this care for patients and families. In order to assess the current access and utilization of palliative care, a systemwide questionnaire and retrospective chart review were conducted.

Methods: A 27-item questionnaire was dispersed to all clinical staff throughout the system via Web link using SurveyMonkey software. The questionnaire contained items addressing communication among clinicians, patients, and families; access and utilization of palliative care services; perceived barriers; and staff education needs on palliative care topics. Retrospective chart reviews were conducted on 48 randomly selected patient records based on primary diagnostic codes indicating a serious illness. All were readmissions within 30 days over a 6-month period. Each chart was reviewed for 8 quality indicators related to communication, palliative care utilization, and pain and symptom assessment and management.

Outcomes: One hundred seventy-seven respondents completed the questionnaire. The largest respondents were registered nurses (62%) and physicians (19%) from a variety of specialties. The following areas were identified for improvement: earlier goals of care/advanced care planning, more timely referral to palliative care, implementation of a standardized palliative care screening process, increasing use of interdisciplinary family meetings to improve communication, improving strategies for pain and symptom assessment and management, considering referral to palliative care if uncontrolled pain or symptoms for more than 48 hours, and implementing palliative care education for all clinical staff.

Conclusions: Conducting a staff questionnaire and retrospective chart reviews demonstrates an effective way to identify gaps and barriers to early access and utilization of hospital-based palliative care services.

Implications: (1) Prior to implementing process changes to improve hospital-based palliative care access and utilization, it is important to first assess the current palliative care practices, perceived barriers, and staff education needs. (2) The clinical nurse specialists, with expert clinical knowledge, communication, and consultation skills and their work among the 3 spheres, are an important part of improving hospital-based palliative care practices and providing education for staff, patients, and families.

High-Fidelity Simulation to Teach End-of-Life Care and Interdisciplinary Team Skills to Pharmacy Students

Monica Marquez, BSN, RN; and Antonio Torres, BSN, RN, University of the Incarnate Word

Purpose: To assess the effect of a high-fidelity simulation (HFS) scenario on attitudes, competencies, and interdisciplinary collaboration of students enrolled in an interdisciplinary palliative care course.

Significance: Nurses and physicians have been thought of as the only participants in the end-of-life (EOL) care process; however, there has been a call for more research associated with EOL care in regard to a collaborative effort from an interdisciplinary team. All healthcare workers should be educated on how to effectively and sensitively interact with angry, anxious, or overly optimistic family members and how to help them cope with the prognosis of their dying family member.

Background: A mixed-methods design was used to examine student perceptions of a simulated death experience and its effect on student attitudes and competencies regarding EOL care and interdisciplinary collaboration.

Methods: A prewritten HFS scenario utilizing a high-fidelity computer-controlled mannequin with human-like features and physiologic functions was conducted in a highly realistic, simulated hospital environment. Students enrolled in the Interdisciplinary Approaches to Palliative and End of Life Care graduate-level course participated in this study. They were asked to take a pretest and a posttest, both consisting of 17 Likert scale-type questions with 7 open-ended reflection questions added on the posttest, used to analyze qualitative data and to identify common themes.

Outcomes: The sample consisted of 12 students enrolled in an interdisciplinary palliative care elective course. Two students (17%) were nurses, and the others (83%) were pharmacy students. There were equal numbers of Hispanic (3; 25%), Caucasian (3; 25%), and Asian (3; 25%) students. Most were female (10; 83%) and Christian (8; 67%), with a mean age of 33 (SD, 10) years (range, 25-54 years). The majority of students (11; 92%) reported having had a previous experience with death and dying: 1 professional experience (8%) and 10 personal experiences (84%). A nonparametric Wilcoxon signed rank test found no significant difference on EOL care attitudes, competencies, and interdisciplinary collaboration as a result of the simulation. Analysis of qualitative data showed that students had an improved understanding of their roles in EOL care. Common themes identified included maintaining comfort for the patient and family; increased communication between patient, family, and the interdisciplinary team; increased comfort of the professional during the death and dying process; and maintaining a calm and soothing demeanor. Students stated that this simulation positively impacted their views about death and dying. Qualitative findings suggest that utilizing an HFS scenario experience as a teaching strategy improves students' outlooks on the death and dying process and improves their interdisciplinary skills.

