Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients

OBJECTIVES: To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Canadian critical care practitioners. MEASUREMENTS AND MAIN RESULTS: A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092). CONCLUSIONS: There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.     

Utilization of research findings by graduate nurses and midwives

BACKGROUND: There is mounting pressure on nurses and midwives in the United Kingdom to use research findings to inform their practice. However, many still find research difficult to understand and are poorly prepared by education to make use of it. Hence, there is a pressing need to evaluate the research education included in nursing and midwifery curricula. AIM: This paper reports a study assessing the impact of research education on the attitudes towards research and use of research findings in practice by graduate nurses and midwives. METHOD: A cross-sectional survey using a self-completed postal questionnaire was conducted with a sample of 340 nurse and midwife graduates in the South East of England. FINDINGS: A response rate of 51% was obtained. A large number of respondents stated that their critical appraisal (96%) and search skills (87%) had improved following graduation and they reported using research findings in practice (16.8% all the time, 50.5% frequently and 32.6% sometimes). Furthermore, the majority expressed positive attitudes towards research and these were related to the research education received. However, a significant number reported finding statistics difficult to understand, lack of time to read research and limited access to research findings at their place of work. Also, a number of respondents would still like more help with searching the literature, implementing research findings in practice and developing their critical appraisal skills further. CONCLUSION: It is crucial that some of the major barriers to research utilization are addressed at both individual and organizational levels if evidence-based care is to become a reality. Also, health service managers should consider a number of strategies suggested by respondents to increase the use of research findings in clinical settings.     

The role of human resource management and governance in addressing bullying,burnout and the depersonalization of junior and senior psychiatric nurses in Saudi Arabia

This study examined the level of perceived responsibility junior and senior psychiatric nurses have for human resources and governance in Saudi Arabia. Bullying is a significant issue in nursing and an entrenched cultural practice that highlights a failure in governance and human resource responsibilities. A total of 90 responses (43.1%) to a 5-point Likert Scale survey that sought respondent perceptions on leadership, governance and human resources. This study is reported using EQUATOR network recommendations (SQUIRE 2.0). This survey revealed that junior and senior nursing respondents weakly agree with all statements. Neither nurse rank, educational status nor nationality affected the answers of the respondents; there were age, gender and experience effects. There is a significant correlation between all responses to the statements implying there is a social desirability bias to the responses. If bullying, and its derived consequence of burnout, is to be addressed there needs to be a cultural shift in the attitudes of junior and senior nurses towards more acceptance of their HR and governance responsibilities. Furthermore, there needs to be an increased focus on shared leadership responsibilities, with greater nurse-manager interaction and cooperation on transformational practices that will bring cultural change to the clinical space.     

Use of prolonged standing for individuals with spinal cord injuries

BACKGROUND AND PURPOSE: Prolonged standing in people with spinal cord injuries (SCIs) has the potential to affect a number of health-related areas such as reflex activity, joint range of motion, or well-being. The purpose of this study was to document the patterns of use of prolonged standing and their perceived effects in subjects with SCIs. SUBJECTS: The subjects were 152 adults with SCIs (103 male, 49 female; mean age=34 years, SD=8, range=18-55) who returned mailed survey questionnaires. METHODS: A 17-item self-report survey questionnaire was sent to the 463 members of a provincial spinal cord support organization. RESULTS: Survey responses for 26 of the 152 respondents were eliminated from the analysis because they had minimal effects from their injuries and did not need prolonged standing as an extra activity. Of the 126 remaining respondents, 38 respondents (30%) reported that they engaged in prolonged standing for an average of 40 minutes per session, 3 to 4 times a week, as a method to improve or maintain their health. The perceived benefits included improvements in several health-related areas such as well-being, circulation, skin integrity, reflex activity, bowel and bladder function, digestion, sleep, pain, and fatigue. The most common reason that prevented the respondents from standing was the cost of equipment to enable standing. DISCUSSION AND CONCLUSION: Considering the many reported benefits of standing, this activity may be useful for people with SCI. This study identified a number of body systems and functions that may need to be investigated if clinical trials of prolonged standing in people with SCI are undertaken.     

