Malnutrition among hospitalized patients is prevalent and associated with adverse outcomes. At the health care facility for which this quality improvement (QI) initiative was developed, patients were not consistently fed within the nationally recommended 48 hours. The purpose of this project was to facilitate the early initiation of enteral feedings to prevent malnutrition in a vulnerable patient group by development of an evidence-based enteral feeding policy, algorithm, and nursing education module. The find, organize, clarify, understand, select, plan, do, check, and act model provided a systematic approach for development of the project. Validation of the QI initiative was through the use of Likert scale which was completed by 2 nurses and a head dietician. The content validity index average was 1.0 for the QI initiative products (policy, algorithm, educational module). Ten team members completed a summative evaluation of the educational module and presentation using a 7 item, Likert scale. Basic descriptive analyses were employed to analyze the data, revealing broad support for the module and the DNP student's leadership. A recommendation was made to conduct an audit using a formal software program to quantify the number of patients who were not being fed within the time frame of 48 hours. Implementing an evidence-based enteral feeding protocol can be a significant intervention that produces better patient outcomes.The implications for social change in this project relates to improvements within the critical care environment.

Most nurses receive limited formal education regarding end-of-life (EOL) care, which affects their ability to meet dying patients' needs. Guided by Bandura's social learning theory, this explanatory correlational study examined the relationships between critical care nurses' personal and professional characteristics and their perceived knowledge and self-efficacy when providing EOL care at an academic medical center. Convenience sampling was used to recruit participants from the eligible adult, pediatric, and neonatal critical care nurses for this study. The 67 participants completed the End-of-Life Professional Caregiver Survey (EPCS) to assess EOL care knowledge and self-confidence. Total EPCS scores revealed only moderate levels of EOL knowledge and self-confidence. The Fisher's exact test indicated that higher EPCS scores were significantly associated with nurses' age and completion of advance directive. A 3-day workshop was designed to address deficits related to EPCS scores and advance directive completion, while educating younger nurses to gain confidence in their EOL discussions. Additional research is recommended to distinguish between nurses' actual knowledge and perceived knowledge about EOL care, the long-term effects of EOL care education on the quality of patient care, nurses' levels of moral distress and burnout, and nurses' communication skills with patients and other health care providers. The result of this research promotes positive social change through EOL education to improve the confidence of nurses working with dying patients and their families, as well as to understand the challenges of communicating difficult decisions regarding EOL care.

A decline in the number of vowed religious who teach and administer in Catholic high schools has placed the responsibility for transferring the founders’ Charism, the traditional mission and identity of the schools, in the hands of lay educators. This study examined how one Catholic independent single-sex high school established programs and methods to transfer the founders’ Charism to its lay educators and students in the areas of social justice, diversity, and social and political awareness. The researcher collected data about Charism transference by interviewing five adults selected as a purposive sample and conducting focus groups with 15 students selected on a nominative basis. Additional research included prolonged researcher emic observation and an analysis of school documents and archives; the data were codified and an emergent analysis of the data was performed. The analysis focused on social justice, diversity, and social and political awareness at the school. Informing the analysis were the theories of Catholic Social Teaching, critical pedagogy, and liberation theology. The emergent analysis identified that the school institutionalized the founders’ Charism, established an atmosphere of care for others in the areas of social justice and diversity, and promoted awareness of feminine identity and a sense of students as leaders, as well as an understanding of social justice and diversity issues. However, factors including social reproduction, social capital, cultural capital, and class complicated the transformational praxis of action in the areas of social justice and political and social awareness.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第21678号 / 医博第4484号 / 新制||医||1036(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 柳田 素子, 教授 福原 俊一, 教授 今中 雄一 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

The biphasic cuirass ventilation (BCV) device is an alternative respiratory support device for patients with chronic respiratory failure. Considered by some a “forgotten” mode of supportive ventilation, the device is portable, lightweight, and easy to operate. Biphasic cuirass ventilation can also be used to rapidly resuscitate patients in acute respiratory distress and requires minimal technical skill to operate. Biphasic cuirass ventilation can be employed by the patient’s caregiver in the home setting, making it a viable alternative to other forms of mechanical ventilation (e.g., BiPAP) for patients enrolled in home hospice or palliative care. The article reviews current knowledge and aims to enhance awareness and encourage further study about cuirass ventilation, particularly with regard to its use in treating patients in the palliative care setting and in the home.

Myeloid-derived suppressor cells (MDSC) expand during sepsis, suppress both innate and adaptive immunity, and promote chronic immunosuppression, which characterizes the late/chronic phase of sepsis. We previously reported that the transcription factors Stat3 and C/EBPb synergize to induces the expression of microRNA (miR)-21 and miR-181b to promote MDSC expansion in a mouse model of polymicrobial sepsis that progresses from an early/acute proinflammatory phase to a late/chronic immunosuppressive stage. We also showed that Gr1+CD11b+ cells, the precursors of MDSCs, from mice genetically deficient in the inflammatory protein S100A9 lack miR-21 or miR-181b in late sepsis, and are not immunosuppressive. In the present study, we show that S100A9 induces miR-21 and miR-181b during the late sepsis phase. We find that S100A9 associates with and stabilizes the Stat3-C/EBPb protein complex that activates the miRNA promoters. Reconstituting Gr1+CD11b+ cells from the S100A9 knockout mice with late sepsis with S100A9 protein restores the Stat3-C/EBPb protein complex and miRNA expressions, and switches the Gr1+CD11b+ cells into the immunosuppressive, MDSC phenotype. Importantly, we find that this process requires IL-10 mediated signaling, which induces S100A9 translocation from the cytosol to the nucleus. These results demonstrate that S100A9 promotes MDSC expansion and immunosuppression in late/chronic sepsis by inducing the expression of miR-21 and miR-181b.

