Feasibility of using quadriceps-strengthening exercise to improve pain and sleep in a severely demented elder with osteoarthritis – a case report

BACKGROUND: Osteoarthritis (OA) of the knee, which is prevalent among older adults in nursing homes, causes significant pain and suffering, including disturbance of nocturnal sleep. One nonpharmacologic treatment option is quadriceps-strengthening exercise, however, the feasibility of such a treatment for reducing pain from OA in severely demented elders has not been studied. This report describes our test of the feasibility of such an exercise program, together with its effects on pain and sleep, in a severely demented nursing home resident. CASE PRESENTATION: The subject was an elderly man with severe cognitive impairment (Mini-Mental Status Exam score 4) and knee OA (Kellgren-Lawrence radiographic grade 4). He was enrolled in a 5-week, 10-session standardized progressive-resistance training program to strengthen the quadriceps, and completed all sessions. Pain was assessed with the Western Ontario and MacMaster OA Index (WOMAC) pain subscale, and sleep was assessed by actigraphy. The patient was able to perform the exercises, with a revision to the protocol. However, the WOMAC OA pain subscale proved inadequate for measuring pain in a patient with low cognitive functioning, and therefore the effects on pain were inconclusive. Although his sleep improved after the intervention, the influence of his medications and the amount of daytime sleep on his nighttime sleep need to be considered. CONCLUSIONS: A quadriceps-strengthening exercise program for treating OA of the knee is feasible in severely demented elders, although a better outcome measure is needed for pain

Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools

BACKGROUND: Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia. METHODS: This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales. RESULTS: Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities. CONCLUSION: Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility

Theory-driven evaluation of a multisite nursing professional practice model

Evaluation of the professional practice model is an expectation in Magnet-designated facilities. Few evaluations of practice models are theory driven. A multisite, theory-driven model evaluation was conducted that included input from a variety of sources resulting in a comprehensive revision of the model

Differing perspectives: Research on reasons for heart failure readmission

Background/Introduction: Heart failure is a staggering clinical and public health problem with a trajectory often associated with readmission. Previous research suggests that patients and clinicians have different perspectives about causes and preventability of readmission, with findings focused on subjective reports without clinical context. Purpose: To gather patient, caregiver, nurse, and physician subjective reason(s) for 30-day heart failure readmission. To evaluate responses in context with clinical data to gain insights to improve care. Method: A convergent parallel mixed methods design was used including brief investigator-designed guided interviews and an electronic health record chart review to gather contextual information from both hospital stays. Subjects included decisional adults readmitted within 30 days of a previous inpatient stay with coded diagnosis of heart failure and their associated caregiver, attending physician, and assigned nurse. Enrollment occurred intermittently over two years (2019-2021) due to COVID-19 restrictions. Results: Interviews were conducted with consenting patients (N=44), caregivers (n=6), physicians (n=24) and nurses (n=44). Readmissions were emergent (95%) and occurred an average of 14.9 days (8.1 SD, 2-28 days) after discharge. Patients reported symptom-based readmission reasons and. 14 (32%) thought their readmission was preventable. Physicians reported diagnoses-based reasons, with 38% as preventable. Nurses often reported behavioral reasons and 59% considered readmission preventable. Agreement between the patient, nurse, and physician on reason for readmission occurred in only 30% of cases, predicted by patient marital status (p=0.04). Most patients had high illness severity, multiple co-morbidities, and complex treatment regimens without documented heart failure stage. Discussion: Perceptions about reasons and preventability of readmission are varied and influenced by the training and perspective of participants. Future care must consider context and need for tailored symptom management. Limitations include single site and small sample. Implications: Understanding the context and trajectory of heart failure may help improve shared understanding of status, care planning, and outcomes