Conclusions: The use of HFS as a teaching strategy in the education of pharmacy, nursing, and other healthcare provider students is important because learning to deal with death and dying is a skill not easily acquired and can be developed only with exposure. A limitation was the small sample size, making it difficult to measure small changes.

Implications: Using HFS to teach EOL care and interdisciplinary team skills to healthcare students is an effective teaching strategy; however, more research is needed.

Staff Nurse Practice With Administration of Dexmedetomidine on Intubated and Nonintubated Patients in the Critical Care Unit

Cheryl Ann Hollingshead, BSN, RN, CCRN, University of Arkansas

Purpose: To assess the knowledge and comfort level of staff nurses with continuous intravenous administration of dexmedetomidine to intubated and nonintubated patients and provide education based on survey results.

Significance: Continuous intravenous sedative agents generally used in the critical care area sedate the patient as well as the respiratory drive. Close monitoring and mechanical ventilation are required. However, dexmedetomidine is a selective [alpha]₂-adrenoceptor agonist that is approved for continuous intravenous use on intubated or nonintubated patients in critical care.

Background: Administering sedation medication is common practice in the critical care area within certain guidelines. Institutional policy has prohibited use of continuous intravenous infusions of sedation medications on nonintubated patients. However, physicians have ordered dexmedetomidine in the critical care area for anxious, nonintubated patients and maintain it is safe for use. The medication is approved for administration by the institution and a pharmacy policy exists, but nursing education regarding medication and administration has been minimal.

Methods: The clinical project included a multiple choice staff survey with space for comments regarding knowledge of the medication and nursing comfort level with administration on intubated and nonintubated patients. The initial survey (N = 32) revealed that 77% of staff surveyed had never administered the medication, 65% were not familiar with the safe dose range of the medication, and 61% were not familiar with the potential adverse effects. Therefore, the literature and institutional pharmacy policy were reviewed for development of an educational module and posttest, as well as a nursing protocol for administration.

Outcome: The educational module was posted on the institutional intranet site, and notification through campus e-mail was sent to all critical care nursing staff. Currently, 40% of nurses have completed the module. A postsurvey was administered on December 1, 2011, for comparison.

Conclusion: Pending postsurvey data.

Implications: Pending postsurvey data.

Exploring Characteristics of an Advanced Nursing Assessment

Mitchell R. Knisely, BSN, RN; Barbara Haley, RN; Brenda Grey, MPH, BSN, RN; Eric Fourroux, BSN, RN; Holly Cumberland, RN; and Dawn M. Sullivan-Wright, BSN, RN, CEN, Indiana University School of Nursing

Purpose: This pilot project explored the characteristics of an advanced nursing assessment directed at identifying self-management of symptoms and functional problems amenable to nursing interventions for persons living with chronic diseases.

Significance: Patient self-management of symptoms and functional problems is a nursing-sensitive outcome. Improved self-management has been related to increased quality of life, increased functional status, and decreased disease-related complications.

Background: Advanced assessment is critical to supporting patients' ability to self-manage. Most advanced nursing assessment methods mimic the traditional general health history and "head-to-toe" format dominant in healthcare and used by physicians. The information obtained from traditional assessments may be of limited value in designing nursing interventions for patient self-management. Little is known about characteristics of an advanced nursing assessment focused on identifying problems amenable to nursing interventions.

Methods: Six clinical nurse specialist students each created a tailored advanced nursing assessment template for a specialty patient population. All patients were hospitalized, 5 patients were living with long-term chronic diseases, and 1 patient had experienced a traumatic injury. Each student piloted his/her assessment template and, after reviewing the data, drew conclusions about problems amenable to nursing interventions. Using facilitated discussion, students identified common characteristics of an advanced nursing assessment based on their individual assessment templates.

Findings: (1) Assessment should include an in-depth probing of the patient's perception of the experience of living with a chronic disease; (2) information can be obtained through structured conversations; (3) a patient's beliefs and feelings are critical information; and (4) focused objective physical assessment can validate functional abilities. This assessment process can be therapeutic by allowing patients to reflect and participate in goal setting and self-management strategies.

