Efficacia del peer learning sulla capacità di ragionamento diagnostico, sulle capacità decisionali e sulla conoscenza degli studenti di infermieristica: uno studio pilota

Background: Peer learning is an important teaching strategy for nursing students, alongside more tradi-tional approaches, in the development of diagnostic reasoning and critical thinking, leadership, teaching and tutorship skills. Objective: to evaluate the effectiveness of peer learning for nursing students in developing knowledge, diagnostic reasoning and decision making skills. Design: Randomized controlled single-centre pilot study. Setting: Degree Course in nursing in Turin, in June 2019. Participants: Nursing students were 113 (intervention group = 68, control group = 45) . Intervention: The peer learning method was used in sessions attended by 1st, 2nd and 3rd year students simultaneously. These students conducted a clinical case study without teacher supervision. Results: The intervention group students (IG) responded better than those of the control group (CG). Statistically significant differences were found in the percentages of correct answers given to questions requiring diagnostic reasoning (p=0.001; p=0.008). Two students of the intervention group were shown to have competence with regard to nursing diagnosis and to be at a higher level in terms of diagnostic rea-soning skills. Conclusion: Better diagnostic reasoning skills were demonstrated by students in the intervention group. There were, however, few items with statistically significant differences in favour of these stu-dents. This could be attributed to the limited available time for the experimentation and to the small number of students on the degree course.. A formal assessment with certification could also enhance the peer learning experience more than a simple training exercise. The fear of teacher's vote could lead students to a better performance Keywords: peer learning, studenti infermieristici, competenza, ragionamento diagnostico, strategie pedagogiche.Introduzione: L’apprendimento tra pari è una strategia didattica importante, insieme a quelle tradizionali, nello sviluppo di competenze di ragionamento diagnostico e pensiero critico, di leadership, di insegnamento e tutorship degli studenti infermieri. Obiettivo: valutare l’efficacia dell’apprendimento tra pari nello sviluppo delle competenze di ragionamento diagnostico, di capacità decisionale e conoscenza degli studenti infermieri. Disegno: Studio randomizzato controllato monocentrico di tipo pilota. Setting: Sede di un Corso di Laurea in Infermieristica di Torino, nel mese di giugno 2019.Partecipanti: 113 studenti infermieri (gruppo di intervento: n=68, gruppo di controllo: n= 45). Intervento: Applicazione dell’apprendimento tra pari in sessioni in cui erano presenti contemporaneamente studenti del primo, secondo e terzo anno. Questi studenti hanno condotto una discussione di un caso clinico senza la supervisione dei docenti. Risultati: Gli studenti del gruppo di intervento (GI) hanno risposto meglio rispetto al controllo (GC); sono state rilevate differenze statisticamente significative rispetto alle percentuali di correttezza delle risposte ai quesiti di ragionamento diagnostico e capacità decisionale (p=0,001; p=0,008). Rispetto alla diagnosi infermieristica, due studenti del gruppo di intervento hanno dimostrato di possedere questo tipo di competenza. Conclusioni: Gli studenti del GI hanno dimostrato competenze di ragionamento diagnostico più elevate. Sono pochi però gli items nei quali sono emerse differenze statisticamente significative a favore degli studenti del GI. Ciò potrebbe essere attribuito al poco tempo a disposizione della sperimentazione e al numero esiguo di studenti coinvolti nello studio. Una valutazione certificativa, e non solo formativa all’esperienza, potrebbe potenziare ulteriormente l’efficacia dell’apprendimento tra pari. Keywords: “peer learning”, “nursing students”, “competence”, “diagnostic reasoning”, “pedagogic strategie

Characteristics of Breakthrough Pain and Its Impact on Quality of Life in Terminally Ill Cancer Patients

Purpose. This study aimed to characterize breakthrough pain (BTP) and investigate its impact on quality-of-life (QoL) in terminally-ill cancer patients. Similarities and differences between high and low predictable BTP were also tested. Methods. Secondary analysis of a multicenter longitudinal observational study included 92 patients at their end-of-life. BTP was assessed with a short form of the Italian version of the Alberta Breakthrough Pain Assessment Tool. QoL was assessed with the Palliative Outcome Scale (0-40). Patients were stratified by self-reported BTP predictability into unpredictable BTP (never or rarely able to predict BTP) and predictable BTP (sometimes to always able to predict BTP). Results. In all, 665 BTP episodes were recorded (median 0.86 episodes/day). A median duration of 30 minutes and a median peak intensity score of 7 out of 10 were reported. Time to peak was <10 minutes, 10 to 30 minutes, and 6530 minutes in 267 (41.1%), 259 (39.9%), and 30 (4.6%) of the episodes, respectively. Onset of relief occurred after a median of 30 minutes. Time to peak (P <.001) and duration (P =.046) of BTP was shorter in patients with predictable pain (n = 31), who usually were younger than those with unpredictable pain (P =.03). The mean (SD) QoL score was 14.6 (4.6). No difference in QoL between patients with predictable and unpredictable BTP was found (P =.49). Conclusions. In terminally-ill cancer patients, BTP is a severe problem with a negative impact on QoL and has different characteristics according to its predictability

