A Qualitative Study of Role Transition from RN to APN

Role transition from registered nurse to advanced practice nurse is a difficult process. A qualitative thematic analysis guided the integration of various experiences of 24 students in a twocredit, web-based role development course in a Master’s of Science in Nursing program at a large Midwestern university. Findings supported that students had developed an understanding of the core competencies and complexity of the advanced practice nurse role, and that beginning role transition had occurred. An overarching theme, ‘the essence of nursing’ was evident. Three subthemes supported the occurrence of role transition, which included the importance of: a) building a framework for nursing practice, b) direct patient care, and c) comprehension and exemplification of professional responsibilities. This study has implications for nurse educators interested in promoting advanced practice nurse role transition early in the educational process

Development of an Index to Predict Risk of Nursing Home Placement for Home and Community-Based Waiver Participants

Nursing home placement (NHP) is costly, and the majority of older adults prefer to remain living in the community. The purpose of this research was to examine NHP among a cohort of participants in a home and community-based waiver program during 2002 to 2007 to develop a risk model for predicting who may transition to a nursing home. Methods: This longitudinal study was conducted on data from the minimum data set-home for care linked with medicaid claim files and death certificates. The sample included 6525 participants who had two assessments and survived through 2007 or had NHP. A risk index was developed to identify participants who had NHP. Results: Using the risk index, the probability of NHP was 50%, with sensitivity of 0.4 and specificity of 0.9. Forty percent of participants who had NHP were correctly identified. Conclusion: This NHP risk index may inform waiver agency personnel as to when participants may need more intense interventions, and consequently provide additional care to delay or prevent NHP when possible

Testing an implementation strategy bundle on adoption and sustainability of evidence to optimize physical function in community-dwelling disabled and older adults in a Medicaid waiver: a multi-site pragmatic hybrid type III protocol

Background: In partnership with a state Medicaid home and community-based waiver program, this study tests implementation strategies for adoption and sustainability of an evidence-based intervention to support disabled and older adults who have difficulty with physical function and daily living tasks. A multi-level implementation strategy bundle will be directed at relationship, coalition, and team building; readiness to implement, leadership, and clinician attitude toward evidence assessments; intervention and facilitation training; interdisciplinary coordination; facilitation; and audit and feedback to support practice change. Methods: Knowledge-to-Action model underpins this 2-arm, 3-year pragmatic mixed method randomized hybrid type III trial in 18 waiver program sites in Michigan. Data will be collected on sites, 775 clinicians (registered nurses, occupational therapists, social workers), and 15,000 disabled and older adults. Consolidated Framework for Implementation Research guides examination of site, clinician, and beneficiary characteristics; clinician attitude and self-efficacy; leadership and readiness to implement; and intervention impact on beneficiary outcomes. Sites will be randomized to either usual waiver care with internal facilitation of the bundle of implementation strategies or usual waiver care with both internal and external facilitation of the bundle. Primary outcomes are site-level adoption and sustainability over 12 months, and intervention effects on these outcomes are hypothesized to be mediated by clinicians’ attitude and self-efficacy. At the beneficiary level, by addressing the individual’s capabilities and home environment, the intervention is hypothesized to improve secondary outcomes of activities of daily living, pain, depression, falls, emergency department visits, and hospitalizations. Baseline site readiness and leadership and stages of implementation at 6months will be explored as potential moderators. Linear mixed effects models will be used to test intervention effects on primary outcomes, with bias-correcting analytic strategy in mediation analyses. Generalized linear mixed effects modeling will be employed for the analysis of intervention effects on secondary outcomes. Discussion: Synthesizing findings within and across the sites, we will specify how leadership, readiness for change, and level of facilitation enhance capacity for adoption and sustainability of an evidence-based intervention in an underresourced Medicaid setting that cares for disabled and older adults

