Volume 3, Number 1, 2010

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Clinical
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Clinical
Scholars CSR
Review
Editor
Jennifer A. Smith, DNP, MBA, MPH
Senior Associate Dean
Columbia University School of Nursing

Managing Editor
Manuel Cortazal, MS
Columbia University School of Nursing

Board Members
Robert Brook, MD, ScD Elaine Larson, PhD
RAND Health Associate Dean of Research
Columbia University School of Nursing
Colleen Conway-Welch, PhD
Dean Lucy Marion, PhD
Vanderbilt University School of Nursing Dean
Medical College of Georgia
Sarah Cook, DNP School of Nursing
Vice Dean
Columbia University School of Nursing Mary O. Mundinger, DrPH
Dean
Richard A. Cooper, MD Columbia University School of Nursing
University of Pennsylvania
Department of Medicine Janice Smolowitz, EdD, DNP
Co-Director, DNP Program
Judy Honig, EdD, DNP Associate Dean for Practice
Director, DNP Program Columbia University School of Nursing
Associate Dean of Student Services
Columbia University School of Nursing Patricia Starck, DSN
Dean
Robert Kane, MD University of Texas at Houston School of
Professor Nursing
University of Minnesota
School of Public Health Nancy Woods, PhD
Dean
Kenneth W. Kizer, MD University of Washington School of Nursing
Medsphere Systems Corporation

CSR_InsideCover.indd 2 3/25/2010 5:06:20 PM

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CSR_InsideCover.indd 3 3/25/2010 5:06:21 PM

Clinical Scholars Review
The Journal of Doctoral Nursing Practice
Volume 3, Number 1, 2010

From the Editor ....................................................................................................................................................... 2
Jennifer Smith
Health Care Reform and Comprehensive Care: Where Are the Nurses? ................................................................ 3
Mary O’Neil Mundinger
Who Defines Advanced Nursing Practice in an Era of Health Care Reform?......................................................... 5
Connie M. Ulrich
Control Practice Growth: Maximize First Visits, See Fewer Patients, and Improve Practice Income ...................... 8
Thomas A. Mackey
Health Care on Aisle 7: The Growing Phenomenon of Retail Clinics ................................................................... 10
Disseminating Evidence-Based Practice Projects: Poster Design and Evaluation .................................................. 14
Diane McNally Forsyth, Tracy L. Wright, Cindy A. Scherb, and Phyllis M. Gaspar
An Evidence-Based Review on Guided Imagery Utilization in Adult Cardiac Surgery ........................................ 22
Jesus ( Jessie) Casida and Suzanne A. Lemanski
Long QT Syndrome: A Case Report, Genomics, and Clinical Implications ......................................................... 31
Jiaming Yao and Kathleen Hickey
Evaluating the “Innovativeness Quotient” (IQ) in a Collaborative Model ............................................................. 36
Juli C. Maxworthy
Medication Safety in the Elderly: Translating Research Into Practice ................................................................... 43
Julie A. Lindenberg

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CSR_TOC.indd 1 3/25/2010 5:04:48 PM

dialogue will continue about issues con- As Doctorate of Nursing Practice (DNP)-prepared cerning the ABCC examination and how to inform oth- clinicians. seize every opportunity to inform stakeholders that we Clinical Scholars Review continues to publish contri- are a resource that could. Volume 3. offered by the National Board of Medical months. This is not the all DNP graduates from programs with a clinical focus will time to assume someone else will speak for us—we must plan on taking the examination. Scholars Review editorial board continues to believe that this credential is the gold standard for doctorally prepared Jennifer Smith. we have an opportunity to tell policy makers in ers of its importance. prehensive Care (ABCC) remains controversial to some.indd Sec1:2 3/25/2010 8:07:49 PM . Along with the insurance or even the most basic health care. DNP clinicians. Number 1. for both the public and the profession. 2010 © Springer Publishing Company DOI: 10. offered again in October.2 Article_01. lieve this journal is an appropriate forum in which DNP The results from the second DNP graduate certifica. policymak. MPH. MBA. faculty and graduates may focus on subjects relevant to tion examination will be announced soon. much has happened to the world economy that Examiners (NBME) and the American Board of Com- will affect the ongoing health care debate in the nation.1. Washington and in our state capitals that we are capable We are looking forward to celebrating the results of and ready to help meet the growing demand for compre. American Association of Colleges of Nursing (AACN) ers and the public will grapple with the difficult decisions and the Council for the Advancement of Comprehensive intended to ensure and expand coverage. those who took the examination in October and hope that hensive care providers across the country. The Clinical today’s doctorally prepared nurse clinicians. and should. With the unemployment rate hitting record highs and both inside the field and out. _ COMMENTARY/EDITORIAL From the Editor What a difference a year can make. During the past 12 examination. be utilized for the butions from clinical scholars across the country who be- benefit of all.1891/1939-2095. Care (CACC). This Editor 2 Clinical Scholars Review. but the boards’ resolve to pro- increasing numbers of Americans unable to afford health mulgate this certification is unwavering.3.

show up in the ER. women. monitoring. Americans are not yet ready to conform to care.1891/1939-2095. and meaningless settings. The nature of the prac- for the aging baby boomers. development for patients. and by changing the place vision—toward health care reform that includes expanded where care is delivered. early treatment. huge new demand for comprehensive primary care? Phy- covered by this test at an age now being considered too sicians have been fleeing primary care for decades. coaching.1. Those who have been clos. which could be We will still have a diverse system of choices subsi. _ COMMENTARY/EDITORIAL Health Care Reform and Comprehensive Care: Where Are the Nurses? Mary O’Neil Mundinger. preventive care. practices. is central to ad- who cannot afford the premiums is essential.3. Much of emergency room care insurance coverage. 2010 © Springer Publishing Company 3 DOI: 10. and those who is not necessarily the correct term for what is happening. such decisions. Their care. so good.3 Article_02. Nurses have can save money to help fund this new system by ensuring been paid (at a discount) for basic site-specific (outpatient Clinical Scholars Review. Indeed. Number 1. could and should have been avoided. some states may be able is not equipped or organized for necessary follow-up care to do so legally. exactly. scientific studies were published showing as well as the ethical one in terms of why we must expand that mammograms should not be used liberally for young access to routine care (and specialist care when needed). and the ER penalties for opting out. which requires expert diagnostic skills. is going to meet this complete with anecdotes from those who had cancer dis. The same week that EBP was written into This is not a new observation. We will not have a system “reformed” to ensure adoption of healthful behaviors or compliance to assure the right care at the right time for those who with treatment. especially to move on to specialty training. Even young for routine screening. the cost and content of covered care today is not care requiring the expensive resources needed have been the major concerns. DrPH Columbia University School of Nursing.indd 3 3/25/2010 8:08:59 PM . is not what most physicians de- What could we have expected in true health reform? sire. is inordinately expensive in an ER. those without est to this momentous advancement know that “reform” insurance to access a primary care provider. to be ready for a real emergency. NY As the nation marches carefully—and in deep political di. It is a financial reason legislative drafts. This leads to further expensive care that need it. EBP is okay theoretically. No access to care Although evidenced-based-practice (EBP). But who. and resource not based on EBP their entire lives. has occurs. However. those few who initially take a primary care residency tend But it will be a difficult process to implement. Volume 3. New York. we vanced practice nursing goals and expertise. but which empowered and entitled (and reimbursed) for procedures also requires teaching. many of whom have been tice. This personal Certainly expanded coverage is a start. Subsidies for those health advancement paradigm. however. in their careers. or are reimbursed for. within conventional - appointment slots of outpatient als are required to have insurance. may not have transportation or child care coverage to fit The only thing that may be reformed is whether individu. This caused a national outpouring of disapproval So far. appropriately managed in low-technology primary care dized by federal and state tax dollars. And yes. which at all is also a major reason that late-stage expensive care embodies this right care/right time/right purpose. Clearly it is cost effective—for the system and for been considered necessary for cost containment in this the patient—to have a source of comprehensive primary new system.

deep” and Hotspur answers. This is a message that Clinical Scholars Review readers Nursing is a critically needed answer to health re- know well. and develop a costly system that has care. “I can call spirits from the vasty have funding and regulatory reform to fully contribute. health reform will requisite skills to be equivalent to physicians in compre. be empty words.indd 4 3/25/2010 8:08:59 PM . the barriers to practice authority to allow Diplomats of Enter the Doctor of Nursing Practice. We must which Glendower says. but will they come when you do call for them?” Correspondence regarding this article should be directed to Mary There will be a call for primary care providers. Insurers must viewed as a full replacement for physician practice. and have the payment for care. teaching/resource development attributes that make for continue to provide care too late and in the wrong place such a preferred contribution to patients seeking primary at untenable costs. E-mail: fragmented and burdened with regulatory barriers to allow mm44@columbia. is the preferred answer to resolving the health reform. DrPH. School of Nursing. but the system is too sity. States must take down ricula. NY 10032. in resource deficit in comprehensive primary care. But they have not been the full contribution that could be made.edu 4 Commentary/Editorial Article_02. but we have not communicated the urgency form’s goals. 617 W. inadequate provider resources. We will hensive care practice. Not only do Comprehensive Care (DCC) full access to provision and these graduates fulfill the needs of patients. 168 Street. leading to bitter recriminations. at its most sophisticated level of this solution to those who are still crafting “health of practice. in recognize (and reimburse fully) nurses with the requisite part because of the cross-site practice authority and skills skills to become fully authorized comprehensive primary needed to follow patients wherever their care is needed. setting) for more than  years. The profession. New York. care providers. “Why so can I. Without these steps. or so can any Who will make the case? man. Columbia Univer- indeed nursing is ready to respond. Room 139. Certification from the American Board and in part because more sophisticated diagnostic and of Comprehensive Care (ABCC) can provide this assur- treatment expertise has not been taught in nursing cur.” Shakespeare had it right in King Henry IV. ance to insurers and their clients. but they also have those coaching/ as a nation have changed nothing in the cost saving areas. and O’Neil Mundinger.

In fact. Ulrich. Much of the most trusted professional groups in society. their physician colleagues. All people in this country have a significant stake that are delivered to the public and whether advanced in the outcome. sively address disparities in care. FAAN University of Pennsylvania School of Nursing. 2007).” In a roundtable discussion on health domain” (Fairman. economic. and state licensure requirements. who controls the delivery of health care to and those without a medical home. plines are open to critical reflection. but it seems especially true for the in. But who constituent group in the United States—academicians. ). ). advanced NPs because it may endanger the health and Clinical Scholars Review. and prescription are the degree that. As argued by a promi- tional Association of Community Health Centers. And. RN. defines advanced practice nursing in an era of health care politicians. policymakers. practice nurses are uniquely qualified to deliver them? And creasing number of underinsured and uninsured patients importantly. health care reform has been politicized to “clinical decision making. but why are our medical colleagues so con- more challenging for nurse practitioners (NPs) and other cerned about scope-of-practice expansions or how wisely advanced practice nurses as they legitimately assert their nursing uses its resources to educate nurses? autonomous role within a practice field that is fraught To argue against scope-of-practice expansions for with regulatory. dialogue. Philadelphia Health care reform has piqued the interest of almost every terests—both within and outside the discipline. and political in.3. public. in press). this is even development. diagnosis. this was a thorough review. including an extensive background on their This question evoked many responses. specialization. Unfortunately. 2010 © Springer Publishing Company 5 DOI: 10. care issues at a national meeting that I recently attended. and everyday reform? Who determines the type and range of services citizens. or health care needs of the chronically ill and aging seg. nent nurse historian at the University of Pennsylvania. p.1. nursing is one of the viders and their value to the common good. PhD. _ FEATURE COLUMN: LEGAL AND ETHICAL ISSUES AND TRENDS Who Defines Advanced Nursing Practice in an Era of Health Care Reform? Connie M. professional jour- the conversation centered on the value of nursing to the nals of interest. physicians?” (Daniels.1891/1939-2095. Data Series (AMA. Certainly. comparing and contrasting them to talents. Number 1. skilled laborers. . depending on one’s political persuasion. Volume 3. but the essence of education and training. how can nursing respon. an entire issue was dedicated to tion to the group: “What would ‘better care’ look like?” the role of NPs. more specifically. Unfortunately. 56 million those in need when “the demands of justice in health care Americans have limited or no access to basic health care may pose a threat to the economic interests and power of services due to primary care physician shortages (Na. Today. In the American Medical Association Scope of Practice one of the attendees asked a simple yet provocative ques. and critique tity and convey the distinct contributions it makes to the on the processes that guide their intellectual growth and health and well-being of the nation. including the unmet it does not help the public.indd 5 3/25/2010 8:09:29 PM . and should no longer be considered solely in the medical ernmental takeover. professional.5 Article_03. now the domains of several different health professionals. professionals. the public remains unaware of nursing’s inimitable preparation of NPs. all professional disci- The discipline has long struggled to define its iden. By all accounts. it is perceived as either “morally just” or a “sweeping gov. but to some concerns raised by the AMA focused on the educational degree. others understand the critical role of advanced nurse pro- ments of the population? Indeed. billing. physicians.