Conclusions: A traditional health assessment and physical examination can inform advanced nursing assessment, but is of limited value. To better identify symptom and functional problems amenable to nursing interventions, clinical nurse specialists need a tailored nursing assessment format. Conducting assessments that are the same or highly similar to assessments conducted by physicians or other providers does little to advance the practice of nursing.

Implications: Advanced nursing assessment should provide data for drawing conclusions about problems amenable to nursing interventions. Clinical nurse specialists should provide the leadership in developing advanced nursing assessment methods.

Development and Implementation of Standardized Seizure Precautions in the Clinical Research Environment

Rachel C. Perkins, RN, University of Arkansas

Purpose: The implementation of an approved standard of practice (SOP) will provide evidence-based guidance to all nursing staff in regard to seizure precautions. In addition to the development and implementation of this SOP, an evaluation of the understanding and utilization of the approved seizure precautions by nursing staff will be performed.

Significance: Although there is no national consensus for specific seizure precautions, it is clear that safety among patients at risk for seizures is paramount and should be addressed by any facility that cares for them. The creation of an approved, evidence-based SOP for seizure precautions will provide guidance to nursing staff who care for patients at risk for seizures.

Background: Many organizations caring for seizure patients institute seizure precautions. The National Institutes of Health (NIH) Neuroscience and Pediatric Programs of Care have long histories of caring for patients at risk for seizures. Informal precautions have been drafted and revised over time; however, the organization has no formally approved seizure precautions SOP. Specific aims of the project will be to describe evidence-based precautions, which may reduce seizure-related injury; determine the perceived need for standardized seizure precautions among nursing staff at the NIH utilizing a gap analysis of seizure safety practices and the Iowa Model of Evidence Based Practice; and to describe the preimplementation and postimplementation practices of staff.

Methods: The Iowa Model of Evidence Based Practice was utilized as a foundation for the development and implementation of the SOP. A gap analysis revealed that although informal seizure precautions had been drafted and revised over time, no formally approved document was available to assist nursing staff in the care of seizure patients. Prior to SOP implementation, a Web-based survey will be sent to 2 nursing units at the NIH. Specific survey indicators will include current clinical practices and general understanding of seizure classification. After implementation of the SOP, a Five-Minute Forum brochure will be distributed to the nursing units. The brochure will provide evidence-based seizure information, as well as key interventions outlined in the SOP. A knowledge assessment will be included in the brochure.

Findings: The project is in progress.

Conclusions: Collaboration with NIH is ongoing. The survey will be distributed in January 2012, prior to approval of the SOP. After approval in March 2012, the Five-Minute Forum will be distributed. Preimplementation and postimplementation results will be analyzed to detect differences in staff understanding and seizure precautions utilization.

Implications: Many patients participating in biomedical research, either because of their disease process or as a result of investigational therapies, are at risk for seizures. To maximize safety among hospitalized patients at risk for seizures, an evidence-based SOP for seizure precautions will be developed, approved, and implemented. It is hoped that the availability of approved seizure precautions will increase seizure awareness among nursing staff and decrease the risk of injury and negative patient outcomes associated with seizures.

Patient and Family Education Combined With an RN-Led Teach Back Session as a Fall Prevention Intervention

Susan Schedler, MSN, CNS, Unversity of Detroit Mercy

Purpose: To utilize patient and family education combined with an registered nurse (RN)-led Teach Back session as a fall prevention intervention to reduce incidence of falls in cognitively intact adult medical-surgical patients.

Significance: Falls are a leading patient safety incident event in general hospitals and are especially common among older patients. Approximately 30% of falls result in injury, which cause an increased length of stay, increased hospital costs, and the possibility of litigation against the health service. The 48-bed medical-surgical unit of a 450-bed community hospital experienced an 85% incidence of falls in the cognitively intact adult patient.

Background: A review of literature revealed 5 studies supporting patient and family education as a fall prevention intervention for the cognitively intact adult patient. An 11-minute patient education video entitled Fall Prevention is available for patients on the medical-surgical unit but had been watched only 3 times in 2011 in the 9 months prior to the project period.

