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Adult Nursing

Beyond the Sleeping Pill: Cognitive Behavioral Therapy for Insomnia

11 Jun, 17 | by rheale

Contributed by Roberta Heale, Associate Editor EBN, @robertaheale, @EBNursingBMJ

There’s not a more frustrating than tossing and turning all night.  However, between 30-50% of adults identify ongoing sleep disturbances.  While restless sleep once in a while is a nuisance, insomnia is a different story. It can be a significant problem particularly with older adults who are at higher risk of depression, falls, stroke, decline in cognitive and overall functioning.  The risks are exacerbated when mixed with sleeping pills which, themselves, increase the risk of falls, fractures and mortality. 1

So what is there to offer a patient other than medication?  Turns out, a lot.  One treatment is showing great promise, Cognitive Behavioural Therapy-Insomnia, or CBT-I.  Using the same exploration of the interactions between thoughts, emotions and behaviours, the focus is on sleep.  Sleep patterns, sleep hygiene, anxieties and thoughts that run through a patient’s mind at night are addressed.  CBT-I requires a commitment from the patient to make changes to their routines and practice the techniques that are offered, however, the outcomes can be very good.

One study, reviewed in a commentary in the EBN journal, identifies the usefulness of CBT-I.  Check out: Cognitive–behavioural therapy for insomnia is effective, safe and highly deployable http://ebn.bmj.com/content/early/2017/04/12/eb-2016-102523  Encouragingly, although training is required to deliver CBT-I, but one does not need to be a healthcare professional to provide CBT-I therapy, which adds to the potential of this treatment.

Sleep permeates every part of our lives.  With so many adults struggling with insomnia, CBT-I is an encouraging, positive, non-pharmacological option.

1. Alessi  C, Martin  JL, Fiorentino  L, et al. Cognitive behavioral therapy for insomnia in older veterans using nonclinician sleep coaches: randomized controlled trial. J Am Geriatr Soc 2016;64:1830–8.

 

International Council of Nurses Congress – Using Social Media to Engage with Nurses

21 May, 17 | by josmith

Roberta Heale (@robertaheale) & Joanna Smith (@josmith175) Associate Editors, EBN

We are presenting how Evidence Based Nursing (EBN) is using social media to engage with nurses at the International Council of Nurses (ICN) Congress, being help at the end of May 2017 in Barcelona, Spain. Nurses across the globe will be exploring nurses’ roles in leading the transformation of care, & is an opportunity for nurses to build networks, share & disseminate nursing practices across specialties, cultures & countries, http://www.icnbarcelona2017.com/

The ICN ams to

Demonstrate & advance the nursing contribution to informed & sustainable health policies;

Support nursing’s contribution to evidence-based healthcare & encourage problem-solving approaches to health priority needs:

Provide opportunities for an in-depth exchange of experience & expertise within & beyond the international nursing community.

We are excited to be representing the work of EBN at the ICN Congress, and networking with peers. Although the journal’s main purpose is to publish expert commentaries on current research that is relevant to nursing, over the last few years EBN editors have implemented a social media strategy to increase engagement with our readers, their access to evidence for practice & awareness of important health issues. We will be sharing our social media strategies that include:

  • Posting regularly on our Facebook @BMJNursing & Twitter account @EBNursingBMJ;
  • Hosting fortnightly Twitter Chats which are linked to a new Opinions article series relating to discussing participants’ key messages during the Twitter chat;
  • Publishing weekly blogs (http://blogs.bmj.com/ebn/);
  • Recording podcasts with authors of commentaries to expand & debate in more depth issues raised in the commentary.

Caring for agitated patients

14 May, 17 | by josmith

This week’s EBN Twitter Chat on Wednesday 17th May 2017 between 8-9 pm (UK time) will focus on caring for agitated patients and is being hosted by Angela Teece (A.M.Teece@leeds.ac.uk), Trainee Lecturer in
Adult Nursing, University of Leeds @AngelaTeece and Sam Freeman (samantha.freeman@manchester.ac.uk) Lecturer in Adult Nursing, University of Manchester Twitter @Sam_Freeman.