family. be addressed. V. Nurse practitioners: The evolution and Nevertheless. M. p. and others have asked: “What are an NP’s ca- yond the sample surveyed. “How do they differ from physicians?” To exists that indicates a causal relationship between per. UK: Cambridge together to improve the care of any patient who enters University Press. overlap exists within the realm of is important because it provides a baseline for future in. for NPs and other advanced nurses “to function ceived educational preparation of NPs and quality of care well.. A more knowledge and craft” (Sullivan. (2010). M. many individuals in our so. ing integrative solutions. must continue to exhibit exemplary technical. future of advanced practice (5th ed. None.indd 6 3/25/2010 8:09:30 PM .). receive national certification broadly about the academic educational requirements for their level of expertise. D.. profession include an epistemological body of inquiry. However. p. tyre. they need room for discretion in how they apply their or other health-related patient care outcomes. ). we sets that impact clinical practice. and our physician colleagues. civic mindedness. Benner. Hart and ues. no data currently pabilities?” Or. col- tively. those who share care responsibilities in our society if we are Some may question if it is ethical or simply fair for to meet the ethical and scientific challenges of the human others to exert a powerful influence on the professional condition and the overall health care needs of the public. boundaries of another discipline. remain unsubstantiated. and risk communication. requires empirical evidence to justify such conjectures. 6 Ulrich Article_03. Stanford. are sometimes unclear to the public. Who then defines advanced practice nursing in by Hart and Macnee (). as reported in the AMA document. Sutphen. P. Moreover. Sullivan. It should not be interpreted nega. that end. (2009). val- theless.). safety of patients (as stated by the AMA) or that the pro. Additionally. . there Jossey-Bass. CA: plinary collaboration between professional groups. Leonard. Nurse practitioners and the opportunities of health reform. Edu- discourse. all professional groups are essentially self. and in doing so. is an expectation that all health care providers will work Daniels. the health care system. everyday practice. McGivern. where knowledge and benefits and expertise of advanced practice nurses needs to innovation increase at an astonishing rate” (Benner. Kuhse () ar- gues that nurses fail both themselves and their patients if References they continually allow role misperceptions—“physicians make decisions and nurses carry them out”—to influence American Medical Association.. accurately. This includes not only the content areas outlined tinuum. Friends. Both professional competence in the provision of humanistic professional groups—physicians and advanced NPs—will care in a complementary and collaborative fashion with need to be prepared “to practice safely. the boundaries of who can quiry and necessitates a conversation on the educational rightfully care for patients within our health care system gaps that may exist. Increased public awareness of the compassionately. Macnee () found that half of the NP respondents in . but also other important skill an era of health care reform? We do. Fairman & single provider can address all aspects of a patient’s care. this should not preclude interdisci- cating nurses: A call for radical transformation. J. N. (1985). ). Today. Sut. robust research design and statistical analysis is needed they must actively convey this knowledge and authority to to determine the reliability of the findings across people. J. and are prepared to address a that will prepare practitioners for the challenges that lie range of health problems across the health-illness con- ahead. and the fundamental beliefs. ethical codes of conduct. the public. Cambridge. & Day. AMA scope of practice nursing’s agenda for the public good or dominate public data series: Nurse practitioners. however. Additionally. & Day. and norms that underlie its existence (Greenwood. and ethical decision-making. Advanced practice nurses graduate from ac- Nonetheless. Just health care. These claims. Historic and historical opportunities: ciety are chronically ill with co-morbid conditions need. O. L. professional authority and credibility. such as basic genomics. Greenberg (Eds. Chicago: Author. and do this in a way that is memorable (McIn- items. during health care reform because although each group is ment. leagues. including billing and coding for services. in press). Sullivan-Marx. New York: Springer. their survey did not feel substantively prepared for clinical Tensions will continue to exist between physicians and practice in several areas. This ranged from complementary advanced practice nurses and may even appear heightened and alternative medicine to issues of financial manage. (in press). however. ). S. as does the educational requirements for all phen. . A. all disciplines need to think more credited schools of nursing. in varied settings. The study conceptually distinct. Fairman. thus making it unlikely that a In E. Important attributes of definition for any for advanced practice in light of hospital labor shortages. ethical. as one study is not usually generalized be. In fact. and time. A. Leonard. regulating and must determine for themselves what good fession is “siphoning off ” bedside nurses to educate them ends they serve.

W. 13–23).edu Nursing Practice in a Health Care Reform Era 7 Article_03. In E.upenn. from http://nachc. Fairman. FAAN. McIntyre. Vaidya (Eds. M. (2008). Philadel- future of advanced practice (5th ed. Professions in ethical focus: An antho.indd 7 3/25/2010 8:09:30 PM . New York: Springer. J. January 3. Kuhse. Canada: Broadview Press. (2005). A. M. In F. Correspondence regarding this article should be directed to Connie ners. 19(1). H. Sullivan-Marx. A. RN. PhD. Challenges to professionalism: Work inte- tionnaire study. Journal of the American Academy of Nurse grity and the call to renew and strengthen the social con- Practitioners. E. How well are nurse research/Access_Denied42407. Allhoff National Association of Community Health Centers. (2007).). 14(1). & A. Nurse practitioners: The evolution and Nursing. O. PA 19104. 35–42. M. L. D.). phia.. E-mail: culrich@nursing. women and ethics. 418 Curie Blvd.com/client/documents/ Hart. (1997). Retrieved logy (pp.pdf practitioners prepared for practice: Results of a 2004 ques. J. Caring: Nurses. Public relation strategies for nurse practitio. Access denied: A look at America’s disenfranchised. A. Maldon. MA: Blackwell. Room 339. Attributes of a profession. University of Pennsylvania. School of & S. Greenberg (Eds. Toronto. Claire Fagin Hall.. 2010. ON. American Journal of Critical Care.). Greenwood. J. 78–84. (2007). tract of the professions. Sullivan. & Macnee. (in press). McGivern. C. Ulrich.

“What a gold mine! I never service. 29) patients result in lost revenue? Most insurance carriers allow providers in a primary As shown in Table  the CPT codes for a new pa- care setting to charge a new patient current procedural tient and new preventive patient visit with the subse- 8 Clinical Scholars Review. At last. _ BUSINESS OF ADVANCED PRACTICE NURSING Control Practice Growth: Maximize First Visits. FNP-BC. The practice and again if the patient has not visited the practice in  was located in a small rural southern town in a state friendly years. Likewise. After all. FAAN. as in the case above. the DNP was excited to provide or. Despite the fact population-centered care. one essential of DNP patients might visit the DNP on the first visit for a par- practice relates to population-centered care. See Fewer Patients. care services to a population in need. subsequent visits fall into the estab- to nurse practitioners. and Improve Practice Income Thomas A. In fact. electronic health re. Number 1. required to document at a higher level was not performed.). and a hospitable clinic environment. lished patient category (CPT codes -). referral base. During the first month of opening the practice the If an abnormality/ies is encountered or a preexisting DNP was overwhelmed when the phone rang and pa- problem is addressed in the process of performing tients booked appointments. billed at lower new patient code levels because the work physician collaboration. Now was the ticular illness. skills.3. then the knowledge. p. more appointment slots nificant. preventive medicine services can still be time to actualize the knowledge learned in school. policies and procedures. maximized. “I am so glad my DNP program gave me components of a problem-oriented EM service. the first-visit CPT code was not being dentialing. For fice.” enough to require additional work to perform the key she thought. Consequently.8 Article_04. Otherwise. a nurse practitioner with a Doctorate of Nursing terminology (CPT) code (-) at the first visit Practice (DNP) degree started a new practice. This is great. ing patients in a new practice. Volume 3. most days of the first this preventive medicine evaluation and management month were already half full. separately identifiable Evaluation and Man- filled and the DNP started to double book time slots just agement service was provided by the same physician to keep up with the demand. Rushing to deliver health on the same day as the preventive medicine service. managed care contracts. cre. cords. 2010 © Springer Publishing Company DOI: 10. The local population was thrilled to have health Additionally. (American Medical Association. Prior to opening the primary care of. build solid business infrastructure (billing. the DNP did not use the preventive care services close to home and pledged to support the medicine services code permitted to be used once a year DNP. at the first visit. I am using my skills to their fullest and should also be reported. the DNP described above. How could seeing more 2005. Modifier 25 should be added have my own business. etc. the DNP worked very hard to establish excellent com. and if the problem/abnormality is significant thought in my wildest dreams I would be this successful.1891/1939-2095. provided and reflected with the CPT code and charged. PhD.” to the Office/Outpatient code to indicate that a sig- As the month progressed. the DNP failed to The appropriate preventive medicine service is ad- realize how much revenue was being lost by double book- ditionally reported. more office visits were being munity relations.indd 8 3/25/2010 8:09:58 PM . and confidence to open up my own the appropriate Office/Outpatient code 99201-99215 practice. Mackey. FAANP University of Texas School of Nursing at Houston Recently.1.

Suite not the key to increasing charges.386 (40–65 y/o) US$125. TX 77030. the occasion to code and then documents and charges at the . FNP-BC. US$. Chicago: Author.63 Same 99.204 US$143. Mackey. when the DNP sees four patients at the .and gender-specific history. Learn and practice. the a new patient preventive visit only knocks once: the first income is US$. level per hour. When the DNP opening a new practice fills be billed as an established patient visit and will be reim- the schedule with four patients per hour (-minute visit) bursed at a much lower rate. per Correspondence regarding this article should be directed to Thomas year. when the DNP time a patient visits the practice. CPT Codes. Usually. less) American Medical Association. Such a scenario demonstrates numbers of patients are A. Take advantage of the sees only three patients per hour (-minute visit) provides opportunity.tmc. per week.19 Expanded problem-focused history and exam plus straightforward medical decision making 99. Rather. Thus. On the other hand. exam.387 (>65 y/o) US$137. level. CPT 2006 professional for the practice. and documents a new preventive visit Mind your nursing business.385 (18–39 y/o) US$107. counseling/anticipatory guidance/risk factor reduction interventions..). TABLE . FAAN.56 Same quent Medicare-allowable rates are quite different from Once the patient is seen in clinic. Houston.. (2005). per day.A.Mackey@uth. the next visit must one another. some preventive care. PhD. to potentially lose US$. seeing more patients would result in a lower income (US$. E-mail: Thomas. and US$. Medicare Allowable (Example). edu Control Practice Growth 9 Article_04. labs/diagnostics 99.34 Age..202 US$64. US$.indd 9 3/25/2010 8:09:58 PM . charged determines the charges generated by the DNP. per month. the CPT code 1620.80 Comprehensive history and exam plus medical decision making of moderate complexity New Preventive 99. 7000 Fannin. FAANP.. Over an -hour day such a practice stands edition. and ordering of appropriate immunization(s)..203 US$93. the income increases to US$. (. and Work Documentation CPT Code Medicare Allowable (Example) Work Documentation New Patient 99. level rather than Reference three patients at the .30 Detailed history and exam plus medical decision making of low complexity 99.

The care is typically delivered by a characteristics of retail clinics. champions lights of particular relevance in our journal.  projects across the health policy spectrum. research focused on three areas: • Retail clinics typically serve younger adult patients . peer-reviewed documents.S.S. Costs. with extended weekend and evening hours. with an international reputation for conducting ments. • Most (%) U. The population can easily access a clinic. vider groups. Pro- some key findings in short. Robert Brook. urban researchers conducted several studies of retail clinics. and preventive care delivery: How cian and  in  visits to an emergency department do retail clinics compare on these dimensions with (ED) are for a problem that can be treated at a retail other health care settings? clinic.10 Article_05. RAND researchers examined the and preventive care. At any given time. Using cross-sectional data nurse practitioner. retail clinics de- them? liver lower-cost care of equivalent quality compared .000. such as the American Medical Association. the lost opportu- Dr.3. such as bronchitis. Retail clinics are medical clinics located in pharmacies. To date. They offer care for simple acute conditions. retail clinics are located in major To improve understanding of these issues. Health highlights Retail clinics have also generated controversy. Volume 3. 2010 © Springer Publishing Company DOI: 10. what services do they offer. In two different projects.indd Sec1:10 3/25/2010 8:10:47 PM . user-friendly Research Highlights. no appoint- icy research. RAND Research briefs present policy-oriented summaries of published. Conversely. The Highlight of the retail clinic model have pointed to their potential in this issue focuses on health and medical care spending of benefits: Retail clinics provide a less costly alternative to the elderly. RAND vice president and director of nities for preventive care. the team identified This product is part of the RAND Corporation research brief series.rand. Number 1. All of RAND Health publications and Research care for patients who otherwise would go to EDs.1891/1939-2095. retail clinics.org/health. quality. which are intended to disseminate research to professionals both have raised concerns about quality-of-care issues. Patient characteristics and service use: Who uses with other settings. increasingly widespread. includ- inside and outside the Health arena. Retail clinics are becoming policy-relevant research of the highest quality. and what services do patients obtain? • Approximately  in  visits to a primary care physi- . and the disruption of existing RAND Health. The first retail clinics opened in Health’s more than  professionals are working in more than 2000. Retail clinics emphasize convenience. has encouraged us to include Research High. and short wait times. and who owns • For a selected group of conditions. ing the overprescribing of antibiotics. RAND Health metropolitan areas. and by 2008 they numbered close to 1. 10 Clinical Scholars Review.1. patient–physician relationships. Highlights are available at www. such as Target. Most Retail Clinics Operate in Large Metropolitan Areas grocery stores. the controversy over retail clinics has occurred without much factual grounding: There has been little Key findings: empirical analysis of clinic characteristics and activities. _ FEATURE COLUMN: COMMUNITIES OF INTEREST Health Care on Aisle 7: The Growing Phenomenon of Retail Clinics RAND Health is the nation’s most trusted source of health pol. A profile of retail clinics: Where are retail clinics who do not have a regular health care provider. located. from industry and foundation sources. and “big box” stores. and one-third of the U.

conditions. Louis Richmond Los Angeles Nashville Raleigh-Durham Charlotte San Diego Phoenix Atlanta Dallas Tucson Jacksonville Austin Houston Orlando Number of retail clinics Tampa Miami 46–65 26–45 16–25 6–15 2–5 1 Figure 1. Texas. Source. Paul Detroit Milwaukee Cleveland New York Chicago Pittsburgh Philadelphia Columbus San Jose Indianapolis Washington. The results showed that retail clinics are widespread and easily accessible to large numbers of Americans. Even after adjust- such as the Mayo Clinic. cally underserved neighborhoods than in other areas. clinics were located in five states (Florida. urban population lived Ownership within a -minute driving distance of a retail clinic. Location of retail clinics in the United States. Minnesota. DC Los Vegas Kansas City St. and gust 2008). and Mehrotra (2009). Califor- nia. Minneapolis-St. but these organizations operated only % of chains. pregnancy testing. but the Services results did not support the claim that these clinics are im- proving access to care for underserved populations. 982 retail clinics operating in the United States (as of Au. RAND Health Research Highlights 11 Article_05. Reprinted with permission. immunizations. More than % offered treatment of skin served areas. Pollack. Walgreens. since • All clinics offered treatment for pharyngitis (sore most of the clinics were located outside medically under- throat). Rudavsky. the average cost for a sore (%) and Midwest (%). and Tar- of metropolitan areas that had lower poverty rates and get—operated % of the clinics. clinics were less likely to be located in medi- the clinics. • Retail clinics were more likely to be located in regions • Three organizations—CVS. Aurora Health Care. • Nearly all accepted private insurance (%) and Geographic Distribution Medicare fee-for-service (%). % accepted some form of Medicaid. and ing for the location of pharmacies and supermarket Sutter.S. • The majority of retail clinics were located in the South • For an uninsured patient. in medically underserved areas. Nearly half (%) of all throat visit was US$.% of the U. An estimated . see Figure ). More than half higher median incomes. Census tract analysis of  of the  organizations that operated retail clinics clinics indicated that only % of clinics were located were existing hospital chains or physician groups.indd Sec1:11 3/25/2010 8:10:48 PM . and Illinois. Analysis of these clinics revealed the following: lipid or diabetes screening.