Methods: The 11-minute Fall Prevention video will be viewed by the patient and family for all cognitively intact patients admitted in private rooms 1 to 24 of the 48-bed medical-surgical floor. Cognitively intact patients admitted to beds 1 to 24 were asked to watch the 11-minute Fall Prevention video within 8 hours of admission. Patients were encouraged to watch the video with a family member. The RN-led Teach Back session took place following the video. The patient and family were asked: "The most important thing you learned was?" Reinforcement education of item learned was provided by the RN. Incidents of falls for the cognitively intact patient were followed for all 48 private rooms during the 5-week project intervention period.

Outcome: The unit had a 110% increase in use of the Fall Prevention video in cognitively intact adult patients. Sixty-six percent of patients viewed the video without a family member present. Patients and their families welcomed the discussion of fall prevention during the Teach Back session. Zero falls were recorded for the cognitively intact patients who viewed the video. Two falls were recorded in the cognitively intact adult patient in private rooms 26 to 49. The RN staff felt the Fall Prevention video was outdated and too long. An updated voice-over PowerPoint presentation entitled Call Don't Fall was created to replace the video.

Conclusions: Patient and family education combined with an RN-led Teach Back session as a fall prevention intervention was effective at reducing the incidence of falls in the cognitively intact adult medical-surgical patient.

Implications: The medical-surgical unit will expand use of patient and family education combined with an RN-led Teach Back session as a fall prevention intervention to all 48 beds of the medical-surgical unit. All patients who are cognitively intact will be asked to watch the Call Don't Fall presentation followed by an RN-led Teach Back session.

Relationship Between Perceived Seriousness of Diabetes and the Adherence to Standardized Foot Assessment and Diabetic Foot Care Practices

Anna L. Glasgow-Martin, BSN, RN; and Somjai Prajakrattanakij, BSN, RN, University of the Incarnate Word

Objectives: (1) To examine the relationship between perceived seriousness of a diabetes diagnosis and adherence to diabetic foot care practices; (2) to examine the relationship between age, length of diagnosis, race, gender, and education level in adherence to foot care in persons 55 years or older with type 2 diabetes; and (3) to examine the relationship between physician compliance of American Diabetes Association (ADA) practice guidelines regarding foot assessment and patient adherence to podiatry referrals.

Significance: As elderly populations increase, the number of older people with diabetes is expected to grow (ADA, 2011). Reportedly, approximately 40% to 60% of the elderly population, 65years or older, suffer from foot problems related to diabetes (Pataky et al, 2007). Patients' self-care behaviors play a major role in diabetes management. The degree to which patients follow advice is determined by their health beliefs of diabetes (Harvey and Lawson, 2009). Diabetic individuals with severe complications and symptoms may believe diabetes to be more severe than those having few symptoms or complications (Lange and Piette, 2006). American Diabetes Association guidelines recommend annual diabetic foot assessment for those without loss of protective sensation, peripheral artery disease, or deformity and every 3 to 6 months for those with loss of protective sensation and/or deformity (Boulton, et al, 2008). Although the 2011 ADA practice guidelines include formal diabetic education and foot assessment among standard-of-care practices, few studies evaluating the inclusion of foot assessment and patient referral for specialized foot care in general private care settings have been done.

Design: A correlational design examined the relationship between perceived seriousness of diabetes and adherence to practice guideline.

Method: Data were collected from 2 questionnaires administered to a convenience sample of person attending a diabetic health fair. The Brief Illness Perception Questionnaire (Brief IPQ) has 8 items that assess illness perceptions. Three short-answer questions were developed for study purposes asking about foot care practices, and these were compared with national guidelines.

Findings: The majority of the 30 study participants were Hispanic (12; 40%) and female (16; 53%). Mean age was 65 (SD) 7.4 years (range, 55-80 years). Nineteen (63%) had a high school degree or lower. The mean number of years living with diagnosed diabetes was 14 (SD, 11.44). Findings indicated a 96.7% adherence to guidelines by healthcare providers performing foot assessment at least once within 6 to 12 months. Every participant receiving podiatry referral complied, indicating compliance regardless of perceived seriousness. There was no statistical significance between perceived seriousness of diabetes and adherence to guidelines. Demographic variables of age, length of diagnosis, race, gender, and education level had no statistically significant effect on adherence of foot care guidelines.