This is a quality improvement project that focuses on implementing screening for acute stress disorder using the Acute Stress Disorder Structured Interview–DSM-IV tool in a Trauma Intensive Care Unit (ICU) at a Level 2 Trauma Center in Nashville, TN. Currently, at this hospital there is not a screening process implemented for these patients. Every trauma patient meets the criteria for acute stress disorder. Starting the process early aims for patients to be properly educated about their trauma and gets them the resources they need to heal mentally from the trauma. During the 6-week implementation period of this project, the trauma performance investigator (TPI) team screens patients for acute stress disorder. The team records how many patients screened, how many patients were available to screen, if they screened positive with a 9 or greater score, if they received a “telepysch” visit, and if a referral card for mental health visit after discharge was given. From this information, it will be determined how to continue to improve the implementation process. Information gathered data by the TPI will be recorded in Excel spreadsheets. The ASD screening tool scores will be used to compare the mechanism of injury to the score to determine if a correlation exists. Some patients that do not screen positive still want a referral card due to the education provided during the screening process. This shows the continued need for patient screening and education about acute stress disorder for this patient population.

No description available.

Background: Critical care nurses (CCNs) provide end-of-life (EOL) care for critically ill patients. CCNs face many obstacles while trying to provide quality EOL care. Some research has been published focusing on obstacles CCNs face while trying to provide quality EOL care; however, research focusing on family behavior obstacles is limited.Objective: To determine if magnitude scores (obstacle item size x obstacle item frequency of occurrence) have changed since previous magnitude score data were first gathered in 1999.Methods: A random geographically dispersed sample of 2,000 members of the American Association of Critical-Care Nurses (AACN) was surveyed. Responses from quantitative Likert- type items were statistically analyzed for mean and standard deviation for size of obstacle and how frequently each item occurred. Current data were then compared to similar data gathered in 1999.Results: Six items’ magnitude scores significantly increased over time. Four of the six items related to issues with families including families not accepting poor prognosis, interfamily fighting about continuing or stopping life-support, families requesting life-sustaining measures contrary to the patients’ wishes and, families not understanding the term “life-saving” measures. Two other items included nurses knowing patients’ poor prognosis before families knows and unit visiting hours that were too liberal.Seven items significantly decreased in magnitude score over time, including two items specifically related to physician behavior such as physicians who would not let patients die from the disease process or physicians who avoid talking to family members. Other items which significantly decreased were poor design of units, visiting hours that were too restrictive, no available support personnel, and when the nurse’s opinion regarding direction of care was not valued or considered.Conclusions: EOL care obstacles emphasized in 1999 are still valid and pertinent. Based on magnitude scores, some EOL obstacles related to families increased significantly, whereas, obstacles related to ICU environment and physicians have significantly decreased. Based on this information, recommendations for areas of improvement include improved EOL education for families and nurses.

Background: Nurses working in intensive care units are at high risk for experiencing moral distress, a response to an ethical event, in which a nurse recognizes or partakes in an action that does not align with their values. In response, nurses may experience negative health effects, which drives attrition. This can negatively impact patient care and the stability of healthcare organizations. There is a scarcity of high-quality and effective organizational interventions to mitigate moral distress, and even lesser work has been done to understand nurses’ practice-based needs to ameliorate moral distress. New conditions of moral distress in the context of COVID-19 have increased the relevance of these shortcomings. Aim: The purpose of this study was to learn about intensive care unit nurses’ responses to moral distress experienced in their professional practice during the COVID-19 pandemic. Methods: This interpretive descriptive study explored the experiences of 40 intensive care unit nurses, who self-reported experiencing moral distress in their professional practice during the COVID-19 pandemic (March 2020 – Sept 2021). Data generation included a demographic questionnaire, including the Measure of Moral Distress - Healthcare Professionals survey, and one-to-one semi-structured virtual interviews. The categorization and synthesis of the data was guided by methods of reflexive thematic analysis and rapid qualitative analysis. Results: Findings indicated that nurses regularly navigated pre-existing and novel ethical events in practice, which were exacerbated in the context of the COVID-19 pandemic. In response, they often experienced moral distress under the complex interplay of two overarching and broad conditions: (1) when nurses’ voices were not heard; and (2) when patients received substandard levels of care, that was not patient-centered, pain free, or that did not align standards of care. Moral distress experienced by nurses resulted in negative outcomes across serval health domains, that drove feelings of burnout and attrition. To cope, nurses engaged in patterns of action, avoidance, and acquiesce. Finally, they made recommendations for mitigative interventions rooted in their desire to be heard, in efforts to optimize patient care and nurse well-being. Conclusion: Intensive care unit nurses’ voices need to be amplified and valued, in the context of various healthcare organizations (e.g., practice, research, education and polity), to mitigate moral distress and the associated negative outcomes. / Thesis / Master of Health Sciences (MSc)