see Figure ). (US$.indd Sec1:12 3/25/2010 8:10:48 PM .3 million visits to retail clinics from 2000 to 2007 and Retail Clinics Offer Lower-Cost. respectively). or EDs. ED aver- conjunctivitis. clinics. the proportions of 0 Retail Physician Emergency patients who received preventive care within  months clinics offices departments of their first visit did not vary significantly across the Figure 2. enrollees in a large Minnesota health plan who received Nationally. The aggregated scores were similar clinics on existing patient–physician relationships. compared with % of visits to tiated at retail clinics were substantially lower than primary care physicians. sore throat. Overall. There have been concerns that retail 30 clinic visits represent missed opportunities for pri- 20 mary care doctors to identify and provide missing pre- 10 ventive care. and physician. physician offices. simple acute conditions and preventive care: upper Average prescription costs were similar in retail respiratory infections. Despite concerns that retail 90 clinics would overprescribe antibiotics. Data are drawn from authors’ analyses of claims data obtained fices. this group made up only % of patients care for one of three common conditions: otitis media (in- who visit primary care physicians (see Figure ). Analysts used claims data from age –. ancillary tests) in which these illnesses were treated first in ally who reported a usual source of care. % for sore 60 throat). other health care settings. primary care physician offices and % of ED visits. and urgent care centers immunizations. The only regular provider. Similar-Quality compared information from that analysis with national Treatment for Some Medical Conditions data on visits to primary care physician offices and EDs. urgent care centers. swimmer’s ear.  non-ED settings (retail clinics. physician offices. for retail clinics. Another study examined the characteristics of patients and thus it is possible that retail clinics could be a substitute who use retail clinics and the medical services they site of care for some patients who now seek care in EDs. inner ear infections. • Two-thirds of retail clinic visits were paid for with • Costs of care. researchers developed quality scores for the four Though the research did not examine the impact of retail provider settings. and EDs (see Figure ).%. receive. and US$. RAND researchers analyzed details of more than 1. those of matched episodes initiated at physician of- • About % of visits to retail clinics were for  fices. and screen blood age prescription costs were slightly higher (US$). 40 • Preventive care. pharyngitis. . costs of care for episodes ini- health insurance. US$. sinusitis. Another study examined the costs and quality of care at According to the study’s findings: retail clinics and compared these with costs and quality in • The largest group of clinic users was young adults. The exception was that a smaller proportion of high-risk patients received a urine culture at retail clinics. 100 • Antibiotic prescribing. deliver poor quality care. tests. Despite this concern. . flammation of the middle ear).%. pharmaceuticals. . or urinary tract • Retail clinic patients were less likely to have a per. overprescribe antibiotics. Typical Retail Clinic Patients Are Younger Adults With results provided some support for the view that retail clinics No Regular Provider are attractive to patients who do not seek care at doctor’s of- fices. urinary tract infections. physician offices. or ad- 12 RAND Health Research Highlights Article_05. retail clinics. physician of- Note. who accounted for % of patients. and EDs (% and %). it is no. urgent care centers. bronchitis.%. Adults under 45 were the heaviest users of retail clinics. Using  quality-of-care measures. compared with % of patients nation. so there was no relationship to disrupt. The same conditions accounted for % of visits to • Quality of care. The profiles of ED and retail clinic users were similar. Treatment was aggregated into care episodes (in- sonal doctor: % said that they had a primary care cluding initial and follow-up visits. and lower for EDs (see Figure ). urgent care 50 centers (% and %). the share of Percentage of patients 18–45 80 patients who were prescribed antibiotics was similar 70 for retail clinics (% for otitis media. physician offices (% and %). urgent care centers. and urgent care table that the majority of retail clinic patients did not have a centers. infection. from retail clinic companies and survey data from the National Ambulatory Medical Care Survey and the National Hospital The results did not support concerns that retail clinics Ambulatory Medical Care Survey.

(2008). Columbia University. ownership.. Lave. 945–949. Pollack. Retail clinics had similar at retail clinics with that of other medical settings for 3 com- quality of care compared with physician offices and urgent mon illnesses. versely impact preventive care..S. E-mail: mc1313@columbia. examining more closely the patient facing the public and private sectors around the world.rand. Based on data presented in Mehrotra. Adams. Annals of Internal Medicine. Retail clinics provide comparable quality. RAND is a registered trademark. (2009).. E. since retail clinics are more likely to be located in rela- tively affluent sections of large urban areas. primary care physicians. Note. RAND’s populations and geographic areas that retail clinics serve. J. was conducted only in Minnesota. NY 10032.. M. Rudavsky. the National Center for Re- have gone to EDs used retail clinics instead.. E.. M. How. 168 geson. J.&Armstrong. antibiotics were prescribed in almost all cases at each site. RAND Health is now conducting objective analysis and effective solutions that address the challenges some of this work. The geo- These studies uncovered little evidence to bear out con. Retail clinics provide comparable quality at lower costs without discouraging preventive care.org/health. The geographic accessi- and among patients of only one retail clinic chain. C. Archives Concluding Thoughts of Internal Medicine. among insured patients. and urinary tract infection.&Mehrotra. They treat a limited number of conditions at lower cost and equivalent quality relative to other settings. This Highlight Summarizes RAND Health Research Reported in the Following Publications Correspondence regarding this article should be directed to Manuel Mehrotra. The study emergency departments: A comparison of patients’ visits. Cortazal. Support for this research was provided by the did not determine whether patients who might otherwise California Health Care Foundation. health care system RAND Corporation is a nonprofit research organization providing across all dimensions. 321–328.. . Abstracts of all RAND dustry.. Adamson. Clinics frequently serve a popu. Retail clinics. 1272–1282.. urinary tract infection. (2009). A. gram at the University of Pennsylvania. bility of retail clinics for underserved populations. Note ever.. tice at retail clinics. 315–320.edu RAND Health Research Highlights 13 Article_05. tient convenience. Mehrotra.&McGlynn. Wang. 617 W. N.. (2009).indd Sec1:13 3/25/2010 8:10:48 PM . A. Liu. Liu. Comparing costs and quality of care Street. H.. care clinics and surpassed that provided in EDs. Annals of Internal Medicine.. L.. A. 151(5). A good deal more study will be required This research highlight was written by David M. publications do not necessarily reflect the opinions of its research clients and sponsors.. Adams.. (2009). Retail and The Robert Wood Johnson Foundation Clinical Scholars Pro- clinics represent a growing segment of the health care in. Health Affairs. K.without discouraging preventive care Retail clinics Physician offices Urgent care centers Emergency departments 0 10 20 30 40 50 60 70 0 100 200 300 400 500 600 0 2 4 6 8 10 12 14 16 Meets quality indicators across three Overall costs per episode ($) Any preventive services provided within conditions (%) 3 months of start of episode (%) Figure 3.. MS. pharyngitis (sore throat).. search Resources (a component of the National Institutes of Health). The to understand their impact on the U. Further research is needed to examine this issue. Health publications and full text of many research documents can be found on the RAND Health Web site at www. Wang. prices. based on a new model of care that emphasizes pa. the researchers caution that their findings might not gener. Lave.. R. M. et al. and scope of prac- cerns about retail clinics. and alize to care provided at all retail medical clinics. E. A. Thy. The analysis Acknowledgments. C. R. 169(10). et al. . R. 27(5). Conditions studied were otitis media (inflammation of the middle ear). lation that lacks access to a regular primary care provider. L.. the research also did not support the claim by some champions of the retail clinic model that these clinics are 1. J. New York. C.at lower costs. improving access to care for the medically underserved. J. However. C. For the third condition studied. Source. School of Nursing.. Pollack. 151(5). graphic distribution.

poster evaluation. Examples of an EBP literature review and a DNP student poster are provided. The purposes of this article are to provide suggestions for EBP poster creation and to describe the process of developing a Poster Evaluation Rubric for Evidence-Based Practice (PER-EBP).3.indd 14 4/5/2010 10:36:02 PM . Miracle formation regarding how to create posters for research dis. be provided to staff in a poster format. Keywords: evidence-based poster. Miracle noted that new policy information might practice improvement” (p. 2004. there is a need for clear criteria identifying the essential information to be shared. Garrison of the literature and other documents from which the new & Bushy. Findings from such innovative efforts ought to be widely distributed. aimed at some specific objective. Minnesota Tracy L. . Number 1. Maltby & Serrell. & Poole. Volume 3. evaluation rubric. the challenge to better accommodate EBP poster presentations has been unmet. how to share it effectively.14 Article_06. Bushy. According to Matchar et al. Miracle (2008) provided guidelines for research real benefits of an evidence report are achieved through poster presentations at professional meetings or in clinical dissemination . Synthesis of existing evidence is imperative 14 Clinical Scholars Review. McDaniel. Wright Minnesota State University Moorhead Cindy A. The doctor of nursing practice (DNP) degree has created opportuni- ties for nurses to implement EBP projects in collaboration with academic and clinical teams. provides a guide for EBP poster creation and criteria for EBP poster evalua- tion by self and others. However. 1993. 2010 © Springer Publishing Company DOI: 10. The PER-EBP tool. 1991. EBP dissemination It is vital to disseminate evidence-based practice (EBP) 1998. yet such projects have unique dissemina- tion needs that are not readily met by traditional research-based presentation venues. such as settings. (2005). policy is based. Scherb Winona State University. Despite a breadth of in. Ohio The international emphasis on evidence-based practice (EBP) as a basis for quality care has elevated the importance of EBP dissemination. Minnesota Phyllis M. _ BRIEF REPORT Disseminating Evidence-Based Practice Projects: Poster Design and Evaluation Diane McNally Forsyth Winona State University. 2007. “the stance. To facilitate timely and quality dissemination of EBP projects. Sexton.1. Thus far. developed by the authors. Johnson & Green. . Gaspar University of Toledo. and how to evaluate the end product. For in- in other settings. Bach. 1120).1891/1939-2095. Current literature focuses on presentation approaches for research-based poster content and evaluation rather than EBP posters. 2009. 1984) there findings to stakeholders and other health care professionals is a lack of thorough direction in the literature regarding so that innovations for practice can be replicated or applied dissemination of EBP efforts via poster format. did not mention approaches for presenting the synthesis semination (Burns & Grove.

2000). upon a search of the literature. Betz. An evaluation tool for EBP posters was cific units or public places in health care settings.to post-tests of knowledge regarding Dissemination Method content. posted to guidelines to assist the students in preparing their EBP websites that target key audiences. to efficiently and succinctly disseminate knowledge (Sex- tion Rubric for Evidence-Based Practice (PER-EBP).. pathways. most likely to engage in a rich discus- Stevens (2005) differentiated how clinical changes are sion. Posters are a means of address. Posters as an Evidence-Based Practice p < . . active participation. had learned from the processes of creating and presenting a sionals and are thoroughly presented by Betz et al. Smith.indd 15 4/5/2010 10:36:04 PM . consumers. & Dunstan. no This form of dissemination is a rapid method to educate tools were found for evaluation of EBP posters. or protocols. poster formats resources were void in the literature. Hess. ). ton. Since parties when a project is on-going. Moore. had from EBP efforts. Unlike podium or oral pre- is the dissemination of findings. Information provided in a poster for- the immediate need to provide guidance to DNP students mat enhances the credibility of the project for consumers regarding dissemination of EBP projects via a poster and who are a part of the project. While Betz et al. The au. . also created by the authors. Halligan () found only a few empirical studies tions into actual practice and addresses the efficiency of (Horn. (2004).. the poster setting is less formal and not bound translation. A few tools share up-to-the-minute information and are displayed are available for evaluating research posters (Bushy. Augspurger. or polices. & Proffitt. The dissemination. evidence. and most apt to provide feedback to the presenters. . Russell. However. 2007). Knowledge synthesis. thus creating a nonthreatening atmosphere for cians via clinical guidelines. lated to poster presentations. Finally. diverse. and displayed in spe- poster content. and learning. and exchange are vital to strengthen health by time restrictions. Posters are also helpful in educating the public and thors of this article. sentations. outlined pragmatics of tively easy to construct and provide a helpful means for general poster content and construction. outcomes. people. Posters are used at professional conferences to ists regarding how to evaluate EBP posters.. the final phase for EBP area for further dissemination. The foci of these studies were ing both the translation and integration of EBP. concise way ( Jackson & Sheldon.) from pre. The participants indicated that limiting information EBP Poster Design and Evaluation 15 Article_06. Gregory. Fuller. who are faculty teaching in a doctor. change adoption into the practice of individual care pro. mechanisms for nurse clinicians to present their EBP projects in a forum. The Miracle () noted that posters are effectively shared first stage includes translation of evidence into practice with small groups of staff to circulate current research or where summarized evidence is readily provided to clini. ) re- viders and organizations. a gap in the EBP literature ex. & Carpenter. posters are a to determine a mechanism for evaluating EBP posters as a method of keeping communication flowing to interested part of the doctoral students’ final capstone projects. and improve practice decisions based dialogue with the poster presenter are those most inter- on current clinical evidence ( Waters & Armstrong. King. n. ) found that posters at- tracted more staff participation than short oral presentations and there was a significant increase in learning (t = . and Rickey A poster serves as a storyboard to share information in a (2004) provided an array of options to disseminate evidence. ested in the poster. inform policy. Gates. second stage involves integration of these recommenda. others. Smith. the faculty developed are also distributed electronically to list servers.d. . Usually. ) as well as share in-depth. For ex- Evidence-Based Practice Dissemination ample. informing stakeholders about the processes and products ate of nursing practice (DNP) consortium program. One study (Horn et al. those viewers who stop to care. Posters broadly disseminate findings to a variety of As previously stated.. poster. transformed into practice using a two-stage process. the ability to ask questions of the poster presenter about literature reviews or outcomes from EBP projects Importance of Dissemination of Evidence may allow a viewer to take information back to the work As with the research process.. ). EBP poster evaluation were absent. Melnyk. & als about practice changes. The purposes of this article are Advantages of posters presented at a conference or in to provide some suggestions for EBP poster creation and an open forum include the ability of the poster presenters to describe the process used to develop the Poster Evalua. or other health care profes. findings. for EBP dissemination. individualized infor- mation about the EBP project (Betz et al. ) surveyed Numerous methods are appropriate for EBP dissemination poster presenters at a conference to determine what they to stakeholders. Posters are rela- including posters. Additionally. The second study (Moore et al. Kopser. at health care facilities to inform health care profession- Garrison & Bushy.