Participating in the Twitter chat requires a Twitter account; if you do not have one you can create an account at www.twitter.com. Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to adding #ebnjc (the EBN Twitter chat hash tag) to your tweet, this allows everyone taking part to view your tweets.

What is an agitated patient? It could be a patient who is restless, kicking their legs over the bed rails or refusing to lie still. Or maybe it is the patient who repeatedly flicks off the saturation probe, causing the machine to alarm. Or do you see an agitated patient as one whose behaviour risks serious harm to themselves or you as their nurse? The underlying causes for admission to critical care areas is vast. The commonality is the individual is experiencing illness so severe they cannot be managed elsewhere and require drastic intervention. The admission can be traumatic and potentially life altering event. Delirium, which is common amongst intensive care (ICU) patients, can present as extreme agitation, and lead to poor compliance with essential therapies and rehabilitation (Collinsworth et al., 2016). Awakening from sedation or withdrawal from alcohol and drugs may also lead to agitated behaviour.

Management of agitation is dependent upon the severity of the problem and the clinical area where the patient is being nursed. A restless patient might require extra supervision, particularly at night when staffing and patient visibility is poor. Such patients benefit from regular reorientation. In ICU, agitated patients are at risk of removing essential devices, such as central venous catheters, potentially causing serious harm or death (Mion, 2008). In more severe cases of agitation the management approach may be either sedation (chemical) or physical restraint, such as cuffs or ‘boxing gloves’. Management of agitated patients presents many issues for nurses in terms of staff morale, resource management and patient safety. Nurses might be concerned about the ethical issues underpinning the use of restraint. A recent court case highlighted that sedation cannot be classed as a deprivation of liberty to critical care patients as they physical illness is restricting their freedom, rather than any sanctions imposes by the hospital. Howver the use and role of physical restraint in management of agitation in critical care was not clarified.

Freeman et al. (2015) sought the opinions of nurses in relation to the use of physical restraint and  found some nurses expressed discomfort about the use of physical restraint and needed more education and support regarding physical restraint use. The authors of this blog are currently involved in further research in this area and would welcome your responses and opinions in this week’s Twitter chat., which will focus on:

  • How do you feel about caring for agitated patients?
  • Have you experienced problems with patient agitation where you work?
  • Do you receive help when managing agitated patients?
  • Do you use restraint?

https://medhealth.leeds.ac.uk/profile/1100/1715/angela_teece

https://www.research.manchester.ac.uk/portal/Samantha.Freeman.html

COLLINSWORTH, A. W., PRIEST, E. L., CAMPBELL, C. R., VASILEVSKIS, E. E. & MASICA, A. L. 2016. A Review of Multifaceted Care Approaches for the Prevention and Mitigation of Delirium in Intensive Care Units. J Intensive Care Med, 31, 127-41.

FREEMAN, S., HALLETT, C. & MCHUGH, G. 2015. Physical restraint: experiences, attitudes and opinions of adult intensive care unit nurses. Nurs Crit Care, 21, 78-87.

MION, L. C. 2008. Physical Restraint in Critical Care Settings: Will They Go Away? Geriatric Nursing, 29, 421-423.

Seeing the Wood and the Trees: Using Construal Level Theory to see what Proxy Decision Makers are thinking about

23 Apr, 17 | by josmith

Helen Convey. Lecturer in Adult Nursing, School of Healthcare, University of Leeds

Individuals who are living with dementia and who lack decision making capacity require proxy decision makers to make decisions for them. Individuals may express their interests and desires through behaviour and verbal communication, however, memory loss results in a lack of psychological continuity between the past and the present self. When there is a conflict between the individual’s past values and interests and their present values and interests proxy decision makers encounter an ethical dilemma. The aim of this feasibility study was to explore the potential use of Construal Level Theory (CLT) as a way of analysing the thinking of proxy decision makers where this conflict occurs.