Attitudes towards, and knowledge of, clinical effectiveness in nurses, midwives, practice nurses and health visitors

The dual concepts of evidence-based practice and clinical effectiveness have become ever more important for nurses, midwives and health visitors in recent years. In order that suitable initiatives can be derived and future policy shaped and evaluated it is important that the current level of knowledge and attitudes towards these concepts are recorded. The current study set out to examine these variables in a large, representative sample (n = 370, response rate = 74%) of nurses, midwives and health visitors. Results indicated that although a positive attitude towards evidence-based practice exists, individuals consider themselves to be lacking in certain key skills. Specifically, these appeared to be related to research-based skills. However, despite this, respondents indicated a large take up of evidence-based practice, although this may have been greater were it not for the considerable clinical workload. The necessity for greater dissemination of key research principles to nurses, midwives and health visitors by members of their own profession is emphasized.     

Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke

BACKGROUND AND PURPOSE: The purpose of this study was to identify practitioner barriers (education, attitudes and beliefs, interest and perceived role, and self-efficacy) and organizational barriers (perceived support and resources) to physical therapists' implementation of evidence-based practice (EBP) for people with stroke. SUBJECTS: The participants were 270 physical therapists providing services to people with stroke in Ontario, Canada. METHODS: A cross-sectional mail survey was conducted. RESULTS: Only half of respondents had learned the foundations of EBP in their academic preparation or received training in searching or appraising research literature. Although 78% agreed that research findings are useful, 55% agreed that a divide exists between research and practice. Almost all respondents were interested in learning EBP skills; however, 50% indicated that physical therapists should not be responsible for conducting literature reviews. Average self-efficacy ratings were between 50% and 80% for searching and appraising the literature and below 50% for critically appraising psychometric properties and understanding statistical analyses. Despite Internet access at work for 80% of respondents, only 8% were given protected work time to search and appraise the literature. DISCUSSION AND CONCLUSION: Lack of education, negative perceptions about research and physical therapists' role in EBP, and low self-efficacy to perform EBP activities represent barriers to implementing EBP for people with stroke that can be addressed through continuing education. Organizational provision of access to Web-based resources is likely insufficient to enhance research use by clinicians.     

A survey on the use of outcome measures by musculoskeletal physiotherapist’s in India

Abstract

In recent times, there has been great pressure on physiotherapists to become accountable for their practices and to provide evidence for effectiveness of their treatment. Therefore, it has become necessary to integrate standardised outcome measures (OMs) into clinical practice and boost evidence-based practice. The aim of this study was to determine the extent of use of outcome measures among physiotherapists in India and to identify the commonly used measures. A survey was conducted using a questionnaire consisting of 23 closed-ended questions. It was administered face-to-face and via email to Indian physiotherapists working with musculoskeletal patients. The response rate was 54% (n?=?81). The results indicated 80% of the respondents used OMs with impairment-based measures being the most commonly used. Education qualifications, years of work experience and workplace setting were not significantly associated with utilisation of OMs. Various benefits and barriers to use of OMs were also identified. The findings of this study give insight into possible changes that could be incorporated in clinical practice and educational system for developing a standardised level of assessing patients and to tailor future implementation strategies.     

Perspectives on faculty clinical practice: views of occupational therapy curriculum chairpersons and faculty members.

OBJECTIVE: This study investigated whether and how faculty clinical practice (FCP) was being implemented in occupational therapy professional education programs. METHOD: Chairpersons and faculty members from all accredited entry-level occupational therapy curricula in the United States were asked to complete questionnaires about their involvement in FCP. The chairperson questionnaire consisted of primarily closed-ended questions that addressed the organization of faculty practice within their programs, whereas the faculty questionnaire was primarily open-ended and addressed faculty members' individual involvement in FCP as well as the perceived benefits and drawbacks. Responses were analyzed for 39 program chairpersons and 136 faculty members were analyzed. RESULTS: Twenty-five chairperson respondents reported that their educational program had FCP, and 44 faculty respondents indicated involvement in FCP during the past year. FCP was more prevalent in public-funded institutions and academic health centers. Faculty members primarily engaged in FCP in order to stay current, enhance teaching, and develop networks. They reported increased credibility with students as an important benefit of clinical practice. The primary reasons faculty members did not engage in clinical practice were insufficient time and institutional policies. CONCLUSION: Although many faculty members in occupational therapy education programs value clinical practice as a part of their educator role, it is necessary to negotiate responsibilities and rewards to prevent role overload and comply with institutional policies.     