2004. The 2009 MNRS criteria for EBP post- for the poster presentation. (b) following conference guidelines. The background. They found that students preferred poster with the title at the top and the content presented in the presentations to individual oral presentations and that the columns that are read in a downward sequence from left poster format decreased their nervousness. data to note importance of the problem Synthesis of evidence guiding practice change is reflected in Clinical question stated abstract. Article_06. Thompkins. 1996) and should be at the top center project information is essential to ensure active involvement of the poster. Provision of a to right. (e) balancing content with white space. Handouts are especially helpful to educate creation (Bauldoff & George. A complex data analysis should be avoided. It is Society’s guidelines for EBP posters (MNRS. Smith... as the process of literature review. information about the 1996. Russell et al. Additional detailed assessment guideline is necessary in the scoring of materials. Additional fine points. 2008.. Johnson and Green () explored the response of the poster space is divided into three columns. 1990) is common. Miracle. where manner. ) explored the ratings of post. such as poster EBP Specific Poster Formatting size and type (hanging or freestanding). Additionally.indd 16 4/5/2010 10:36:04 PM . 2004) Purpose is clearly stated Statement of the problem—background. such Maltby & Serrell. are There are many sources outlining the esthetics of poster also an option. as well as the stakeholders will view the poster. The poster undergraduate students who completed poster presentations is organized to reflect a newspaper-like reading sequence in class (n = ). 2004) provide reminders of poster (research or EBP). references. 2000. development include: (a) early planning with a clear focus. The rule and promote continuous learning in a creative and effective of thirds (Duchin & Sherwood. strength of evidence addressed. (2004). less stressful and inviting environment to disseminate EBP is vital (Russell et al. Melnyk. such as clinical pathways or project outcomes. 2009) and also important to consider who the target audience is Betz et al. Halligan noted that posters can assist may be appropriate especially for clinically-based viewers. 2009) General Suggested Content (Betz. along with the project author(s). rationale. link between nursing implications and best practices Proposed change in practice discussed Search for evidence/accepted practice—methods. in addition to the poster. the world of nursing to narrow the research-practice gap A three-or-four column display is recommended. and/or noted by these authors are important to follow in any type contact information (Betz et al. and purpose of clinically-based health care professionals. & Ricky. for the actual poster display. are normally at the top left with the conclusions (find- ings/product/outcomes) presented at the bottom right. (c) using bullet points or abbreviated wording. others about the project minutiae that are too detailed Duchin & Sherwood. 1984. For instance. 1999. At Creating a Poster for EBP Dissemination professional conferences. it does not need to be provided on Basic Elements of Research and EBP Posters the poster itself. therefore. Betz et al. an abstract is already provided in the program. sources used to collect evidence Strategies to be used for implementation outlined Presentation and critical appraisal of the evidence—summary of conclusions drawn from evaluation of evidence Stakeholders identified Describe clinical practice implications Method for evaluation of change discussed Significance of the work to this conference 16 Forsyth et al. Sexton. health care jargon and importance of relating to others during the presentation. tations of a poster may require that handouts be used to ers at a scientific conference.. The poster title. instruments. 1998. The space limi- third study (Smith et al. These authors reported that a assist in providing information to the viewers. Basic principles theoretical framework. posters. significance. Jackson & Sheldon. (d) incorporating pictures Table 1 shows examples of common content for an EBP or graphics.. Common Content for EBP Posters MNRS Criteria (MNRS. Handouts. 1990. if public or lay ers (for students) provided specific guidelines to follow TABLE . and poster as derived from 2009 Midwest Nursing Research (f ) using a large font size for viewing at a distance. 1995). on the poster was the most challenging. Elements essential for poster to assist the audience and make the poster memorable.

When showing the de- purpose is to convey rationale for the implementation of velopment of the evidence foundation. when combined evidence. a clinical guideline). ). it is important to follow the specific criteria Since the poster is a storyboard. ). The  is an example of a DNP student’s literature review for poster is merely one step toward promoting individuals poster presentation wherein themes are grouped by level and the organization to widely and sustainably integrate of evidence and key references noted (Thackeray. (Appraisal of well in a poster. and major con- clusions (Betz et al. for posters accepted at their annual conference. ). The target audience of the thesis of the literature is complex and difficult to capture poster will change the focus and details of the process pre- concisely in a poster. by Betz et al. The theoretical basis of primary audience. on the implementation process. which addresses “population. Table the adoption process and the benefits of adoption. ). including education for staff or stakeholders. the evidence and ing approach is to list publications chronologically. thorough understanding of the research practice change. the EBP into practice. “substance and design. Sexton. As noted Customization of the Poster for the Target Audience previously. comparison intervention or group. There are be interested in factors that facilitated and hindered the many ways to show the literature in a concise manner. such as the top left side. findings or outcomes of the project. The development was necessary since. The content of the poster will de- Another approach for succinct display of evidence is to pend on the audience and purpose. another organiz- a change in policy to unit nursing staff. However.. the rigor needs to be conveyed. one should consider how provided by conference organizers. Those viewing the poster want the key process. For instance. As Miracle () stated. For ers. can serve as an effective vehicle for con- Guidelines for Research and Evaluation) which assesses veying information to colleagues” (p. . which is mainly visual and allows sented. if the audience consists of clinicians who will whether examination of the poster in more detail is war- be implementing the suggested changes from the proj- ranted. such as the method(s) used to gather Process of Evaluation Tool Development data. “Remem- tation of the practice change in their organization would ber. some content about the on the method used for the EBP project. manuscript for the purpose of evaluating DNP student propriate for the intended audience. any EBP project and reflects the critical thinking of the Usually. provide other professionals the opportunity for critical re- Depending on the clinical issue. they show” (p. regu- the project should also be included. elements such as cost analyses. and change. after a lit- EBP Poster Design and Evaluation 17 Article_06. the purpose of a poster in a clinical arena is presenter(s). this syn- information about the process. If administrators are the p. such as the AGREE instrument. ). If the depict ranked levels of evidence. com- drive the entire EBP project and are of interest to view- ponents of the entire project should still be noted.g. the quality of clinical guidelines (AGREE Collabora- tion. and excellent writing skills. posters do not tell. the literature review and the process of obtaining the out- PICO format. as these should elements are deemed a priority to the audience. the main focus of the poster can be outcome of interest” (Melnyk & Fineout-Overholt. is general and may be used for various EBP 2000). posters. What makes the most sense to a prospective audi- posters. However. and/or utility information Synthesis of the literature is a vital component of should be highlighted. Other content within an EBP poster may be similar Evidence-Based Practice Poster Evaluation to a research poster. (). The content suggested the project’s story should unfold ( Jackson & Sheldon. it may be important to view of the project.. Those reviewing the poster for possible implemen- minimal content. According to further tactic is to use existing tools to summarize the Betz et al. This information assists the reader in determining example.indd 17 4/5/2010 10:36:04 PM . intervention come is needed to lend credence to the suggested practice or interest area. If the purpose is to briefly outline the process and types of evidence searched. Implications for The PER-EBP tool was developed by the authors of this nursing practice should be included at a level of detail ap. . The format of the clinical question may depend ect (e. lations guiding the project. ence? Do they want more about research evidence or do Statements regarding the significance of the clini- they want to know about the process? Are the outcomes cal problem and the clinical question are included in a of the project the most important element? Whatever prominent place. A change in quality of care is essential content. ). process. is common for EBP work. If the purpose is to promote the adoption of the A decision is needed regarding the approach for orga- project within the organization. EBP literature synthesis requires detailed to provide a summary for care providers to translate a organization. the details are specific to nizing the multifaceted EBP literature synthesis.

Next. Kaplan. Byham et al. other graduate nurs- ate EBP posters. Day (2000). could lend insight and new perspectives to the PER-EBP tium Program and a useable draft was developed. but was ing faculty consented to participate in the evaluation of not originally developed for application to EBP posters. Gandossy and Verma (2006). Note. McConnell recommend solutions SOE I (n = 1): RQR (1) (2006). Redman (2006) 3. Soares (2002) 2. Tourville. During the student capstone mission to adapt the tool for EBP poster evaluation. This feedback EBP poster evaluation tool. Bower (2000). Noyes. Bolton and Roy (2004). Level VII: Evidence from the opinion of author and/or reports of expert committee.5) (2006). dent EBP posters.75 × 2. After the authors refined the tool. • Assess critical positions SOE VII (n = 10) and Pease (2002). (2002). and Glazer (2006). LeBoeuf (2007). RQR = Research Quality Review Score. graduate nurs- 30-item tool for appraising research posters. National Center for Healthcare Leadership • Firm commitment to execution (2005). Nursing Executive Center (2006). Byham. . Groves (2006). was contacted and granted per. Harris et al. Article_06. National Center • Job assignments for Healthcare Leadership (2005). LeBoeuf (2007). Source. 10).5) (2006). Gandossy and Verma (2006). and usability of the tool. • Identify and develop talent SOE VI (n = 4): RQR (1. Soares (2002) 4. Rollins (2003). university IRB was secured. Ponte. tool and process. Comments semination. Goudreau and Hardy • Target the development of bench strength and . Preliminary validity and reliability mea- 18 Forsyth et al. McConnell advancement SOE V (n = 1): RQR (. • Action learning SOE V (n = 1): RQR (. Fralic and SOE VI (n = 2): RQR Morjikian (2006). Goudreau and Hardy (2006). The R-PAT is a well-known was used in revision of the criteria. TABLE . Magnum (2006). Cadmus (2006). Gross. Galante. Develop a Senior Nurse Leader Fellowship Program • 360-degree feedback multisource rating of Effective Bellack and Morjikian (2005). Nursing Executive Center (2006). • Mentoring of protégés SOE VI (n = 7): RQR (1. Cadmus (2006). (2001). These criteria tium program was having access to faculty members who were developed into a rating scale that was congruent with may not have been involved in the course and therefore the evaluation criteria schema used in the DNP Consor. DNP faculty evaluated the stu- Several steps were involved in developing the PER-EBP. Conger and Fulmer (2003). student posters using the draft PER-EBP tool. Level VI: Evidence from a single descriptive or qualitative study. and Robinson (2002).5) and Triolo (1998). (2002). Redman (2006). criteria for creating an EBP poster were developed for ing by multiple faculty provided feedback about content a course assignment based on the literature for EBP dis. Smith. Thomas and Herrin (2008) Level V: Evidence from systematic reviews of descriptive or qualitative studies. Create a Succession Planning Framework • Align program with strategic direction Effective Bolton and Roy (2004). Bushy’s (1991) R-PAT (Research Poster ing faculty members teaching in the DNP Consortium Appraisal Tool) was used as a beginning template for an Program were asked to provide feedback. Day (2000).indd 18 4/5/2010 10:36:04 PM . Thackeray (2009). Melnyk and Fineout-Overholt (2005. performance SOE VII (n = 7) (2002). McNally. Corso (2002). poster event presentation. Rollins (2003). Identify Senior Leader Competencies to Develop Through a Fellowship Program • Align competencies with strategic direction Effective Bellack and Morjikian (2005). Gandossy and Verma (2006). . National Center for Healthcare • Ensure development takes place Leadership (2005). Next. SOE = Strength of Evidence. . The use of the PER-EBP tool and scor- First.75 × 4.5 × 2) (2002). Byham et al. Collins and Holtan (2004). validity. Mahaffey. An advantage of the consor- student assignment criteria and EBP content. Collins and rigorous selection process SOE VII (n = 10) Collins (2007). Redman • Measure program and placement of protégés (2006). p. these criteria were compared with Bushy’s from faculty regarding PER-EBP tool utility and sug- () R-PAT and items were added or deleted based on the gested changes were solicited.75) National Center for Healthcare Leadership (2005). Corso • Diagnose developmental opportunities and SOE VI (n = 2): RQR (. Formal Bushy. Garman • Executive coaching . Groves (2006). no published tools were found to evalu. (1.5 × 2) and Tyler (2004). the R-PAT author. Modified from Guyatt and Rennie (2002). Determine a Succession Planning Process • Identify high-potential candidates through aEffective Bolton and Roy (2004). • Congruent with performance management SOE VII (n = 5) Byham et al. erature review. feasibility. Bower (2000). Example of Synthesis of Evidence for Poster Display Activity of Interest Level of Effectiveness References 1.

4/5/2010 10:36:04 PM . If three items were marked not applicable.  Text is legibly readable from 5 feet. Draft of Poster Evaluation Rubric for Evidence-Based Practice (PER-EBP).  Concise analysis of data collection and relevant project information are          provided with results in a sequential/logical manner.           Relevant processes of project implementation are noted (e.          Information appears applicable to the clinical problem. Poster Evaluation Rubric for Evidence‐Based Practice (PER‐EBP) Article_06.      Correct spelling.          Handouts enhance/adjunct the poster content.          Current evidence (including the rating of the evidence) related to the          clinical problem is succinctly presented.            SUBSCORE D: _____                                                                                                                                                TOTAL POINTS: _____                                                                                                                                               *PERCENTAGE:   _____  (Total Points x 2)    *If the not applicable selection was used. barriers. graphics.      Information regarding protection of human subjects. and charts are relevant/contribute to the topic          and the audience.          Cost analysis is provided and adequate.          Overall content is logically arranged/organized to depict the process. grammar.indd 19 Directions: Rate each of the scale items using the rating descriptors provided below.  Clinical practice implications are described.    SUBSCORE C:  _____  Category D: Presentation/Professionalism  Rate the level at          which the:  Author was available to respond to viewer’s questions.             SUBSCORE B:  _____  Category C: Content  Rate the level at which the:          Title reflects the essence of the project. key          stakeholders. setting.  Project recommendations/outcomes/findings are highlighted in manner          appropriate for the audience.   Theoretical and/or EBP framework are identified.          Future plans for project are detailed.          Author was knowledgeable about the subject matter and able to answer          questions.        SUBSCORE A: _____  Category B: Overall Appearance  Rate the level at which the:  Exemplary  Average  Weak/Absent  Not  2 pts  1 pt  0 pts  Applicable  Display holds the viewer’s attention and provides overall attractiveness.g. divide total points earned by the total points possible to determine the percentage. affiliation.          EBP Poster Design and Evaluation Text.  Author professionally presented him/herself.           Methods/procedures for project implementation are clearly stated.g.   Category A: Essentials  Identify if the poster display contains:  Present  Weak/Absent  2 pts  0 pts  Author’s name..     (e.      Appropriate focus on intended audience. the total points would be divided by 22 to determine the percentage)  19 Figure 1..          Purpose/aim/goal is clearly stated.          Clinical question is clearly stated. facilitators of change). and APA. and          identified population. and funding sources (if applicable). pictures.