Best fit for nurse advancement: Program development & evaluation

Background: Nurses are provided resources and guidance early in their careers, but they need continued support, opportunities, and assistance to professionally develop and make next steps in their careers. Literature has shown that nurses report professional development as fundamental to the profession of nursing (Mlambo et al., 2021). Moreover, supporting nurses with development and career advancement has been shown to aid in retention (Williamson et al., 2022). Purpose/Objective: The Best Fit for Nurse Advancement (BFNA) program was developed and implemented in 2022. The program’s purpose is to provide experienced nurses with the opportunity to explore professional development and career progression. The 6-month cohort introduces participants to advanced roles through a professional panel and shadowing experiences. Additional content covers tuition reimbursement, realistic job preview of advanced roles, scope of practice and role descriptions, mentorship, strategic planning with outcomes, mock interviews, resume building, education requirements, and graduate school visits. Evaluation: A program evaluation is completed at the end of each cohort. The revised Casey Fink nurse retention survey is conducted at the beginning and end of the program (Buffington et al., 2012). Employee retention data and career advancement are tracked for two years following program completion. Results: In 2022, two cohorts (n=15) completed the BFNA program. Participants were 87% female and, on average, had 5 years of nursing experience. Free text responses related to professional goals in the next year fell into two categories, career/job progression and education. To date, there have been 93% organization retention, 4 (26%) have accepted a new leadership position, 3 (20%) have enrolled in graduate school, and 86% have applied or taken on additional leadership responsibilities. Implications: Successful implementation and feedback from BFNA program have shown its positive impact on nurse’s growth and organization retention. The program will continue with two cohorts per year and track nurse retention, education enrollment, and career advancement

Best fit orientation: A novel strategy for on-boarding new nurses

The ‘Best Fit Orientation’ is a novel approach for onboarding newly licensed registered nurses utilizing standard orientation tools, a realistic job preview, self-reflection, and a sequenced experience on three different med/surg units with best fit unit selection. Positive evaluation and limited turnover with additional cost makes this program attractive. Purpose: To design and implement a novel approach for effectively onboarding newly licensed registered nurses (NLRN) by providing a realistic job preview during a sequenced orientation experience on three different units. The process ends with a “best fit” decision for the NLRN to support nurse retention. Relevance/Significance: Premature NLRN turnover is a costly problem. Orientation programs support nurses to transition into their first position, but their effectiveness is in question. Creative approaches are needed to expose NLRN to practice realities, develop skills/confidence, and support them to select a “best fit” position based on preferences for population, culture, and peer/manager relationships. Strategy and Implementation: This project was implemented at a large urban Magnet designated quaternary medical center with NLRN hires that were undecided about their unit/role preference. The “Best Fit Orientation” (BFO) utilized a centralized cost center and existing orientation materials and unit-based preceptors. Hires were provided with a realistic preview opportunity to experience the work environment on three different med/surg units with open positions and a desire to participate. Orientees completed questionnaires designed to support them in self-assessment, reflection, and problem solving. Each hire completed a portion (13 days) of their orientation on each unit, facilitated by the clinical education coordinator. Each unit experience culminated with a transition day with formal evaluation by unit leaders, preceptors, and the newly hired nurse. Input from leaders and participants were used to optimize the program over time. Costs were transferred to the hiring unit. Evaluation/Outcomes: All orientees (n=29) completed orientation on time and were hired onto their unit of choice with 95% retention at 2 years. NLRNs gave high ratings for clinical knowledge, skills, confidence, and knowing how to access resources. The preview experience supported them to build relationships and find their specialty. Leaders provided high ratings regarding candidate selection, design, execution, and paperwork. The BFO process is cost neutral compared to the standard orientation process. Implications for Practice: The BFO program allows for NLRN to experience and identify the unit where they best fit through self-reflection and structured evaluations. Participant and leader evaluations were positive with no turnover. Ongoing feedback and employment duration will be monitored for effectiveness over time. References: Bilal, S., & Bashir, N. A. (2016). Effects of the realistic job previews on employee job satisfaction and met expectations. International Journal of Business and Management, 11(4). doi:10.5539/ijbm.v11n4p219 Gilmartin, M. J., Aponte, P. C., & Nokes, K. (2013). Time for realistic job previews in nursing as a recruitment and retention tool. Journal for Nurses in Professional Development, 29(5), 220-227. doi:10.1097/01.NND.0000433146.51557.b7 United States Office Personal Management. (2019). Assessment & Selection: Realistic Job Previews. Retrieved from https://www.opm.gov/policy-data-oversight/assessment-and-selection/other-assessment-methods/realistic-job-previews