The use of personal digital assistants by nurse practitioner students and faculty

PURPOSE: To describe the prevalence and patterns of use of personal digital assistants (PDAs) by nurse practitioner (NP) students and faculty, examine relationships between patterns of use of PDAs and demographic characteristics of NP students and faculty, and describe patterns of use of PDAs that support evidence-based practice (clinical scholarship). DATA SOURCES: Responses to a 20-item questionnaire administered via electronic or postal mail from 227 NP students and faculty. CONCLUSIONS: A majority (67%) of the participants used PDAs. Use was higher among men (82%) than women (64%) (p < .05). On average, respondents who used a PDA (N = 153) had been using it just over a year (M = 13 months). Respondents reported using a PDA most days of the week (M = 5 days). The top three medical software programs identified by respondents as the most useful in clinical practice were ePocrates Rx (82%), Griffith's 5-Minute Clinical Consult (26%), and MedCalc (22%). Most participants (96%) related that PDA use supported clinical decision making. IMPLICATIONS FOR PRACTICE: Personal digital assistants may facilitate the application of evidence-based knowledge to practice. However, until there is evidence that PDA software is valid and reliable, clinicians should continue to use a multitude of references to assure the quality and safety of care provided.     

Theory use in practice: a national survey of therapists who use the Model of Human Occupation.

OBJECTIVE: This study describes how occupational therapists who reported using the Model of Human Occupation (MOHO) actually use the concepts and tools of this model in everyday practice as well as identifies supports and barriers to its use. METHOD: A systematic random sample of 1,000 occupational therapists was surveyed as to what theories they used in their practice. Those using MOHO (430) were sent a detailed questionnaire; 259 therapists (60.2%) responded to the survey questionnaire. RESULTS: More than 80% of respondents indicated that they used MOHO in their practice at least some of the time. Therapists reported that MOHO supports holistic, occupation-focused, client-centered, and evidence-based practice. They reported finding MOHO concepts useful for treatment planning and intervention. Most saw the major barrier to using MOHO as their own lack of knowledge. CONCLUSION: Making resources more readily available and accessible to therapists might enhance the extent to which they use conceptual models such as MOHO.     

A web-based Italian survey of current trends,habits and beliefs in hemodynamic monitoring and management

Significant evidence outlines that the management of the high-risk surgical patient with perioperative hemodynamic optimization leads to significant benefits. This study aimed at studying the current practice of hemodynamic monitoring and management of Italian anesthesiologists. An invitation to participate in a web-based survey was published on the web site of the Società Italiana di Anestesia Analgesia Rianimazione Terapia Intensiva. Overall, 478 questionnaires were completed. The most frequently used monitoring techniques was invasive blood pressure (94.1 %). Cardiac output was used in 41.3 % of the cases mainly throughout less-invasive methods. When cardiac output was not monitored, the main reason given was that other surrogate techniques, mainly central venous oxygen saturation (40.5 %). Written protocols concerning hemodynamic management in high-risk surgical patients were used by the 29.1 % of the respondents. 6.3 % of the respondents reported not to be aware if such document was available at their institution. 86.3 % of the respondents reported that they usually optimize high risk patients but to use blood flow assessment rarely (39.7 %). The most used parameter in clinical practice to assess the effects of volume loading were an increase in urine output and arterial blood pressure together with a decrease in heart rate and blood lactates. The 45.1 % or the respondents outlined that hemodynamic optimization in the high risk patients is of major clinical value. Our study outlines an important gap between available evidence and clinical practice emphasizing the need for a better awareness, more information and knowledge on the specific topic.     