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Winona State University DNP student) for use of her Synthesis NCHL white paper on best practices in leadership succes- of Evidence example in Table 2.S.. W... Modern Healthcare. ness. Seminars for Nurse Mana. 18(6). W. 30–32. Winona State gers. 100–104. R. Paul. & Gates. Collegian. 2009.org/files/public/CallforPosters09. K. F. Seminars for Nurse Managers. Hess. University. March). M.. 5–16. (2007. G. (2006). O.. Executive Nurse Fellows Program: A model for learning in date: Getting their attention. B. 27(3). Bach. (2005). McNally Forsyth. Woolf. Science Center at San Antonio. Winona. 3). Soares. 240–243. (2006). C.. 42. St. 91–98. Aesthe- aura: Preparing a poster. 340–341. V. Mulrow. 34–35. & Dunstan. 10(4).. Preparing tomorrow’s leaders through succession planning Correspondence regarding this article should be directed to Diane from the provider perspective. from http://www. Angeline Bushy for her per- Applied Nursing Research. D. 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health and well-being (NCCAM. mind-body intervention The utilization of complementary and alternative medi. 2007). The and 80. However. _ LITERATURE REVIEW An Evidence-Based Review on Guided Imagery Utilization in Adult Cardiac Surgery Jesus ( Jessie) Casida. Number 1. . adult cardiac surgical population typically have included demic medical centers. ).1. A report published by the or visualization of tranquil or peaceful sceneries. enabling NCCAM at the National Institutes of Health suggests the patient to enter into a relaxed state and/or directing that guided imagery. Sendelbach. . & Wild. Research has become more prevalent among adult cardiac surgery outcomes surrounding guided imagery utilization in the patients. tion to positively affect mental attitude and potentiate native Medicine [NCCAM]. 2002. ). & Cosgrove. CAM use positive outcomes” (Ezra & Reed. . 2007).3% that facilitates working with the power of the imagina- in 2007 (National Center for Complementary and Alter. Keywords: guided imagery. a mind-body intervention technique. PhD.3. In survey studies conducted in two large aca. as well as hospital length of stay may be reduced. Kshettry. 2010 © Springer Publishing Company DOI: 10. Henly. including guided imagery (Ai & these outcomes is through purposeful use of imagination Bolling. evidence-based review. the rate of CAM use among adults in the Guided imagery is defined as a “therapeutic process United States has increased from 36. Acute and critical care nurses can offer guided imagery to their patients based on the documented safety of its use and clinically significant findings that it may have a direct impact on patients’ recovery outcomes. ). and larger-scale studies are warranted to establish the efficacy and standard utilization of guided imagery during perioperative and rehabilitative periods. Liu et al. Volume 3.indd 22 3/25/2010 8:14:07 PM . and critical appraisal of the research evidence surrounding guided imagery utilization in cardiac surgery. RN Wayne State University College of Nursing This article illustrates a comprehensive review. specifically on physical and psychological health.1891/1939-2095.0% in 2002 to 38. APN-C Suzanne A. p. surveyed respondents for the purposes of maintaining cine (CAM) in the United States is on an upward trend. 22 Clinical Scholars Review. cardiac surgery.9% (N = 182) of 225 participants in the Midwest mechanism of action by which guided imagery achieves confirmed use of CAM. pre. In recent years. in spite of fairly strong “level” of evidence. Lemanski. Carole. Cwynar. Future studies should also address long-term outcomes.. attention away from unpleasant or undesirable sensation is one of the major CAM modalities frequently used by (Tusek et al. RN. CAM utilization rates were high reduction of anxiety and pain (Deisch. Tusek. and overall quality of life after cardiac surgery.and postoperative anxiety and pain. among adults who had undergone cardiac surgical proce. the limited number of studies and low research quality deter the full acceptance of guided imagery as a standard therapeutic modal- ity in this population. By adding guided imagery in the “usual care” of adult cardiac surgery patients. 2000). Soukup.22 Article_07. Similarly. synthesis. & dures: 75% (N = 188) of 263 participants in the Northeast Kummer.. methodologically rigorous. CCRN-CSC. Adams. BSN. Higher quality. well-being.

In the hospital setting. cited by over % of anco. Ezra review. which we excluded. artery bypass graft surgery (CABG). ). King. To date. Studies have shown that the foundation of professional nursing practice. anecdotal in nature. guided intervention. . CapoBi- preferred evidence for guided imagery. was a preliminary report (Ashton et al. et al. education. Pubmed. article’s conceptualization and development.. & Barnett. Additionally. while . inclu- had positive perception of the legitimacy of guided imag. .indd 23 3/25/2010 8:14:08 PM . Cochrane Library. listen to or use the guided imagery program in a portable Dearholt. & Griffiths. protocol or a nursing intervention must be based on the ated with guided imagery (Deisch et al. formation available to acute and critical care nurses as a tioner to the use of recorded media. includes proven mechanism of Kshettry et al. Our experience with nurses who have expressed skep. Halpin. & Kshet. We sought assistance from that such therapy is “just fluff. reviewed research and review articles. ). cardiac/heart valve surgery. The articles in- sity to use its legitimate utilization in nursing practice. Tusek et al. and critical care areas and requires little time (generally – integrative therapies with the sub-categories of coronary min)... Speir. and research as three elements that form Swan. although comprehensive search was completed. the model suggests that the perioperative period (Ackley et al.% did not have knowledge about or propen. the surveyed participants. had is worth noting that the majority of respondents indicated subjects older than the age of  years. CAM. ). Poe. commercially To fill this gap of knowledge. the College of Nursing reference librarian to ensure that a ing attitudes of nurses toward guided imagery. . Ladwig. . . for or intervention as well as appraising and translating evi- treating anxiety and pain experienced by patients during dence into practice. source of scientific knowledge supporting the utilization the common method employed by nurses in administering of guided imagery in the adult cardiac surgical population. Deisch et al. including assumptions search articles and reviews.. we conducted a systematic prepared script. there exists no published comprehensive in- ies from one–on–one interaction with an imagery practi. The search generated a total of  titles with and search findings from a survey of  critical care nurses in without abstracts. Patients are usually advised and encouraged to Evidence-Based Practice Model ( JHNEBP. Lapensky. and values. “ON and OFF pump” ticism or resistance to embracing the utilization of guided CABG. and after the surgery (Ackley.. and robotic cardiac surgery. and were published they would like to know more about the evidence of CAM. & White. work ethic. The model ing guided imagery as a complementary therapeutic delineates the process of identifying a clinical problem modality. PsycINFO. ). clinical trials (Tracy et al. and appraisal of the research literature. Sendelbach. Only . Comprehensive terms indicates that the negativity is primarily due to cultural were combined in various arrangements to search for re- background.% of the surveyed participants critical care nurses described in the above survey. such as research findings. sion criteria for the present review were limited to peer- ery. agery into the nursing care of these patients is primarily and the Cumulative Index of Nursing and Allied Health due to nurses’ lack of knowledge and skill to perform the Literature. guided imagery is the use of a structured. ). as featured in this article. before using it for personal reasons research articles met the inclusion criteria (Ashton et al.. & Reed. .. recorded on a compact disc (CD. As a response to the preferences of the United States. thus yielding a total of seven articles. surgery. The method of administration of guided imagery var. have been partially supported by re. . guided the nurses are proactive about integrating or recommend. . Despite decisions about developing or changing a patient care the prevalent use of CAM.” The beliefs and discomfort. and in critical care in general. & Tucker.. and evidence derived from however. and the increasing trend of guided imagery utilization in many hospitals in the United Methods States (Ezra & Reed. Carole. The . One of these. ery in adult cardiac surgery programs within the databases The reluctance to partially or fully integrate guided im. of MEDLINE. ). during. self-hypnosis. minimally invasive imagery in cardiac surgery. ). Guided Imagery in Adult Cardiac Surgery 23 Article_07. ). systematic search of resistant about using or incorporating guided imagery in published literature related to utilization of guided imag- the standard of care for cardiac surgery patients. Pugh. The Johns Hopkins Nursing try. or integrating and/or recommending its use in practice. Tusek et al. Only eight such as guided imagery. our experience shows many nurses and other health care providers are still skeptical or We conducted a comprehensive. in conjunction with pharmacologic agents.. Hattan. between January  and November . practice. guided relaxation. synthesis. It cluded in the present review were written in English. action. the positive outcomes associ.. Search terms included guided imagery. ). which illustrates CD player before. Newhouse. successful use in practice. Kshettry strongest type of evidence. even though it can be done easily in acute and visualization.

For example. Gangahar. 2003. twice for each article. and sage) group with “usual care” (Kshettry et al. one compared two groups of program to the usual care of adult cardiac surgical patients patients receiving guided imagery with a placebo group before. and after surgery (Table 2). quality of evidence of each article using the JHNEBP All studies used audiotapes (i.e. Shapiro.. p. a wide range of the duration (e. inconsistencies were found centage of agreement between two raters (authors) was in authors’ descriptions of intervention dosages (amount calculated by dividing the number of same ratings by the and frequency) and durations (time frame). with the primary aims of evaluating effects of therapy. guided imagery + light mas- ery. 24 Casida and Lemanski Article_07. (Astin. Per. assigning letter grades of “A” (high) to “C” ers) as a method of delivering the intervention (i.e. playing) during the intervention TABLE . In these articles.. (2007. Strength and Quality of Research Evidence Rating Scheme Level (Strength) Type of Evidence Grade (Quality) Type of Evidence I Evidence obtained from an experimental A (High) Consistent results with sufficient sample. adequate study/randomized controlled trial control. fortunately. III Evidence obtained from a C (Low/Major flaw) Little evidence with inconsistent results. consistent (RCT) or meta-analysis of RCTs recommendations based on extensive literature review that includes thoughtful reference to scientific evidence. quency (e.. hierarchical level) and health care utilization. continuous during surgery. The use of these terms is consistent with Patients in the placebo group (Ikedo et al. ). and conclusion. The research design reported in these articles (Table ) cess provided us with a comprehensive. Un- aggregated according to conceptual framework (if indi.. Variations were found in conceptualizations. This step-wise.. conclusions cannot be study. outcome variables. Iterations of this process were done at least historically consisting of . or meta-synthesis drawn. ). articles were clustered and tabulated according to 2004).e. self-hypnosis.g. and procedures. of the article. and definitive conclusions.e. We implemented a quality their studies. Quader. guided imagery). However. cated). total number of responses for each rating scale category.. B (Good) Reasonably consistent results. All but two studies (Halpin Results et al. including guided relaxation. qualitative insufficient sample size. Of the two stud- on evaluation of the effects of adding a guided imagery ies not using this design. and descriptive/nonexperimental (N = ) methods.%. variables. see Table ) (Newhouse et al. nonexperimental study. ) listened related publications cited in the health sciences literature to a blank CD in a portable CD player with headphones. sufficient sample. 2000. – min) and fre- yielding an inter-rater reliability of . ). cassette and CD play- Rating Scale. experimental study some control. and appraisal of the research articles. critical included experimental (N = ). II Evidence obtained from a quasi. The seven research articles in the present review focused compared guided imagery to usual care. evaluated overall strengths and weaknesses of each article. & Smith. Tusek et al. (Ikedo et al.  min daily. A multaneous review of each section of a particular article diverse sample of surgical techniques and procedures was with consensus between the two authors on a specific sec. as well as representations of the adult cardiac sur- tion achieved first before proceeding to the next section gical patient population during the years of publication... Eisenberg. Each article was summarized and pling. & Forys... during.indd 24 3/25/2010 8:14:08 PM . design. control strategy during the review process through a si..e. and determined the strength (i. . only two research teams (Deisch et al.. the (low/major flaw. continuously “ON” (i. with fairly definitive conclusions.g. sample.. Adapted from Newhouse et al. ). quasi-experimental (N review. we = ). reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence. while the other compared a “usual we found variety of terms used to describe guided imag. noted. systematic. designs. and hourly at night) of intervention ad- ministration were observed.to -year-old White males. Finally.. 1999) provided a conceptual framework for tion. and patient satisfaction outcomes. Next. Van Kuiken. relaxation technique. iterative review pro. results. sev- eral times daily. sam- themes and outcomes. 90). care + CAM package” (i. Findings reported in the seven articles were mixed. methodology. Ikedo. interven.

001) and pharmacy direct cost (p = .05). higher satisfaction measures. Pain. N = Pain. No significant difference in mean pain medication direct cost (p = . LOS.032) postoperatively. Evaluated outcomes of N = 789 (N = 134 Descriptive. N = Anxiety. 41. and hospital and LOS during CABG.002) were found. Determined the effects N = 100 (N = 51 RCT (single-blind) A significant reduction I B (1999) of guided imagery intervention. showed reduction in (i. Halpin et al. anger.86) LOS compared to controlled group. overall use of pain imagery) on CABG patients vigor.56) and hospital (p = 0. pain. tension/anxiety. and fatigue levels. and patients comforted. 655 without cost. LOS in postoperative pain. anxiety.046). Replicated Tusek N = 94 (N = 47 Quasi-experiment Patients in the guided II B (2000) et al.e. study with intervention.05) when compared to the “usual care” group.000).indd 25 3/25/2010 8:14:08 PM . valve. and experimental group period. fatigue. Studies on Guided Imagery Utilization in Adult Cardiac Surgery Authors and Aim/Purpose of the Sample Size and Study Design and Level of Quality of Year Study Characteristics Outcome Variables Significant Findings Evidence Evidence Ashton et al. Pain. on anxiety. anxiety. No difference in narcotic consumption was found between groups (p > . and sleepy. “other” cardiac versus control group surgery patients (p < 0. in ICU (p = 0. LOS were found in the perioperative LVAD. patient using guided imagery guided imagery). Evaluated the effects N = 32 (N = 20 RCT (single-blind) Experimental group I C (1997) of self-hypnosis intervention. Tusek et al. consumption.. N = 49 control) anxiety. (Continued) Guided Imagery in Adult Cardiac Surgery 25 Article_07. and . Deisch et al. Their satisfaction pain. pain. Reduced anxiety scores III B (2002) integrating guided with guided nonexperimental were reported by imagery in a cardiac imagery. patient’s mental confusion.5). medication (p = . a significant difference in hospital LOS (p = . procedure (p = .462) and patient satisfaction were found between groups (p > . tension/anxiety (p = and physical mortality. satisfaction with resultant benefits CABG. undergone ASD hopeful. direct cost per. LOS were significantly reduced (p < . patient postoperatively. TABLE .001). guided N = 12 control) depression. LOS. narcotic imagery group had additional outcome 47 control) first. valve.3% of patients surgery program. time CABG anxiety. confident. condition following morbidity No significant difference CABG. repairs Also. of feeling calm. fatigue.and patients LOS. ratings pre.