The Challenges of Oral Agents as Antineoplastic Treatments

OBJECTIVE: Given the increasing use of oral antineoplastic agents in cancer management, patient adherence is critical to successful treatment outcomes. This article reviews the scope of the problem and issues of adherence to oral antineoplastic agents. DATA SOURCES: Research based and other articles, newsletters, and conference presentations. CONCLUSION: Suboptimal adherence to oral antineoplastic agents is a significant clinical problem that may result in disease or treatment complications, adjustment in treatment regimen, disease progression, and premature death. IMPLICATIONS FOR NURSING PRACTICE: Healthcare providers need to monitor and facilitate adherence by identifying barriers and implementing strategies to assure adherence, and therefore, improve clinical outcomes

Interventions Combining Motivational Interviewing and Cognitive Behavior to Promote Medication Adherence: A Literature Review

Aims and objectives: The World Health Organization has indicated medication adherence is a global problem. Both motivational interviewing (MI) and cognitive behavioral therapy (CBT) interventions alone have been found to be effective at improving medication adherence. This article summarizes research that has combined motivational interviewing and cognitive behavioral therapy to improve medication adherence. Background: Projections indicate that by 2015, 33% of cancer treatment will be in pill form, shifting responsibility for managing medication adherence to patients. These regimens are often complex, with multiple doses, drugs, or cycling, and patients often experience side effects from symptoms, making adherence difficult. Patients taking cancer treatment in pill form must strictly adhere to their regimen to achieve a therapeutically effective level for cancer treatment. Design: Literature review. Methods: Data were obtained from six studies that combined MI and CBT in an intervention to promote medication adherence. Analysis was performed based on an integrative review process. Results: Five studies on medication adherence rates using combined MI and CBT reported improved medication adherence rates; and one was trending toward improved medication adherence rates. Conclusions: Combined MI/CBT interventions improved medication adherence in various conditions; and may be effective in challenging clinical conditions, such as when cancer treatment is prescribed in pill form. Relevance to clinical practice: This review focused on interventions that combined motivational interviewing and cognitive behavioral therapy to promote medication adherence. Findings provide nurses with an overview of interventions that may be used in developing programs to help patients manage adherence to cancer treatment in pill form; as well as in other challenging conditions where medication adherence is crucial. A detailed description of the interventions found to be effective is provided to assist nurses in translating evidence into practice

Fall Prevention in Hospitals: An Integrative Review

Purpose: This article summarize research and draws overall conclusions from the body of literature on fall prevention interventions to provide nurse administrators with a basis for developing evidence-based fall prevention programs in the hospital setting. Method: Data were obtained from published studies. Thirteen articles were retrieved that focused on fall interventions in the hospital setting. An analysis was performed based on levels of evidence using an integrative review process. Results: Multifactoral fall prevention intervention programs that included fall risk assessments, door/bed/patient fall risk alerts, environmental and equipment modifications, staff and patient safety education, medication management targeted to specific types, and additional assistance with transfer and toileting demonstrated reduction in both falls and fall injuries in hospitalized patients. Conclusion: Hospitals need to reduce falls by using multifactoral fall prevention programs using evidence-based interventions to reduce falls and injuries

A Trial Examining an Advanced Practice Nurse Intervention to Promote Medication Adherence and Symptom Management in Adult Cancer Patients Prescribed Oral Anti-Cancer Agents: Study Protocol

Aim: To report a study protocol that refines then examines feasibility, preliminary efficacy, and satisfaction of ADHERE, an intervention using motivational interviewing and brief cognitive behavioral therapy as a mechanism for goal-oriented systematic patient education to promote symptom management and adherence among cancer patients prescribed oral anti-cancer agents. Background: Cancer treatment with oral anti-cancer agents shifts responsibility for managing treatment from clinicians in supervised cancer centers to patients and their caregivers. Thus, a need exists to standardize start-of-care for support patient self-management of care at home. Design: A two-phase quasi-experimental sequential design with repeated measures. Methods: Sixty five adult patients newly prescribed an oral anti-cancer agent will be recruited from three community cancer centers. Phase one will enroll 5 patients to refine the ADHERE intervention prior to testing, using an iterative process. After completion, Phase two will enroll 30 patients who receive usual care to examine symptoms and ahderence. Advanced practice nurses will then be trained. Then 30 patients will be enrolled in the intervention group and provided ADHERE, a 4-week intervention using semi-structured interactions (initial face-to-face session and once a week phone sessions over 3-weeks) and a Toolkit to promote self-management of care. Outcome measures include: oral anti-cancer agents adherence rate, symptom presence and severity, feasibility, and satisfaction with ADHERE. This protocol was approved January 2014 and is registered at ClinicalTrials.gov (Identifier NCT02337296). Discussion: This nurse-led intervention has the potential to standardize the start-of-care training for the patients to self-manage when prescribed oral anti-cancer agents for treatment