Significant event analysis: a comparative study of knowledge,process and attitudes in primary care

Introduction Significant event analysis (SEA) is now well established in UK primary care. Previously, considerable variation has been reported in the knowledge, skills and attitudes of general practitioners undertaking SEA. Little is known about the wider team's understanding, participation or perceptions. We therefore aimed to determine the awareness, degree of analysis and perceived risk of recurrence of a recent significant event, types of discussion forums, staff groups' participation and perceived barriers. Comparisons were made with a 2003 survey and significant changes described. Method A postal questionnaire survey was undertaken of a random selection of general practice team members in National Health Service Greater Glasgow in 2008/9. Results In total, 375/711 respondents (53%) from 111 practices participated. The vast majority was aware of a recent significant event, 29% reported not implementing a change and 23% perceived the risk of recurrence as moderate to high. Administrative and community‐based staff were infrequently involved in meetings. Dedicated significant event meetings remain uncommon (P = 0.06). Perceptions improved since 2003, but lack of time remained a concern. Discussion This survey was the first known attempt to include all members of the primary care team while studying SEA. Awareness and analysis levels were high, but only lead to sustainable improvement of care quality and clinical safety if teams implement change. Greater use should be made of dedicated SEA meetings and participation of all staff groups increased to gain full benefits. Lack of time can be managed pragmatically by prioritizing events based on their perceived severity, potential for change and potential team involvement.     

An examination of current stroke rehabilitation practice in Peru: Implications for interprofessional education

This study aimed to better understand current clinical practice of rehabilitation professionals in Lima, Peru, and to explore the existence of and potential for interprofessional collaboration. A secondary purpose was to assess rehabilitation professionals’ agreement with evidence-based stroke rehabilitation statements and confidence performing stroke rehabilitation tasks prior to and following an interprofessional stroke rehabilitation training. Current clinical practice for rehabilitation professionals in Peru differs from high-income counties like the United States, as physical therapists work with dysphagia and feeding, prosthetist orthotists serve a strictly technical role, and nurses have a limited role in rehabilitation. Additionally, while opportunity for future interprofessional collaboration within stroke rehabilitation exists, it appears to be discouraged by current health system policies. Pre- and post-training surveys were conducted with a convenience sample of 107 rehabilitation professionals in Peru. Survey response options included endorsement of professionals for rehabilitation tasks and a Likert scale of agreement and confidence. Training participants largely agreed with evidence-based stroke rehabilitation statements. Differences in opinion remained regarding the prevalence of dysphagia and optimal frequency of therapy post-stroke. Substantially increased agreement post-training was seen in favour of early initiation of stroke rehabilitation and ankle foot orthosis use. Participants were generally confident performing traditional profession-specific interventions and educating patients and families. Substantial increases were seen in respondents’ confidence to safely and independently conduct bed to chair transfers and determine physiological stability. Identification of key differences in rehabilitation professionals’ clinical practice in Peru is a first step toward strengthening the development of sustainable rehabilitation systems and interprofessional collaboration.     

Perceptions of Radiation Therapists about Providing Psychosocial and Supportive Care to Patients at Peel Regional Cancer Center

BackgroundMany patients with cancer undergoing radiation treatment have unmet psychosocial and supportive care (PSOSC) needs. Radiation therapists (RTs) have a unique opportunity to provide PSOSC, but the published literature is limited regarding their perceptions and beliefs about delivering such care. A survey was designed to evaluate these aspects.MethodsA one-time, cross-sectional survey was distributed to 52 RTs at the Peel Regional Cancer Centre, Mississauga, Ontario, Canada. This survey contained six baseline questions and 34 item statements. The 34 statements spanned three themes: (1) convictions and motivations, (2) preparedness and execution, and (3) resources and facilitators. Participants were asked to rank statements on an eight-point scale, from “strongly disagree” to “strongly agree.”ResultsEighty-three percent of the RTs responded. Respondents reported they were engaged for 6.2 hours per week in supporting patients with PSOSC. This was despite a technical focus of organizing and delivering a course of radiotherapy for each patient, a relatively fixed schedule, and short-duration time slots booked per patient. Overall, respondents reported a moderately strong level of convictions and motivations for including PSOSC in practice. They perceived that they were not using all of their existing PSOSC skills and knowledge on the job and that supporting professional (eg, training and scheduling) and environmental (eg, screening tools, physical environment, and policies) infrastructures for PSOSC were not optimized.ConclusionsA majority of the respondents believed PSOSC to be an integral part of providing quality care to radiation oncology patients. Findings showed that staff members were highly motivated to provide this care and perceived that, with additional support, their capacity to provide such care in a way that is meaningful to patients would increase.