CLT (Liberman and Trope, 2014; Trope and Liberman, 2010) contends that people use mental construal to traverse psychological distance and to think about choices, alternatives and perspectives in different dimensions; temporal, spatial, social and hypothetical. In mental construal abstraction is used to move beyond direct, real experiences of the self, across psychological distance, to form a subjective view of an object or action. High-level construal is more abstract, central values receive attention. Low-level construal is concrete, detailed and contextualised.

Participants were given a scenario in one to one semi-structured interviews. They read the scenario and were asked what they were thinking and feeling. Thematic analysis was used to discover patterns of decision making. Participant responses within the themes were then analysed for abstractness of language using the Linguistic Category Model (Semin and Fiedler, 1991). Participants were found to travel across psychological distance to think abstractly about the person in the scenario. They used mostly abstract thinking to establish central values and beliefs and mostly concrete thinking to express pragmatic concerns. We concluded that CLT can be used to analyse the thinking of proxy decision makers.


References:

Liberman, N. and Trope, Y. 2014. Traversing psychological distance. Trends in Cognitive Sciences. 18(7), pp.364-369.

Semin, G.R. and Fielder, K. 1991. The Linguistic Category Model, its Bases, Applications and Range. European Review of Social Psychology. 2(1), pp.1-30.

Trope, Y. and Liberman, N. 2010. Construal-Level Theory of Psychological Distance. Psychological review. 117(2), pp.440-463.

 

 

To tell or not to tell? Honesty and hope in cancer nursing.

19 Mar, 17 | by dibarrett

Jan Hunter, Lecturer in Nursing, University of Hull

In the rather paternalistic past of the NHS, the established wisdom was that ‘doctor knew best’. If it was deemed a patient didn’t need to know they had a poor prognosis, then they didn’t find out (unless they had the wherewithal to put two and two together, or the audacity to ask outright). Thankfully, we are moving away from the days of selectively withholding information, with candour and truth-telling now at the centre of patient care. Nurses – with their ability to forge strong bonds of trust with patients – are well-placed to act as leaders in the discussion of disease progression and prognosis. Though this cements the place of nurses as autonomous practitioners, it also requires us to face one of the key challenges in cancer care: how do we balance truth-telling with the desire to reduce distress and give hope to patients and carers?

In some patients, there may be a temptation to try and ‘soften the blow’ of bad news. For example, a measured disclosure of bad news over time may be deemed the most appropriate approach in patients we judge to be vulnerable or those we perceive to have a lower ability to cope. Superficially, holding back some information might be viewed as nothing more than a ‘white lie’ to protect patients and help prepare them for bad news. However, no matter how well intentioned, making judgements on when to offer full disclosure may serve to undermine the bond of trust between a patient and nurse.

more…

Recognising, Assessing and Managing Deteriorating Adult Patients

20 Nov, 16 | by josmith

By Gilberto Buzzi Senior Lecturer, School of Health and Social Care / Institute of Vocational Learning | London South Bank gilberto-buzziUniversity e-mail: buzzig2@lsbu.ac.uk

When patients are admitted to hospital, the expectation is that they entering a place of safety. Their families, relatives and friends trust that once in the hands of healthcare professionals, their loved ones are not only going to find comfort but also receive the best treatment possible. Patients trust they will be looked after by competent and confident nurses who will prevent their situation from getting worse, and in the event their condition deteriorates, that they will indeed manage it effectively. Sadly, this is not always the case. Hospital mortality statistics have been linked to staff failures to identify or manage early signs of deterioration.