intra-operative and “OFF” intra-operative period. N blind. within and between CABG patients. mitral. post-op CABG + complications. Other clinically significant outcome variables reported. and length of hospital stay. atrial septal defect. relaxation. guided imagery) placebo) patients depression. 2007) defined anxiety/tension as a ). LOS. although not measured in all studies. and again up to  month after surgery (Ikedo et al.. narcotic consumption. N = variables (BP. Investigated the N = 104 (N = 53 RCT (single-blind) Average postoperative I B (2006) impact of CAM with guided Pain. or repairs. Studies on Guided Imagery Utilization in Adult Cardiac Surgery (Continued) Authors and Aim/Purpose of the Sample Size and Study Design and Level of Quality of Year Study Characteristics Outcome Variables Significant Findings Evidence Evidence Hattan et al. ).001). length of stay.. . placebo. . patient tients in three studies received the intervention during the satisfaction. left ventricular modeling. benefits. respiration) and majority of (i. RCT. BP. Despite the mixed picture formed by majority of the investigators defined anxiety and tension 26 Casida and Lemanski Article_07.. pumps).. across outcome and relaxation = 24 prayer. intra-operative period as well (Ashton et al. postoperative No significant CABG patients difference in BP and heart rate between groups (p > . variables (p > . Ikedo et al. patients in All seven articles (Table 2) reported anxiety/tension as a the experimental group were instructed to use guided im. valve. coronary artery bypass graft. narcotic procedures consumption Note. ASD. periods. N = 7 pulse. pain. tricuspid valve replacements. aortic. N experimental group massage) on = 51 without versus control group postoperative guided imagery) (p < . other. CABG. usual care: anxiety/tension. “other” surgical LOS. tension. but pa. valve. tension. All studies with two groups used “usual care” as the reported studies. Instructions about indica- Anxiety/Tension Reduction tions. and cost (see Table ). rest. controlled) variables (p > . valve. operationally defined and measured in agery up to  week before surgery and – weeks after sur. while the these time periods. intervention during CABG (“ON” confusion. variable of interest. TABLE .indd 26 3/25/2010 8:14:09 PM . and how to use guided imagery were con- sistently described in all articles.. calm) Feeling of calm (p = .. Ikedo et al. Outcome measurements were done during each of single concept and measured it as one variable. In one study. left ventricular assist device.e. Evaluated the N = 78 (N = 27 RCT (double. and intubation time. outcomes.05).014) was significant in the guided imagery/ relaxation group. as adjunct undergone anger.. No difference found I C (2007) effect of prayer relaxation. randomized controlled trial. LVAD. pain and tension package (guided imagery + heart rate scores were lower in imagery + light massage).05) of postoperative anxiety. Kshettry et al. vigor. Investigated the N = 25 (N = RCT (nonblind) No significant I C (2002) impact of foot 9 guided Physiological difference in all massage and relaxation. 1997. groups. were fatigue. Each article described the administration of the in.e. and N = 27 Tension/anxiety.05). fatigue. physiological guided relaxation 9 massage.. outcomes.and postoperative period. Ikedo et al. Halpin et al. gery. technique (i. tervention during a pre. three variables were found to impact the control group and guided imagery as the intervention/ patient care outcomes when guided imagery was added to experimental group. Investigators in two studies (Ashton et al. imagery) on control) CABG Psychological psychological the well-being patients variables (pain. several ways. major cardiac and aortic surgery.

” Kshettry et al. 2006).. Lower pain level. 2002). Kshettry et al. p < . tive. The anxiety-reducing effect of guided trol group (218% vs. and three of the six reported of measurements employed. However. in the usual care group but not statistically significant (p > Surprisingly. ) showing significant reduction in which guided imagery alleviates or reduces postoperative patients’ anxiety levels during pre. guided imagery as an effective pain management com- Some notable descriptive and qualitative findings ob. none of the authors Deisch et al. nonexperimental research offering a weak evidence duced (–6%) with guided imagery before and after cardiac showed that . Tusek et al. provided an explanation of the mechanism of action in . Kshettry et al. ). tients who used guided imagery postoperatively (p < ..% (N = ) of patients benefited from surgery regardless of the patient’s age (p < . . was significantly lower compared guided imagery with foot massage and usual for the guided imagery group in comparison to the con- care only (p < .0. 8. pared to . which showed a significant differ- worst anxiety. 6.01). “feeling of calm” was a sig.01) to POD 2 (p < . (1999) reported Overall. and an open-ended ques. anxiety numeric rating scale. with 0 = no anxiety and 10 = by Deisch et al.5) versus the control group (7. including use of the follow.and postoperative pe. Halpin et al. or relief of imagery helped patients create a relaxed state and feeling pain with guided imagery.indd 27 3/25/2010 8:14:09 PM .. as well as the benefit of helping patients cope a reduction in analgesic (narcotic or non-narcotic agent) with stress pre.. a significant reduction in patients’ anxiety levels a remarkable difference in POD 1 through 5 pain scores during pre.% of  patients reporting an overall improvement revealed that feelings of calm. was not clearly ex. .01). 2000. interchangeably.and postoperatively.01..5 to nificant outcome for patients using guided imagery when 5. anxiety visual analog scale. and sleepiness in their anxiety levels (Halpin et al. Three tionnaire was developed by one research team (Halpin studies (Deisch et al. Halpin et al.. p < .. a descrip- et al. compared to those who did not in a very small study that expressed as percent (%) change. the mean increase in pain scores. ) plicated by the majority of investigators in these stud. p. findings were mixed. (1999) found that anxiety can be significantly re. those patients engaged in guided imagery (Deisch et al..e.0 groups across time periods (p > . however. Pain scores were also vs. not fully supported by findings from a replication study Using a 0 to 10 rating scale. Halpin et al. a statistically significant reduction in pain levels of pa- ing tools: profile mood scale. respectively) when compared to pa. comfort. . and an increase in patient satisfaction (Deisch et al. Unfortunately.” and “a means to help cope post-op” (Ashton et al. These results were for patients who received a CAM package (i. 627%..5–5. . imagery group (2. (2000).05).. guided partially supported by a replication study (Deisch et al. . Six out of seven studies (Table 2) measured et al. Tusek et al. ) demonstrating and the strength of evidence for using guided imagery to significant results on the pain-reducing effects of guided reduce anxiety ranges from “strong/level I” to “weak/level imagery postoperatively is “good (B)” associated with III” (Table )..0) icant difference in postoperative pain scores between two and on postoperative (POD) days 1 through 5 (3. riods varies from “good (B)” to “low or major flaw (C). Additionally. the median scores of patients in the imagery ence in pain scores on POD 2 only (p < .0–0. “reduction in were the common resultant effects of pain reduction in stress. the mechanism by which guided .0.04) tients who received usual care only.and postoperative periods was observed in five (0 = no pain to 10 = worst pain) for patients in the guided studies (p < . The quality of the five studies (Ashton et al.01). was frequently associated with of calm. interesting qualitative findings . . imagery + usual care) when compared to a group of pa- 2000) in which the difference in anxiety levels was high tients receiving usual care only (Kshettry et al.. consumption (Ashton et al.0 vs.. but no signif- group were significantly lower preoperatively (3.05). This is reflected by different approaches pain as an outcome variable.05). However.. )... ).% (N = ) who favored pain medication over tained from patients who used guided imagery included guided imagery. The quality of the three studies (Deisch et al. “strong evidence/levels I and II” (Table ).. Pain Reduction Length of Stay Reduction Pain was operationally defined and measured by numeric Five of the seven studies (Table 2) evaluated the effect and visual analog rating scales. except on POD 2 (p < . Tusek et al.. 1999) showed a significant reduction in hospital- Guided Imagery in Adult Cardiac Surgery 27 Article_07. . Most importantly. significantly lower on POD 1 (p < . Tusek evaluation study ( out of  participants).. of guided imagery on hospital length of stay (LOS). Tusek et al. ). These results were imagery reported by Tusek et al. pain..05). ..0 to 0.05). and open-ended questions. Moreover. Kshettry et al. 2002..05).. ies.01). (1999) was impressive. p < . in Halpin and colleagues () program .

) employed a multivariate analy- cally significant differences in anxiety/tension outcomes sis in a very small sample. The reduction in LOS was associated with bining it with other CAM therapies. A greater sense tion outcomes (i. the possibility of having positive results in conjunction with other CAM therapy (e. CABG... but we cannot make such a de- studies with satisfactory research qualities showed con. 2002). termination when we rely solely on the report.01. 1999) supporting the reduction selected for the research was not clearly explicated.g. Moreover. while research articles. imagery to usual care in adult cardiac surgery.g. and relaxed enough to fall asleep after listening to a comparison groups. some patients reported feeling calm. Ikedo et al. effect of guided imagery) on a specific of well-being was also reported by a small number of pa- type of cardiac surgery cannot be drawn. 2000. (2002) reported a remarkable reduction tension and/or pain. either did quality of the three studies (Deisch et al. The current evidence for adding guided compared to patients who did not (p < . ().231. four out of seven studies consisted of a clinical significance and impact overall patient recovery. and length of stay in cardiac surgery is fairly strong. links between guided in mean LOS of patients in the guided imagery group (4. p = ... Most of the investigators failed example. group). Inconsistencies with the “timing” of pain..001. the usual care group incurred costs of US$1. ).00.. and length of stay regardless of the nature and following cardiac surgery (Hattan et al. Therefore. ON and OFF pump) in able. of note. one experimental the findings.. the amount/duration and frequency of the intervention garding the effect of a guided imagery program on anxiety. number of variables studied (Ashton et al. Halpin not provide a clear conceptualization or the framework et al.42 and The majority of the seven studies. consisting of participants with different cardiac surgical Moreover. For example.91 and US$9. finitive conclusions. measurement of outcome variables were common across However. although not statistically significant. and a general- tients (N = 9) who used guided imagery when compared ization that guided imagery has an impact on anxiety/ to those who had a massage as a complementary therapy stress. Problems with analytic techniques were common be linked to the mixed results and questionable validity of in some of these studies. in in patients’ LOS with guided imagery is “good (B)” but which case methodological congruence is obscure. the marginally low quality of the research can studies. Halpin et al.85 (p = 0.. are notable. randomization. the effect of guided imagery publication bias. Although five studies demonstrated statisti.4 days). comfort- procedures (e. Tusek et al. 2002. although derived from lower quality stud- ing” several cardiac surgical procedures in a particular unit ies and not supported by strong evidence. Randomization procedure Based on the criteria delineated in the JHNEBP Rat. These type of cardiac surgery cannot be made or denied at this findings. Sampling consisted of less stringent inclusion and exclusion criteria.5. measurement. only two issue for a pilot study.743. a sistent results. and analytical Other Variables of Interest procedure.indd 28 3/25/2010 8:14:09 PM . small sample size for those types of research designs and physically. the majority of the evidence discussed re.. cannot be ruled out as most of the investiga- 28 Casida and Lemanski Article_07. . Variation in clinical research. specifically from a statistical validity tion in pharmacy and procedure direct costs. Deisch et al. () and Deisch et al.9 imagery and hospital LOS and cost reduction have yet to days) versus no guided imagery group (6. or com- respectively).. This would not have been an when guided imagery was added to usual care. and psychologically.002 and p = 0. Tusek et al. interpretation of interven- guided imagery tape (Halpin et al. among the studies guided imagery (Deisch et al.00. p = . respectively). 2002)..761. p < . ). light mas. . 1999). The inconsistent findings and lack of de- This reduction in LOS was also associated with a reduc. common problems found in these articles in- I” to “weak/level III” (Table 2).. exemplified by “mixing and match- Some findings. Finally.. The mean di. duration and method of delivery of the intervention. can be attributed to poor conceptualizations rect costs for pharmacy and per procedure for the guided and methodological flaws found in the majority of the imagery group were US$942. Also. pain.. standpoint. may have point. was not clearly described by most of the studies and not ing Scale for evaluating strength/hierarchy of evidence in specified in one study (Ashton et al.e.. be established.g. Hattan et al.00. 2000. ranging from “strong/level thermore. was also problematic. is not yet adequate increase in patient satisfaction and overall reduction in to make a clear determination of its effects on anxiety/ cost. valve. if any. For of analysis (e. The of Tusek et al. In addition. published. clude sampling. Fur- varies in strength of evidence. ization days in patients who used guided imagery when sage) is not clear.. pro- Discussion ducing a low statistical power. . with the exception US$11. study (Hattan et al. fatigue was reduced and sleep enhanced with to report the group difference(s)..

. design. Louis. content/script) or the duration and frequency of the may have a significant impact on the recovery outcomes. This evidence- methodological problems of the studies discussed in this based review. Smith. These phenomena and other variables. & Bolling. and rigorous implementation of the re- macologic therapy to complement anxiety and pain med. (i. imperative for clinical scholars (e. intervention. Further testing involving all types of cardiac well-being. A. B. but instead will ery in cardiac surgery. such as acute and criti- ethnic minorities.. The use of complementary and veloping a detailed procedure including randomization. Implications for Clinical Practice and Research Conclusion This review offers an assessment of the state of the sci- ence regarding guided imagery utilization in adult cardiac Using guided imagery to reduce or alleviate anxiety and surgery. 21–27.g. R. Based on the investigating. 17(1). providing statistically valid and significant results. search plan are warranted to advance the knowledge. alternative therapies among middle-aged and older cardiac duration and frequency of the intervention. This recom. and recovery outcomes. J. imagery on the rehabilitation and quality of life outcomes for these patients. These quality control Ashton. rando- Guided Imagery in Adult Cardiac Surgery 29 Article_07. A coherent conceptual framework. B. ery to “usual care” and embrace a commitment to proving Evidence-based nursing care guidelines: Medical-surgical in- the effectiveness of its mechanism of action. and overall quality of life of cardiac surgery surgical procedures.indd 29 3/25/2010 8:14:11 PM .. impli. Whitworth.. The current terventions. tors in these studies were key personnel in their hospitals’ period in order to determine long-term effects of guided CAM programs. F. St. (2002). de- protocol using a commercially prepared guided imagery pression. Michler. American Journal of Medical Quality. such evidence today. Shapiro.. (2007). patients. and consis. R. Ladwig. phenomenon or variable of interest. cost. & Tucker. Research consumers. so that research findings can be CAM modalities (Ackley et al. cal care nurses. We hope this review will not be a deterrent fac- ment of science surrounding utilization of guided imag.. provides lidity. R. the first to address the state of the science review for the purposes of limiting threats to internal va. References Investigators must move beyond comparing guided imag- Ackley. Finally. A. members of patients.g. strategies are paramount for producing valid results and P. Seldomridge.. Swan. S. Nurses caring for translated into clinical practice at a faster pace. must be carefully and thoughtfully crafted during research plan development. and self-care capability. tent measurement of time periods. C. self-efficacy. and women is needed to firmly estab. J. E.. alization. et al. (1995). L. MO: Mosby. population is limited and evolving. lack of methodological precision can be resolved by de- Ai. C. stimulate dialogue and interest to further investigate this along with a clear statement of the mechanism of action promising intervention that has potential to significantly by which guided imagery influences a particular clinical impact patient care quality. B. J..e. investigation. Based on cardiac surgery patients elect to develop a patient care this review. S. and sleep disruption) that may be re- program in conjunction with usual care to reduce anxiety sponsive to the effect of guided imagery are also worth and pain during the perioperative period. we cannot recommend a specific program as locus of control. The science underpinning its use in this cations for clinical practice and research can be drawn. G. It is ications commonly used in cardiac surgery. C.. translating evidence into practice or changing an existing Future research must address the conceptual and standard of care based on limited studies.. other clinical nursing phenomena (e. in general. G. Meeting use guided imagery in cardiac surgery and in critical care these conditions are imperative in facilitating the advance. A. should exercise sound judgment before lish such a protocol in adult cardiac surgery. for guided imagery utilization in cardiac surgery. The effects high quality research products. doctorally prepared mendation is based on the fact that there are no known advanced practice nurses) interested in this area of inquiry adverse effects associated with guided imagery.. future studies must of self-hypnosis on quality of life following coronary artery include longitudinal designs beyond the hospitalization bypass surgery: Preliminary results of a prospective. Thoughtful conceptu- We recommend using guided imagery as a nonphar. some answers to the lingering questions and hesitancy to and enhancing generalizability of the findings. whether to move the current knowledge to a more grounded and used as a stand-alone therapy or combined with other scientifically sound state. geriatrics/older adults.. tor in continuing to use guided imagery.. A. Although the evidence supporting its effects on pain as well as decrease hospital LOS in adult cardiac anxiety/tension and pain during the perioperative period surgery is an increasing prospect that requires further and associated impact on hospital LOS is limited. ). fatigue.