Conclusion: This study implies that provider adherence to standardized guidelines relates directly with patient compliance.

Implications: Implications are hard to draw from these findings because of a small convenience sample, which limits generalizability. More research is needed.

Outpatient Smoking Cessation Approach for Persons With Schizophrenia or Schizoaffective Disorder

Cynthia B. Torres, RN; and Marcus I. Mutidjo, RN, University of the Incarnate Word

Purpose: The purpose of this study was to describe differences in smoking behavior 6 months after smoking cessation intervention of a sample of Hispanic males and females, 18 years or older, diagnosed with schizophrenia or schizoaffective disorder, who had received varenicline, bupropion, nicotine replacement therapy, or counseling through an outpatient psychiatric clinic. The research question was: "What are the differences in smoking behavior among Hispanic adults with a diagnosis of schizophrenia or schizoaffective disorder who received treatment for smoking?"

Significance: Schizoaffective disorder is a mental illness characterized by a combination of symptoms of schizophrenia and a mood disorder. Patients with schizophrenia smoke more cigarettes on average than the general population. Cigarette smoking leads to higher mortality from malignancy and cardiovascular and respiratory diseases in this group. Persons with schizophrenia and schizoaffective disorder rely on cigarette smoking to reduce stress, anxiety, medication adverse effects, and other symptoms. Clinical guidelines for medical practitioners to assist patients with schizophrenia in smoking cessation have been developed by SANE Australia and the University of Melbourne. Few studies document effective interventions for patients with a diagnosis of schizophrenia or schizoaffective disorder to cease smoking.

Method: This study is a retrospective review of medical records using a descriptive design.

Methods: Research approval was obtained from the institutional review board at the affiliated university. Patients' charts at the clinic were selected using a systematic sampling approach. Starting at a random section of the clinic's filing system, the first 66 charts of patients 18 years or older with a diagnosis of schizophrenia or schizoaffective disorder were retrieved. Every second chart, alphabetized by last name, was selected for review. The data abstracted from the chart included age, gender, diagnosis, smoking status, and smoking cessation intervention.

Findings: The sample consisted of 33 Hispanic patients diagnosed with schizophrenia (25; 76%) or schizoaffective disorder (8; 24%). The majority were male (21; 64%), with a mean age of 50 (SD, 10) years (range, 30-83 years). Fifteen (45.5%) were documented as smokers. For 32 patients (97%), smoking cessation intervention was not documented so it could not be determined if any intervention was attempted. Data revealed no significant differences in smoking behavior.

Conclusions: The results were limited by inadequate documentation, so it was not possible to describe differences in smoking behavior after an intervention. According to clinical guidelines, before smoking cessation treatment begins, patients need to be identified as smokers and assessed for readiness to quit. This study revealed that these initial steps were not documented by the practitioner. Smoking cessation does not seem to be a high priority for treating persons with schizophrenia or schizoaffective disorder in this clinic.

Implications: Results shall encourage practitioners to document smoking behavior, assess readiness to quit, and assist in smoking cessation among the aggregate. Although smoking cessation is more challenging for persons with schizophrenia and schizoaffective disorder, clinical practice and future research should incorporate existing clinical guidelines to decrease the high prevalence of cigarette smoking in this vulnerable population.

Appyling a Diabetes Knowledge Test in a Large Continuing Education Program to Improve Healthcare Providers Understanding of Insulin Therapy and Glucose Management

Holly M. Wilson, BSN, RN, CCRN, East Carolina University; Ellen D. Davis, MS, RN, CDE, FAADE; and John D. Howe, BSN, RN, Duke University Health System; and Melanie Elizabeth Mabrey, MSN, RN, ACNP-BC, BC-ADM, Durham Regional Hospital

Purpose: The purpose of this study was to design a process for updating a published diabetes knowledge test (DKT) and to evaluate effectiveness of the new DKT as a method to determine information retention concerning diabetes and insulin therapy in a large health system CE program for inpatient nurses.