Recognising and responding to deteriorating hospitalised patients is an important global issue in nursing. By closely monitoring changes in physiological observations and interpreting early sings of physical and psychological decline, nurses are more likely to identify, manage and therefore avoid serious adverse events before they occur. The National Early Warning System (RCP, 2012) has been introduced to help address this issue. The system is based on objective physiological parameters being scored according to the amount of deviation from normal. The scores are weighted depending on the severity of deviation.  screen-shot-2016-11-18-at-17-37-47
The aggregate score is then calculated and acted upon accordingly. As with everything, the tool is only as good as the professional using it. Therefore, all nursing staff caring for patients in acute hospital settings must be competent in monitoring, measurement, interpretation and prompt response to the acutely ill patient, appropriate to the level of care they are providing as supported by their code of conduct (NMC, 2015).

To be able to calculate accurate NEWS the following should be assessed and documented.

  1. RR (respiratory rate) Record rate on every set of observations (RR is an early indicator of clinical deterioration.
  2. Oxygen Saturations (SpO2) Oxygen saturation should be measured by pulse oximetry.
  3. Temperature (Internal body temperature is preferable over axilla).
  4. BP (Systolic blood pressure) in case of acute deteriorating or if automated machines giving an inaccurate or suspect reading then check with a manual sphygmomanometer.
  5. HR (heart rate) Palpate the pulse, assess rhythm and rate and volume.
  6. Level of Consciousness (AVPU – Alert, responds to Voice, responds to Pain or Unresponsive, is a quick and easy method to assess level of consciousness. Change in consciousness is another sensitive indicator of clinical deterioration.

more…

The challenges of embedding spirituality into acute healthcare settings

2 Oct, 16 | by josmith

This wescreen-shot-2016-09-23-at-12-50-34ek’s EBN Twitter Chat is on Wednesday 5th October between 8-9 pm (BST) and will be hosted by Dr Janice Jones (@JaniceJ6873404) senior lecturer in the Institute of Vocational Learning, London South Bank University,

Wilf McSherry, Professor in Dignity of Care for Older People School of Nursing and Midwifery, screen-shot-2016-09-23-at-12-51-43Staffordshire University, The Shrewsbury and Telford Hospital NHS Trust, UK; Part-time Professor VID Specialized University (Haraldsplass Campus), Bergen, Norway (@WilfredMcSherr1), and

Dr JIMG_0206oanna Smith (@josmith175) lecturer in Children’s Nursing, University of Leeds. The chat will focus on the challenges of embedding spirituality into acute healthcare settings.

Participating in the Twitter chat requires a Twitter account; if you do not already have one you can create an account at www.twitter.com. Once you have an account, contributing is straightforward. You can follow the discussion by searching links to #ebnjc, or contribute by creating and sending a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN Twitter chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

Cultural, religious and spiritual beliefs influence how an individual makes sense of the world, often shaping their experiences. During acute or life-threatening illness drawing on these beliefs can provide comscreen-shot-2016-09-23-at-12-48-12fort, strength and support and often assume greater importance in times of stress. Spirituality can foster the development of coping strategies during acute illness where there is often a search for meaning and purpose in response to changing circumstances. 1 There is increased recognition that individual beliefs such as faith and hope can impact on the healing process, usually enhancing, but sometimes hindering, recovery. Incorporating spiritual care into practice helps health professionals to understand patients’ perspectives, and has the potential to increased patient satisfaction with care delivery.

Meeting the spiritual beliefs of patients in acute health care setting is challenging because of the increased demands on acute care services and meeting the needs of an increasingly diverse populations. Traditional working practices must adapt and respond to change yet ensuring patients are treated with respect, dignity and compassion remain fundamental to the provision of holistic, person-centred care needs to respect the patient’s cultural, religious and spiritual needs. 2 Spiritual care matters because it focuses care delivery on the individual, and recognises and utilises patients’ own resources, strengths, aspirations, hopes and experiences.3

Question to think about in advance of the Twitter Chat:

  1. What are your experiences of supporting patients in meeting their spiritual needs in acute healthcare settings?
  2. How can health professionals working in acute healthcare settings can practice holistically to address their patients’ spiritual needs?
  3. Lack of preparation to address the spiritual needs of patients is often cited as a barrier to implementation. What are your experiences of pre registration preparation or CPD opportunities to enhance your understanding of spirituality?
  4. How do you feel the wide range of dimensions relating to spirituality from religious and non religious perspectives relate to healthcare practice?