Decisional responsibility for mechanical ventilation and weaning: an international survey

IntroductionOptimal management of mechanical ventilation and weaning requires dynamic and collaborative decision making to minimize complications and avoid delays in the transition to extubation. In the absence of collaboration, ventilation decision making may be fragmented, inconsistent, and delayed. Our objective was to describe the professional group with responsibility for key ventilation and weaning decisions and to examine organizational characteristics associated with nurse involvement.MethodsA multi-center, cross-sectional, self-administered survey was sent to nurse managers of adult intensive care units (ICUs) in Denmark, Germany, Greece, Italy, Norway, Switzerland, Netherlands and United Kingdom (UK). We summarized data as proportions (95% confidence intervals (CIs)) and calculated odds ratios (OR) to examine ICU organizational variables associated with collaborative decision making.ResultsResponse rates ranged from 39% (UK) to 92% (Switzerland), providing surveys from 586 ICUs. Interprofessional collaboration (nurses and physicians) was the most common approach to initial selection of ventilator settings (63% (95% CI 59 to 66)), determination of extubation readiness (71% (67 to 75)), weaning method (73% (69 to 76)), recognition of weaning failure (84% (81 to 87)) and weaning readiness (85% (82 to 87)), and titration of ventilator settings (88% (86 to 91)). A nurse-to-patient ratio other than 1:1 was associated with decreased interprofessional collaboration during titration of ventilator settings (OR 0.2, 95% CI 0.1 to 0.6), weaning method (0.4 (0.2 to 0.9)), determination of extubation readiness (0.5 (0.2 to 0.9)) and weaning failure (0.4 (0.1 to 1.0)). Use of a weaning protocol was associated with increased collaborative decision making for determining weaning (1.8 (1.0 to 3.3)) and extubation readiness (1.9 (1.2 to 3.0)), and weaning method (1.8 (1.1 to 3.0). Country of ICU location influenced the profile of responsibility for all decisions. Automated weaning modes were used in 55% of ICUs.ConclusionsCollaborative decision making for ventilation and weaning was employed in most ICUs in all countries although this was influenced by nurse-to-patient ratio, presence of a protocol, and varied across countries. Potential clinical implications of a lack of collaboration include delayed adaptation of ventilation to changing physiological parameters, and delayed recognition of weaning and extubation readiness resulting in unnecessary prolongation of ventilation

The Circadian Rhythm of Breakthrough Pain Episodes in Terminally-ill Cancer Patients

Opioid therapy must be adjusted to the rhythm of a cancer patient's pain to ensure adequate symptom control at the end of life (EOL). However, to-date no study has explored the rhythm of breakthrough pain (BTP) episodes in terminally-ill cancer patients. This prospective longitudinal study was aimed at verifying the existence of a circadian rhythm of BTP episodes in terminally-ill cancer patients. Consecutive adult cancer patients at their EOL treated with long-acting major opioids to control background pain (Numeric Rating Scale ≤ 3/10) were recruited from two Italian palliative care services. Using a personal diary, patients recorded the frequency and onset of BTP episodes and the analgesic rescue therapy taken for each episode over a 7-day period. Rhythms identified in BTP episodes were validated by Cosinor analysis. Overall, 101 patients were enrolled; nine died during the study period. A total of 665 BTP episodes were recorded (average of 7.2 episodes, mean square error 0.8) per patient, with 80.6% of episodes recorded between 8:00 a.m. and 12:00 a.m. At Cosinor analysis, a circadian rhythm of BTP episodes was observed, with a Midline Estimating Statistics of the Rhythm (MESOR) of 1.5, a double amplitude of 1.8, and an acrophase at 12:30 p.m. (p < 0.001). Oral morphine was the most frequent analgesic rescue therapy employed. In terminally-ill cancer patients, BTP episodes follow a circadian rhythm; thus, tailoring the timing of opioid administration to this rhythm may prevent such episodes. This circadian rhythm of BTP episodes in terminally-ill cancer patients should be confirmed in larger samples