Significance: Healthcare providers have a knowledge deficit with insulin therapy. With 40% of all inpatient admissions now with diabetes, the expectation to provide safe quality care for a very common medication is imperative. Insulin errors are among the top 2 reported adverse medication issues. Application of a pre- and post-knowledge test during the CE program can determine gaps and improve content and delivery method of program for now and future use to all healthcare providers.

Background: The Derr DKT has demonstrated the poor knowledge base of healthcare providers concerning administration of insulin. The original study questionnaire results were poor with 51% for faculty, 59% for house staff, and 47% for nurses when first administered in 2007. An updated knowledge test was created to use within a large health system during diabetes workshops and educational events to healthcare providers to measure knowledge obtained from the program.

Methods: A CE program on effective blood glucose management is presented twice a year to healthcare providers to update on insulin regimens and opportunities to educate on reducing medication errors concerning insulin. Content includes pharmacologic therapy, implications of care, considerations of glucose control, selected conditions, skills and resources for success, and real care challenges. The modified knowledge test consisted of 20 content questions concerning demographics of healthcare providers, comfort level of insulin therapy knowledge, and defining insulin types and symptoms of hypoglycemia. Testing is done before and after content to measure knowledge learned.

Outcomes: Spearheaded and organized by the clinical nurse specialist student, the DKT was updated with clinical input from the diabetes clinical nurse specialist, diabetes nurse practitioner, and clinical nurse educator. A total of 37 healthcare providers attended the latest CE program with an average pretest score at 72%. With the posttest score at 87%, there was a 15% increase in the knowledge of diabetes management. The increased results illustrated that providers improved their scores after content presented outlined insulin therapy and diabetes management.

Conclusions: A successful tool used to determine understanding of educational event supports future use of questionnaire to revise and refine content to provide knowledge and further improve patient outcomes.

Enhancing the Precepting Experience Through a Unit-Based Preceptor Forum

Karrima C. Owens, BSN, RN, La Salle University School of Nursing

Significance: The transition from student to professional nurse can be overwhelming. Turnover rates, increasing costs, concerns of patient safety, and improving the quality of care combined with the fact that clinical nurses had less than 3 years' experience and no formal preceptor training lead to the decision to implement a unit-based preceptor forum.

Background: The preceptor forum was created to improve the experience and define the role of the preceptor. Challenges and rewarding experiences related to precepting, tools for effective communication, and suggestions for improving critical-thinking skills were discussed.

Methods: Group discussions and lectures were utilized. Overview of new hospital orientation, updates to the orientation binder, and homework assignment were recommended. Participants recalled their own experience as new nurses and discussed the developmental stages of Patricia Benner's model and development of a mentorship program to promote professional growth.

Outcome: Participants rated the program as excellent and good. Since the forum, preceptors have begun to e-mail one another when sharing orientees to increase continuity of precepting.

Conclusions: The forum empowered the clinical nurses by offering support and tools needed to become comfortable and confident. Future ideas discussed were to conduct a skills workshop for all new orientees, maintain future meetings, and review data regarding nurse retention.

Implications: The spheres of influence of the clinical nurse specialist can be expressed through the preceptor forum. Patient/client sphere involves the improvement of patient outcomes and quality of care when the focus is on transitioning the new-to-practice nurse to a confident and competent professional nurse. Nursing and nursing practice are impacted when continuity of care is improved, and ultimately the organization/system is positively affected by a decrease in turnover rates and increased retention of skilled nurses. Implementation of unit-based preceptor forums can offer the direct care nurse opportunities to transform their own practice in a manner that allows for autonomy and having a voice in how their colleagues will be trained and educated to care for their patient population.

Evaluation of Health Promotion and Disease Prevention Knowledge and Behaviors Among Emergency Department Patients and Families

Phyllis G. Cooper, MN, RN, CNS, Hahn School of Nursing and Health Science, University of San Diego

Purpose: The purpose of this quality improvement project is to gain understanding of health promotion and disease prevention activities of patients and families who utilized the emergency department (ED) for health issues and decrease the number of patients returning for repeat visits from the 27% baseline. From the data collected, health education and follow-up processes will be developed to enhance the health promotion and disease prevention activities of ED patients and families as well as the community served by the ED, and an educational brochure on utilization of healthcare services will be included.