References

1Clarke, J. (2013) Spiritual Care in Everyday Nursing Practice. A New Approach. Basingstoke: Palgrave Macmillan;

2McSherry, W., Smith, J. (2012) Spiritual Care. In McSherry, W., McSherry, R., Watson, R. (eds) (2012) Care in Nursing: Principles, values and skills. Oxford: Oxford University press;

3McSherry, W., Jamieson, S. (2013) The qualitative findings from an online survey investigating nurses’ perceptions of spirituality and spiritual care. Journal of Clinical Nursing, 22, 3170-3318.

Reflections on the hidden extent of restraint in critical care

11 Sep, 16 | by josmith

Angela Teece (A.M.Teece@leeds.ac.uk). Trainee Lecturer in Adult Nursing, University of Leeds

Angela

I recently left clinical practice, where I had worked as a critical care sister in a large district general hospital, to undertake a university role. Stepping back from practice and reading recent legislation on the deprivation of liberty (DoLS), enabled me to reflect on how the care I provided to patients could be viewed as restrictive.

Deprivation of liberty could relate to:

  • Is the patient under close supervision?
  • Is the patient free to leave the clinical area?

Clearly, on this level, all critical care patients, and many patients on general wards, are being deprived of their liberty. DoLS guidance is supported by the 2005 Mental Capacity Act (MCA) in its definition of restraint. This can be physical, chemical or verbal, for example, the use of bed rails restricts patient mobility, and regulated visiting times and controlled entry to the unit reduce opportunities for the patient to interact with their family.

Critical care is a specialised area of practice. Patients are commonly sedated to enable tolerance an endotracheal tube, ventilator and multiple vascular access devices. Each of these things, although used in the patient’s best interest, could be considered a form of restraint under the MCA and DoLS. Physical restraints in the form of ‘boxing gloves’ may be used to prevent agitated patients interfering with life-saving treatment (Happ, 2000) and chemical restraint may also be used to control agitation (Hofso and Coyer, 2007).

Screen Shot 2016-09-03 at 11.35.41On reflection, I believe nurse are generally tasked with applying restraints, either by putting ‘boxing mitts’ on an agitated patient, or by administering at their discretion as required medication. Nurses must be able to justify their actions. Any restrictive intervention must be in the patient’s best interests and decisions can only be made for a patient if they lack capacity (MCA, 2005). Nurses should fully assess the need to restrain their patient using a validated tool, and conduct reassessment regularly whilst maintain their patient’s dignity whilst restraints are being used. Links have been made to patient experience of critical care and long-term psychological problems such as post-traumatic stress disorder (Jones et al., 2001). Rigorous nursing documentation, completion of DoLS referrals and regular patient observation and evaluation are vital to prevent prolonged restrain and promote patient dignity.

Happ, M.B. 2000. Preventing treatment interference: The nurse’s role in maintaining technologic devices. Heart & Lung: The Journal of Acute and Critical Care. 29(1), pp.60-69.

Hofso, K. and Coyer, F.M. 2007. Part 1. Chemical and physical restraints in the management of mechanically ventilated patients in the ICU: contributing factors. Intensive Crit Care Nurs. 23(5), pp.249-255.

Jones, C., Griffiths, R.D., Humphris, G. and Skirrow, P.M. 2001. Memory, delusions, and the development of acute posttraumatic stress disorder-related symptoms after intensive care. Critical Care Medicine. 29(3), pp.573-580 578p.