16(2). S. Henly. T. The Journal of the American Board of Fa.. C. R. S. Choi.. S.. 15(3). L.. and University College of Nursing. Effect massage and guided relaxation following cardiac surgery: of guided imagery on length of stay.. 404–414. C.. A. MI 48202. L. trial... J. Newhouse. the United States. M. Johns Hopkins nursing evidence-based mily Practice. A. 69–75. D. et al. J.indd 30 3/25/2010 8:14:11 PM .. Guided imagery and beyond.gov/news/camstats/2007/camsurvey_fs1. Turner. H. Use of complementary and (2002). P. cardiac surgery patients... D. 10(2).edu 30 Casida and Lemanski Article_07.. Journal of Cardiovascular Manage- 37(2). 335–341.. S. Y. & Reed.nih. Michler. 352. anesthesia on recovery outcomes following cardiac surgery. J. S. Kshettry. CCRN-CSC. patients undergoing cardiac surgery. Speir. ses.... relaxation technique during general imagery practice on outcomes. S. & Smith. bypass graft patients. X. dicine. G. Van Kuiken. & Cosgrove. 199–207. Outcomes mana. Carole. Quader. 131–147.. S. Developing an integrative therapies program in a tertiary 35(2). L. S. Lin. Journal of Alternative and Complementary Me. A. Complementary Therapies in Clinical Practice. & Forys. A meta-analysis of the effect of guided The effects of prayer. The impact of foot Tusek. L. K. Whitworth. L. S. safety. Tau International. Journal of Holistic Nursing.. Mind-body medicine: State of the science. & Barnett. P. Annals of Thoracic Surgery. & Kshettry.. impli... et al. A. M. Eisenberg. (2007). APN-C. Cwynar. CO: Outskirts Press. A. White. D. 164–179. 38(1). L.htm (2003). (2005). Kreitzer. Halpin. V. A National Center for Complementary and Alternative Medicine. from http:// Astin.. (2000). R. alternative therapies: A national survey of critical care nur- gement. prospective. M. L.. D. North America. M. S. Liu. (2008). 22(2). L. P. A. IN: Sigma Theta Deisch. E. S. (2003).. S. 6(3). L. RN. 22–28. C. (1999). Ikedo. care cardiovascular hospital. reduces anxiety following coronary artery bypass surgery.. Self-hypnosis Cardiovascular Surgery. Seldomridge. 5557 Cass Avenue. F. pain and anxiety in A randomized controlled trial. J. Tracy.. 417–425. Whitworth. Denver.. Pugh. J. 14(5). & cations for practice. King.. B. Hattan. (2002). V. Watanuki. L. 85–94. mized. P. 201–205. Detroit. R. F. R. The use of complementary and alternative medicine in Surgery. (2000). S. E-mail: jcasida@wayne. D. Cohn Building impact. (2006). The Journal of Cardiovascular (2007). 1(3).. Shapiro. M.. & Griffiths.. American Journal of Critical Care. 363–372. et al. Retrieved February 23. Carole. M. 285–290. randomized trial.. E. S. Sendelbach. Journal of Advanced Nursing. Critical Care Nursing Clinics of Ezra. 132–137.. 81(1). PhD. K. Adams. Lapensky. L... M.. Lindquist. Gangahar. Use of alternative medicine by Ashton. M.. Shapiro. practice model and guidelines. Journal of Thoracic and Weinberg. F. (2007).. (1997).. nccam. P. M.. M. C. J.. Nursing Clinics of North America. Guided imagery in cardiac surgery. & Wild. D. Wayne State therapies for heart surgery patients: Feasibility. Dearholt. Guided imagery: Replication study using coronary artery Sendelbach. D.. Klaus. Indianapolis. Complementary alternative medical ( Jessie) Casida. M. & Correspondence regarding this article should be directed to Jesus Kummer. 13(2). (2004). L. Soukup. Sendelbach. ment..... Poe. R. P. L. J. CapoBianco. 120(2). 2010. Savik. M. K.

MSN. This syndrome is cardiac events despite beta-blockers therapy (Moss & commonly associated with sudden cardiac death (SCD) Goldenberg. Moss & Robinson. 2008). The article discusses the clinical manifestations. MSN. who presented with episodes of syncope. DNP. The event & Kulikowski. and family history of SCD. FNP-BC Beth Israel Medical Center in New York City Kathleen Hickey. Schwartz et al. and family history of SCD. Case Report While the median age of persons who die of LQTS is 32 years. 2002.indd 31 3/25/2010 8:15:17 PM . riencing his first syncope episode at the age of 9. Schwartz. prolonged QTc & Moss. 2009. Keywords: long QT syndrome. Goldenberg. He subsequently received an ICD for protection against SCD based on his prior clinical history. 1985). The authors describe the case of a young patient who presented with episodes of syncope. teaching. 2002). and an associated increased propensity for arrythmogenic This is a case of an otherwise healthy young patient syncope (Collins & Van Hare. Salem. genetics. and Clinical Implications Jiaming Yao. _ CASE REPORT Long QT Syndrome: A Case Report. Zareba.1891/1939-2095. Volume 3. management of LQTS. he suffered an out-of-hospital car- ranges above 460 millisecond (ms) for women and 440 ms diac arrest with ventricular fibrillation being documented Clinical Scholars Review. adolescents and young adults have the highest The history of this 36-year-old White male included expe- incidence of SCD (Meyer. 2008. Key to the diagnosis is a resting was thought to be a seizure and was treated with phenobar- ECG showing a prolonged QTc interval that generally bital. arising cardiovertor-defibrillator (ICD) is another therapeutic from delayed ventricular repolarization (Moss. children and young adults (Goldenberg et al. FNP-BC. and sequently received an ICD for protection against SCD in fact is one of the leading causes of sudden death in based on his clinical history.000. and counseling the affected patients and families. Mehdirad. Number 1.. The prevalence of LQTS in the United interval on ECG. ANP-BC Columbia University School of Nursing Long QT syndrome (LQTS) is a hereditary disorder in which the majority of affected individuals present with QT prolongation on electrocardiograms (ECGs). & Carleen. option for high-risk patients who experience recurrent Crampton. EdD. 2008).000 to 1/2. arising from delayed ventricular repo- larization. This commonly arrhythmia-associated genetic syndrome can lead to sudden cardiac death (SCD) and increased propensity for arrythmogenic syncope. and role of the clinician in testing. He sub- States is assumed to range from 1/20. 2003). Genomics. sudden cardiac death Long QT syndrome (LQTS) is a hereditary disorder in in men (Roden. Kulikowska..31 Article_08. At the age of 13. Vincent. electrocardiographic (ECG) findings.1.3. prolonged QTc interval on ECG. whereas implantation of an QT prolongation on electrocardiograms (ECGs). Locati. 2010 © Springer Publishing Company 31 DOI: 10. 2006. 2008). Beta-blockers comprise the main- which the majority of affected individuals present with stay therapy for most LQTS.

The Schwartz criteria The patient’s first-degree relatives also include a - is a widely employed scoring system used for the diagnosis year-old brother with a history of borderline QTc. he was found to have a prolonged QT inter. He was placed on a vertor defibrillator (ICD). Prolonged QT/QTc on patient’s ECG.. somal dominant condition (Moss & Robinson. Finally. In fact. and familial his. & Crampton. they are taking nadolol  mg orally daily and restricted from QT interval competitive sports. on the ECG after taking a phenothiazine drug. The patient’s tory (Schwartz et al. old son and -year-old daughter. highly suspicious for LQTS  (Table ). if she was affected gate the possibility of an underlying inherited arrhythmia. His family ing inherited arrhythmia. LQTS refers to the inherited version of LQTS that is transmitted from the parent who carries the mutation to a child as an autosomal-dominant disorder. ). which subsequently effectively beta-blocker by his cardiologist after the event. ECG. because of his further prolonged drugs and might have further exacerbated this patient’s QT interval of  ms and QTc of  ms on ECGs. Notably. both of whom had screening ECGs. the mother is  years old with a reportedly normal ECG. The score is based on the total value of related two older sisters ( and  years old) both of whom have points assigned to ECG features. 2002). After he was resuscitated from the risk of SCD was deemed to be very high. When either V3 V6 parent has the disorder.. the patient’s maternal milligram (mg) daily by his cardiologist. although she his ECG showed a QTc of  ms. Of note. the practitioner would need to be aware that His clinical presentation was consistent with a high prob. the QT is mea. or being startled. tachycardia (Figure ). higher the probability of LQTS (Schwartz et al. normal ECGs and no history of syncope. herited from the parent. Although both are asymptomatic. At the age of . however. there is a % chance of her children inheriting this auto- ability for LQTS using the Schwartz criteria (Schwartz. The patient has a -year-old son and a -year-old daughter. were noted to be prolonged. the last event the patient received an implantable cardio- val of more than 550 ms on the ECG.indd 32 3/25/2010 8:15:17 PM . grandmother died at the age of . ). She had a history of mul- pointes. and a second ECG was never treated with any medication. Discussion V2 V5 Long QT syndrome can be either congenital (inherited) or acquired because of drugs or certain clinical conditions. with the remaining cases con- 32 Yao and Hickey Article_08. the underlying condition. Phenothi. this patient’s sister died called  after they witnessed the event. nadolol  infarction at the age of . taken a few months after his out-of-hospital cardiac arrest. and of LQTS. and the daughter has a QT V1 V4 interval of  ms. Moss. clinical. and defibrillated him immediately with a success. She had a history of when he was still on this regimen. After this event. Approximately Figure 1. four out of five of the identified cases of LQTS are in- sured as 520 ms. Also. The Emergency at the age of  from head trauma sustained during an Medical Services found his heart rhythm was torsade de episode of syncope (Figure ). He remained symptom-free without medications The family history of this patient highlights the im- until he was  years of age when he experienced a brief portance of such information in unmasking an underly- loss of consciousness lasting several seconds. The higher the total value. ventricular tachycardia (VT). he detected and terminated another episode of ventricular discontinued use after a year because of excessive fatigue. The son has a QT interval of  ms. ). being documented on an azine is known to be one of the QT-interval-prolonging ECG rhythm strip. he experienced another multiple episodes of syncope that usually occurred during episode of loss of consciousness (syncope) with sustained emotional stress. with LQTS. whose QT/QTc intervals which led his treating cardiologist to suspect and investi. each child has a 50% chance of being affected (Moss & Robinson. tiple episodes of syncope and had a borderline QTc on her ful restoration of normal sinus rhythm. Vincent. ). Her history is suggestive of LQTS. His father is  years old with a history of myocardial The patient was started on a beta blocker. after cardiac arrest. She has an -year- a few months later revealed a QTc of  ms (Figure ). hearing a loud noise.

tassium repolarization channel (KCNH. Shock delivered Figure 2..60' d. Roden. 2008). and causes the affected individual to be susceptible to type . Moss & Kass. normal. Hungarian/Romania No consanguinity Ashkenazi Jewish Moroccan Sephardic Jewish Hungarian/Romania Ashkenazi Jewish d. NL. sodium channels (SCNA. Long QT Syndrome 33 Article_08. HTN. Note. CA. ). DM. . Sustained ventricular tachycardia detected and terminated by the ICD. ECG reflects the prolongation of the action potential. tributed to de novo mutations (Goldenberg et al. ECG.33 A+W NL ECG 9 7 4 3 2 12 12 11 8 4 1 8 6 all alive NL ECG Key =Lung CA =AMI@50 =Syncope =Borderline QT borderline QT =syncope weekly =HTN =QT 480 often during stress =Syncope LQT. ). diabetes mellitus. electrocardiogram. Schwartz. more genetic abnormalities are expected life-threatening cardiac arrhythmias. 2005). or () an increase in the genes that encode for cardiac ion channels important for late inward sodium current caused by malfunctioning of ventricular repolarization (Moss & Kass.93 alive alive A+W 62 70 64 no ECG no ECG 60 A+W NL ECG all alive no ECG 6 unknown NL ECG 35 34 20 36 32 A+W A+W A+W d. or type . ICD =ECG Normal =Malnutrition =QT 463 borderline QT =DM Holocaust on one exam Figure 3.indd 33 3/25/2010 8:15:18 PM . hypertension. LQT) during LQTS is found to link to at least 500 mutations of 10 phase  of the action potential. An increased duration of the QT interval in the . alive and well. .. While most LQTS cases were identified to be type . A+W. LQT) or the rapidly activating po. AMI. acute myocardial infarction. LQT) (Goldenberg et al. Proband’s Pedigree. It may arise from to be discovered in the future to account for some of the () a reduction in the outward potassium current caused remaining quarter or more LQTS patients who have neg- by either the slowly activating potassium repolarization ative genetic testing currently (Collins & Van Hare. cancer. channel (KCNQ.