How Increasing Personal Care Service Might Delay or Prevent Nursing Home Placement

There is a pressing need to retain dually eligible elderly Medicare and Medicaid beneficiaries in the community. The objective of this study was to examine median personal care services (PCS) hours, and how increasing PCS to the median (for those below), might delay nursing home placement (NHP) and save cost. Methods: Retrospective study of PCS hours, costs, and NHP in a statewide home and community based waiver program in the Midwest serving 6525 dually eligible Medicare-Medicaid beneficiaries aged 65 and older. Two Minimum Data Set-Home Care assessments and Medicaid claim files were examined to identify PCS hours and cost. A model was developed to estimate costs of increasing PCS to the median to compare retaining at home compared to NHP. Results: Participants with PCS greater than the median hours had a NHP rate of 25%, compared to 36% for those with less than median PCS hours. To attain a 25% NHP rate of participants below the median, we estimated savings by subtracting the usual monthly cost of the waiver ($960) from the monthly NHP cost and adding the cost of the additional PCS ($15.67/hour). For this sample, a total of $155,088 per month could be saved by adding PCS hours to the median. Conclusion: The NHP rate could be reduced from 25–36$2 million a year could be realized by increasing PCS hours to the median and retaining participants in the waiver program. Evaluating waiver participants who are below the median number and increasing those who need it could help retain participants in the home setting, where they most want to be, and allow for tremendous cost savings

Falls in the Community Dwelling Elderly with a History of Cancer

BACKGROUND: Falls place older adults at risk for injuries, resulting in functional decline, hospitalization, institutionalization, higher healthcare costs, and decreased quality of life. OBJECTIVE: This study examined community-dwelling elderly to identify if individuals with a history of cancer fall at a higher rate than those without cancer, and if the occurrence of falls was influenced by individual characteristics, symptoms, or function. METHODS: This was a retrospective, cross-sectional study, in 2007, examining 7,448 community-dwelling elderly 65 years or older in a state in the Midwest. Fallers were identified based on a diagnosis of cancer, age, sex, race and ethnicity, poor vision, reduced activities of daily living (ADLs), instrumental ADLs, cognition, incontinence, pain, or depression. RESULTS: Findings indicated that 2,125 (28.5%) had at least 1 fall. Of those who fell, 967 (13.0%) had cancer, and 363 (4.9%) with cancer had a fall. CONCLUSION: Predictors of falls in this population included race, sex, ADLs, incontinence, depression, and pain, all with P IMPLICATIONS FOR PRACTICE: This study found a high frequency of falls and suggests a predictive model for fall risk in the vulnerable, community-dwelling elderly and will be used to inform future studies

Policy Implications of Oral Agents

OBJECTIVE: With the increasing use of oral antineoplastic agents in cancer management, patients and family members need to understand of how to obtain, safely handle, and store the medication, how and when the medications should be taken, and when to report toxic side effects to accomplish efficacious treatment. DATA SOURCES: Research based articles and conference presentations. CONCLUSION: Cancer centers to modify policies, protocols, or practices to assure safe and proper administration of oral antineoplastic agents. IMPLICATIONS FOR NURSING PRACTICE: Clinicians need to monitor and facilitate administration of oral antineoplastic agents, and ultimately improve clinical outcomes