Contemporary topics in respiratory care

4 Sep, 16 | by josmith

Following our summer recess, we are delighted at EBN to welcome new and established Tweeters to our next series of Twitter chats. We have an exciting range of topics planned, starting on Wednesday the 7th of September 8-9pm (UK/BST) with a debate on developments in respiratory care hosted by Jacqui Pollington a respiratory nurse specialist (Jacqui.Pollington@midyorks.nhs.uk).  She leads a home oxygen assessment and review service and an outreach service for patients who are frequently admitted with exacerbations of respiratory disease.

Participating in the twitter chat requires a Twitter account; if you do not already have one you can create an account at www.twitter.com. Once you have an account contributing is straightforward – follow the discussion by searching links to #ebnjc or @EBNursingBMJ, or better still, create a tweet (tweets are text messages limited to 140 characters) to @EBNursingBMJ and add #ebnjc (the EBN chat hash tag) at the end of your tweet, this allows everyone taking part to view your tweets.

The last 10 years have seen significant advances in the diagnosis and management of non malignant respiratory disease. There are around 11 inhaler devices available now, and in total around 25 choices depending on drug, dose and combination required – all to treat airways disease, be that asthma, COPD or….dare I say, ACOS (asthma/copd overlap syndrome). Phenotyping could be considered the vogue, but it is very likely in the era of personalised medicine that phenotyping is here to stay and therefore significantly expand the diagnostic workup currently undertaken by many in primary care. The increasing identification of multi-morbidity in COPD and the profound effects of some comorbidity (for example, the biggest co-morbid predictor of death in the female with COPD is anxiety) brinScreen Shot 2016-09-02 at 17.54.38gs another clinical dimension to respiratory care. In this context, how does the nurse dealing with a patient with obstructive respiratory disease keep up to date in this very changeable clinical landscape.

Screen Shot 2016-09-02 at 17.57.13

 

https://www.nice.org.uk/Guidance/cg101

https://www.guidelines.co.uk/gold/copd

This twitter chat will focus on the following key themes:

  • NICE or GOLD in COPD? Which guidance should we be following and why?
  • ICS or not? That is the question? And after the pneumonia? Do we involve patients in the decision?
  • Pulmonary rehab….why wait til MRC3?
  • Smoking – how do we expose the elephant in the room? What do respiratory clinicians know about addiction?
  • How can nursing influence lung health?

Health care management of advanced, irreversible chronic kidney

21 Apr, 16 | by josmith

Helen Noble, Associate Editor EBN

I am a researcher in health services research contributing to health care management of advanced, irreversible chronic kidney disease (CKD). This is evidenced by publications in leading international journals, leadership of successful funding bids, (most recently a multi-institutional NIHR study) and research awards. My research mainly focuses on people with advanced chronic kidney disease opting for conservative management rather than dialysis. The number of these patients is unknown but likely to be growing as increasingly frail patients with advanced renal disease present to renal services. Conservative kidney management includes ongoing medical input and support from a multidisciplinary team. There is limited evidence concerning patient and carer experience of this choice.

I am leading the PAlliative Care in chronic Kidney diSease: (PACKS study) which is exploring quality of life, decision making, costs and impact on carers in people managed without dialysis. This study, funded by the National Institute of Health Research in the UK, is also investigating symptoms, cognition, frailty and performance. Recruitment opened in January 2015 and patients are being recruited in the UK, by renal research nurses, once they have made the decision not to embark on dialysis. Recrutiment finishes in May 2016 with a further 3 months follow up. Carers are asked to ‘opt-in’ with consent from patients. The approach includes longitudinal quantitative surveys of quality of life and quality of life and costs for carers. Additionally, the decision making process is being explored via qualitative interviews with renal physicians/clinical nurse specialists.

The study is designed to capture patient and carer profiles when conservative kidney management is implemented, and understand trajectories of care-receiving and care-giving with the aim of optimising palliative care for this population. It is exploring the interactions that lead to clinical care decisions and the impact of these decisions on informal carers with the intention of improving clinical outcomes for patients and the experiences of care givers.

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