Significance: Health promotion and disease prevention are activities that can be essential to the effective utilization of the ED and can result in the reduction of nonemergent use of the ED. The Joint Commission on Accreditation of Hospitals includes standards for preventive activities in the form of ED-based patient education programs. According to the Society for Academic Emergency Medicine, World Health Organization, and Canadian and Australian studies, primary prevention and health promotion can be done with ED patients. The Centers for Disease Control and Prevention identifies that many ED patients have risk factors and diseases that can benefit from health promotion and disease prevention activities.

Background: Few data are available from ED patients and families about their health promotion and disease prevention activities, even though health promotion and disease prevention support good outcomes. Health promotion and disease prevention data available are anecdotal and limited. Emergency department nurses who see the patients provide discharge instructions and standardized educational materials and referrals back to their primary care provider or specialist. The ED sees 3000 cases per month, with an estimated 27% of the patients having multiple visits for nonemergent needs. Patients and families lack knowledge and behaviors to promote their health and prevent disease.

Methods: This is a prospective project utilizing a descriptive, cross-sectional, anonymous survey to gather general information (age, gender, ethnicity) and health promotion/disease prevention data such as stress management and eating and exercise patterns. The data will be collected during fall 2011, 1 to 2 days a week. The quality improvement survey is composed of 25 basic items with yes/no and quantitative responses; however, there are some qualitative questions. The survey should take 15 to 20 minutes to complete.

Outcomes: Project data collection is in progress. Both nominal and ordinal data will be collected and analyzed according to the individual questions. Explanations, qualitative data, will be categorized. Pie charts and bars will be used to show the collective data.

Conclusions/Implications: The composite health promotion data from the survey will provide the baseline for a "How to Use Health Services" brochure and will be used for development of more focused and structured health education materials.

Bridging the Gap Between Discharge and Follow-up

Thelma Sellers, MSN, RN, CNS, Governors State University

Problem: The period after discharge from the hospital has been characterized as a vulnerable time for patients. During this period, the patient transitions from an acute care setting to a lower-level care setting, such as home, a rehabilitation hospital, or a nursing home.

Objective: Implementing a discharge proposal to reduce readmission. A reduction in hospital readmission may improve quality and reduce costs. The Centers for Medicare & Medicaid Service has initiated a national effort to measure and publicly report on discharge planning with follow-up appointment.

Methods: A discharge proposal, utilizing Pender's Health Promotion Model as a guide. Pender's Health Promotion Model views behavior as a foundation for change. We use it as we guide the changes that our patients will undergo in order to follow up with their primary care provider after discharge.

Results: Pending review of implementation, a discharge advocate will make the appointment for patients before discharge.

Discussion: Data gathered from the leadership team, nursing staff, and a literature search provide information about patients after discharge and some preventive measures to reduce readmission.

Implications: Quality of care and cost are linked hand-in-hand. As nurses, we must make sure that our patients will have the needed information before discharge, with instructions to follow up with their primary care provider.

Score Card for Codes

Stephanie Wintch, RN; Lucile Packard; and Sarah Ferrari, MSN, RN, CNS, PHN, Lucile Packard Children's Hospital

Purpose: The purpose of this presentation is to convey the improvement process a pediatric tertiary center underwent in an effort to enhance documentation during code situations.

Significance: There is a severe lack of documentation completion during code events that are a mix of both electronic medical record and paper charting. The deficiencies can be attributed to lack of consistent training and lack of communication back to the frontline staff.

Background: A small subcommittee was formed and meets monthly to review all emergency documentation completed. Each emergency event is given a score card that addresses both regulatory requirements as well as institutional policies. Exemptions for certain regulatory requirements are made for nonpatients of the hospital.

Methods: Every month, the results of the score cards are compiled. They are then reported to the Code Committee quarterly. The committee then identifies areas for improvement and recommends a process improvement plan. The results are also shared with the Quality Oversight Committee for the hospital.

Outcomes: We have found that after early identification of problem areas and reeducation of frontline staff documentation compliance has improved. Identifying and involving champions in frontline staff to help with clarification and reeducation on units have also been beneficial.

Conclusions: It is a patient safety and clinical practice issue when staff are not compliant with documentation requirements. By creating a champion committee of frontline nurses, direct peer instruction and education have led to the early identification of problems and improvement in emergency documentation.

Implications: There is a higher compliance with regulatory requirements in documentation. With improved documentation, there is an ability to identify systems errors, thereby improving patient safety.

Telemetry Competency of Medical-Surgical Nurses

Donna Lee, BSN, RN, La Salle University

Purpose: The purpose of this presentation is to provide an overview of an educational plan devised for medical-surgical nurses who had recently become telemetry certified.

Significance: A 30-bed medical-surgical floor has recently added telemetry monitoring capabilities. The nursing staff was provided a 4-hour online training course and completed a test to become telemetry certified. Afterward, the staff verbalized a continued lack of comfort identifying certain cardiac rhythms and requested support from the clinical nurse specialist.

Design: An interactive educational plan consisting of a PowerPoint presentation, weekly arrhythmias to be interpreted by staff members, and online tutorials was developed to increase staff's knowledge of cardiac rhythms.

Description: The PowerPoint was a comprehensive overview of cardiac anatomy and function, detailing several common arrhythmias along with causes and nursing considerations. The "Arrhythmia of the Week" was an ongoing tool that was distributed weekly to the nursing staff and required the nurse to measure and determine various telemetry strips, as well as identify causes and nursing concerns. Finally, an online tutorial was made available to the staff that allowed for independent practice of rhythm identification.

Outcomes: Eighty percent of the nurses participated in at least 1 activity, and 27% participated in each weekly offering. In addition, 100% of nurses who needed initial testing or retesting passed the certification examination. Informal discussions with the staff showed a high level of satisfaction with the education provided, with several stating that they had increased comfort with their cardiac rhythm interpretation skills.

Conclusion: When presented with the opportunity to receive education that is targeted to specific needs, these nurses have shown willingness and enthusiasm to increase their knowledge and skill level.

Implications: As acuity increases in acute-care settings, so must the nurses' ability to care for these patients. Education that is targeted toward the specific needs of the staff can be a valuable tool in ensuring safe, quality patient care.

Simulating the Unmentionables

Stephanie Wintch, RN; and Amy Chapman, RN, Lucile Packard Children's Hospital

Purpose: The purpose of this presentation is to discuss how a medical-surgical solid organ transplant unit at a pediatric tertiary center underwent advanced communication training utilizing simulation.

Significance: Pediatric patients with chronic illnesses and their families can prevent unique challenges. Often, being in a hospital setting for long periods can lead to increased stress, frustration, and even distrust of the healthcare team. Nurses can often be exposed to situations that lead to attempts at staff splitting, aggressive behavior, intimidating language, and even unsafe environments. There is no training that stresses to nurses how to use communication techniques that will deescalate these situations.

Background: A multidisciplinary group led by 3 clinical nurse specialist students met to discuss communication strategies that would be useful for nurses to use with patients and/or families exhibiting hostile behavior toward staff. Staff were given "prework" before attending a simulation session that involved real-life scenarios reenacted with method actors in which staff had to utilize the communication strategies in order to decompress the situation.

Methods: A group of 30 staff nurses were all given the same prework and put through the same scenarios. Staff was also given a presurvey asking about comfort levels in different stressful situations. After completing the scenarios, a debriefing session was led by 3 clinical nurse specialist students as well as parent mentors and communication experts. After completion of the class, staff were given another survey asking about any improvements in their comfort level in dealing with difficult communication situations.

Outcomes: This is a work in progress, but it is believed that after completing this course staff will report an increased level of comfort in dealing with difficult and crucial conversations.

Conclusions: Communication techniques for challenging and demanding situations are not part of a nursing curriculum, yet are part of clinical practice. Teaching these skills is imperative to developing leadership skills and creating a healthy work environment.

Implications: Study is in progress, but if successful, this will be a tool to be rolled out to the rest of the institution as a nurse on any unit could have to deal with these situations.