). mias or primary electrical disturbances is consulted when Lange-Nielsen ( JLN). auditory stimuli (i. The most common symptoms of LQTS include palpi. syncope. Moss. as they get QTc and torsade de pointes. and his niece and nephew of his deceased sister. siblings. ). However. Common Forms of the Long-QT Syndrome (Goldenberg. prevalence. In some situations. and  ms for men (Roden. moderate (++). or exposure to the LQT–LQT genotypes is presented in Table . door bells. LQTS-affected indi- with a cardiac event. sleep swimming. In families moderately prolonged QTc intervals and low-amplitude of patients with genotypically confirmed LQTS. This patient received ICD implantation for protection affected patients oftentimes have events while at rest or against SCD. diving sudden loud noise QT change with exercise Failure to shorten Normal Supranormal QT shortening with mexiletine No No Yes Beta-blockers +++ ++ Uncertain ICD in high risk patients +++ +++ +++ The number of plus signs indicates the relative benefit of therapy in minimal (+). LQT. if the patient undergoes using Bazett’s rate-correction formula ⎛⎜⎝ QTc = QT ⎞⎟⎠ (Bazett. exercise. Rest. QTc intervals greater than  ms cal geneticist or a health care professional trained in the and an extremely broad based T-wave are more commonly evaluation and treatment of those with inherited arrhyth- seen in individuals with LQTS homozygote Jervell. ECG signs of LQTS include borderline or abnormal His children will continue their beta blockers. 2008) Variable LQT1 LQT2 LQT3 Typical resting ECG Low-amplitude T wave Long isoelectric ST Broad T wave with notching segment Chromosome 11 7 3 Disease-associated gene KCNQ1 KCNH2 SCN5A Precalence (% of all genotyped cases) 45 45 7 Setting of arrhythmia Emotional or physical stress. 2008. seizures. The upper limits of the QTc are  ms for women tested for that particular mutation. genetic variation. Patients with LQT may have arrhythmic events festation. A summary of the ECG mani- ming. ). According to Schwartz et al. They will be asked to be actively Romano-Ward syndrome (RWS) patients generally show involved in decision making in terms of a treatment plan. Roden. LQTS patients usually have patients/families with LQTS are evaluated. He opted to defer the is diagnosed after sudden death of a family member or an test when insurance coverage became an issue. LQTS to genetic counseling and testing. Reprinted with permission. Diagnosis is often made after a patient presents notched. All rights reserved. testing and the mutation is identified. dizziness. The morphologic pattern of older. T wave with bifid T waves in the majority of the affected tations. He was subsequently referred for and agreed sleeping (Schwartz et al. TABLE .e. ICD implantation may be considered. his children will be RR ). Emotional or physical stress. telephone ring). presyncope.. segments (Moss. individuals.. Copyright © 2008 Massachusetts Medical Society. peaked T waves pre- triggers of event are different by genotype. isoelectric ST LQT usually have cardiac events during exercise or swim. and treatment for preceded by an emotional event. a clini- onset (Moss. his clinical symptoms suggest a likely diagnosis of LQTS. double-hump T waves. and car. 2008. genetic 34 Yao and Hickey Article_08. accidental finding of QTc prolongation on routine ECG. Typically. viduals often present with late-onset. Patients with ceded by prolonged QTc intervals and long. ). and marked (+++) effectiveness categories. moderately prolonged QTc with normal to tall amplitude LQTS patients may be initially evaluated by a car- of and a broad-based T wave without a distinct T-wave diologist.indd 34 3/25/2010 8:15:18 PM . LQTS patients can also sometimes have diac arrest. as well as his parents. (). The value of QTc is QT interval corrected for heart rate Per geneticist recommendations. The patient the ST segment and T wave largely depends on the time and his family will be counseled regarding genetic testing course of the ion-channel currents. LQTS heterozygote for the family members. or cardiac electrophysiologist.

Advances in congeni- information. and when patients Schwartz. Circulation. Importance of the long QT syndrome. 483–488. C. and managing LQTS. Patients at high risk (i. 71(1). Cardiac Electrophysiology Review. ing information regarding useful resources and support Moss. (2005). tients with long-QT syndrome. E. be evaluated and recognized. & Crampton. (2006).. 8.. & Ku- the clinician should be able to recognize the key charac. and especially noting its genetic Roden. beta-blockers (and other therapeutic measures if needed) Vincent. J. (2008). As an independent care Moss. detecting alarming issues. 259(1). S. S. The long-QT syndrome. J. Diagnostic criteria for the long QT syndrome: An clinicians need to take into account patients’ cultural and update.. Prevalence of the conge- The prognosis for patients with LQTS treated with nital long-QT syndrome. A.. 497–502. P. especially in those who present with a QT/QTc tary long QT syndrome. MSN. G. Pa- genotype to phenotype: Clinical implications. Priori. (2002). D. A. J. 39–47. (2008). New York. R. & Goldenberg. & Robinson. The Moss. (1920). American Family As part of routine practice.. J.. J. Besana. A... Crotti. Spazzolini. J. M. 2(4). M.. P. H... A. yao@msn. Moss. Circulation: Arrhythmia and the proper individualized interventions—such as provid- Electrophysiology. J... P. J. Summary References Bazett. and offering proper referral. Current Opinion in Pedia- work closely with the clinic genetic specialist.. 7. Moss. (Information on such high. 18(5). A. E-mail: jiaming- is excellent. A. Since the disease affects all races and ethnic groups. M. T-wave patterns associated with the heredi- longation. R. counseling and further genetic testing of other family The role of the DNP as a comprehensive care pro- members should be discussed as well as the treatment. 89–95.e. sudden death. vider underlines the importance of detecting. and triggers to avoid. Current Problems in Cardiology... the DNP has a unique role in coaching. J. & Car- DNP should educate family members of patients with leen. those with aborted cardiac arrest or recurrent cardiac events despite Correspondence regarding this article should be directed to Jiam- beta-blocker therapy) have a markedly increased risk of ing Yao. G. A.. Heart. teach... Kulikowska. Zareba. Moss. P. L. ing. 358. 219–226. New information on correlation in the long-QT syndrome: Gene-specific triggers LQTS continually emerges in the literature. 782–784. Long-QT syndrome. decline genotyping. Circulation. Sudden arrhythmia death syndrome: teristics of ECG and clinical presentations of this disorder. & Van Hare.. education. providing support. 784–786. He or she can tal long QT syndrome [Review]. NY 10003. R. advise family members and school teachers to learn nal of Medicine. S. et al. 8 Linsky. opment of the treatment plan and as active care partners. Stramba-Badiale. K. J. 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Diffusion of improvement-oriented innovations is a major challenge facing health care. The application and implications of this project are described. innovativeness The field of health care quality and patient safety has This study reviews the application of the Innova- evolved rapidly over the past 10 years as a result of the tiveness: Openness of Information Processing tool to Institute of Medicine’s report. RN.3. 2010 © Springer Publishing Company DOI: 10. Utilizing a tool to measure innovativeness.” others report difficulty.% of the members of the collaborative who completed the survey were innovators/early adopters compared to % as described for the general population. and ensure that it becomes “hardwired” primarily in the social sciences. Researchers have developed novation and diffuse and disseminate it throughout the the theory for many years in fields outside of heath care. _ BRIEF REPORT Evaluating the “Innovativeness Quotient” (IQ) in a Collaborative Model Juli C. Maxworthy.1891/1939-2095. (2004) described a body of literature on individual traits 36 Clinical Scholars Review. DNP. Number 1. collaborate. a 2000). Patient safety teams throughout the United States -hospital San Francisco Bay Area Patient Safety Col- utilize collaborative models to improve patient outcomes. with a view toward determining their “Innova- Many of the teams report success with initiatives while tiveness Quotient. MacFarlane. Background other unit struggles.” Findings showed that . organization. 2003). Volume 3. the majority may ture on diffusion of innovation in service organizations. Robert. collaborative. Bate. The challenge of putting together a team committed Diffusion of innovations theory describes the spread to innovation confronts leaders of organizations. In a systematic review of the litera- ure.” Patient safety teams are using a collaborative model to improve patient outcomes. members of a patient safety collaborative at Beacon. Rogers’ theory of diffusion of innovation. “To Err is Human” (IOM. diffusion. MBA.36 Article_09. tion of innovators. laborative. Innovativeness refers to and sustained? A gap was noted in reviewing the health interindividual differences in how people react to these care literature on team development and the identifica- new ideas and accounts for much of their success or fail. CNL.1. and Kyriakidou adopt new ideas. MSN. Innovators may welcome new ideas. laggards either slowly or never Greenhalgh. An innovation can be embraced and diffused quickly throughout one unit while an. How of new ideas through social systems as they are adopted does a leader choose team members likely to take an in- or rejected by individuals. “To Err is Human. even in the same hospital. a -hospital patient safety collaborative was evaluated for their “Innovativeness Quotient. gradually adopt new ideas. CPHQ University of San Francisco The health care quality and patient safety movement has evolved rapidly during the past  years largely as a result of the Institute of Medicine (IOM) report. Keywords: innovation. DNP.indd 36 3/25/2010 9:08:58 PM . Diffusion Challenge in Team Building of innovations is a major challenge facing health care (Berwick.

tance of communication channels to obtain the new con- In . 1988). Their prem. a major contributor to this field. is not discussed at all in Leavitt and Walton’s. They also both have elements related to the impor- ing the new idea. have a low threshold for recognizing the potential appli- Utilizing a proactive assessment tool can potentially cation of ideas and do not apply suggestions mechanically. ensure the formation of a group of individuals who by na. and marketing.indd 37 3/25/2010 9:08:59 PM . These researchers play a key role in the diffusion of innovation process in developed surveys to determine different lifestyle dimen. These researchers were from the business and marketing values. financial backing is helpful when possible losses from an The interest in innovativeness started in the s unprofitable experience occur. To that end. The other Evaluating “Innovativeness Quotient” 37 Article_09. There are similarities and differences between the defini- One could assume that someone with a higher “In. than someone with a lower score. 1975. that the financial aspect emphasized in Rogers’s definition ise was that innovativeness is a psychological trait under. The hope and interest in developing teristics of innovators in health care have been largely this global tool was to predict time-of-adoption behavior. their boundaries and act as gatekeepers of the flow of new According to Rogers (). ). Finding a tool to measure openness of ularly of a meaningful sort (not just thrill seeking). The authors of the Innovativeness: Openness of attitude toward the innovation.g. of innovators are common. and effectively. enced by personality traits (Leavitt & Walton. and products. The similarities between the definitions are that the sion-making unit passes. and () confirming the decision. quickly. schools of thought. having a team composed of individuals with high who is open to new experiences and often goes out of “Innovativeness Quotient” scores would increase uptake their way to experience different and novel stimuli. Rogers () defined innovativeness as the degree to which an individual or other unit of adoption is relatively earlier than other members of a system. the traits and charac. this project sought to de. A proactive tool to identify innovators in health which is dependent on information utilization and influ- care was not available. learning styles). Such individuals lifestyle (Goldsmith & Foxall. Venturesome- Review of Innovativeness Literature ness is almost an obsession with innovators. ideas. lying the adoption of new ideas. The innovator has a pro- when advertising researchers originated the concept of pensity for the rash. management. Communication patterns and friendships participants of successful quality improvement projects in (even though geographically challenged) among a clique health care. efficiently. They information processing would be helpful. relevance to their own perceived experience (Leavitt & formation and assist in getting an initiative off the ground Walton. ignored. () implement. tion of innovativeness by Leavitt and Walton. that they launch new ideas into systems from outside sions. (Beacon) was composed of more innovators/early adopt- ers than the normal percentage within a population as Definitions of Innovativeness defined by a diffusion of innovation theory developed by Everett Rogers. motivation. partic- of the new idea. ). services. that they were measuring either the same or highly related termine if the members of a patient safety collaborative constructs (Goldsmith. Most of the studies identified were from busi. One Developing a tool that would measure an individual’s study did show that four of the most commonly utilized openness to innovation would help leaders in health care scales generally exhibited convergent validity indicating quality initiatives. tolerance for ambiguity. and Everett novativeness Quotient” score would have a more positive Rogers. Having access and control of ness. However. The individual is responsive and objective to communica- ture are innovators or early adopters of concepts or ideas. adopt the innovation.. () forming an attitude toward the tem and that they go out of their systems to bring in new innovation. ). The stages include: () first expo. process is one through which an individual or other deci. associated with the propensity to use innovations (e. and thus more likely to Information Processing study (Leavitt & Walton. tion in a selective and constructive way when they see the This innovative personality type can provide valuable in. degree of adoption is earlier than others in the same sys- sure to an innovation. ). intellectual ability. daring. the innovation-decision ideas into a system (Rogers. psychology. 1988) defined the trait of “innovativeness” as a person Thus. 1975. Their keen The literature review revealed little information related to interest in new ideas leads them out of a local circle of the determination of innovativeness as a global trait of peer networks. One of the differences between the definitions is constructed a scale to measure innovativeness. () deciding to adopt or reject. Leavitt and Walton (Ohio State University) cepts. and risky.

surveyed to perform a “small test of change” (Langley.. and the results were easily obtained through the website. and having a low threshold for recognizing questions. the tool is that innovativeness is assumed to be a personal- pharmacists.%). There was minimal cost quo. major difference is the transformation of information for management. approval was given to send the survey to the using this validated tool in the health care setting was its entire Beacon Collaborative membership (. this variable could not be tested 38 Maxworthy Article_09. The web-based survey tool Methods allowed building reports and exporting data to an SPSS worksheet. webinars. style consciousness. ).%) completed By working collaboratively through several mechanisms the survey. or services for of Information Processing. 1988). ing from the Gordon and Betty Moore Foundation. The names and sistency reliability was . therapists. 1999). for the form used in the survey e-mail addresses remained private from the researcher as (Form B). to utilize the web-based tool. Craig and Ginter () factor analyzed Leavitt contact members. Data 39 participating hospitals are committed to improving the from Survey Monkey indicated that  (. workshops). interviews from ~ women. the construct was redefined as “openness to information After the survey was sent to the entire membership. Goldsmith () reported an internal consis- the link was sent out by the administrative staff at Beacon tency reliability estimate of . based clinical. Innovators assessment of the “Innovativeness Quotient” of the Bea- are described as individuals open to new experiences and con collaborative was evaluated using Leavitt and Wal- novel stimuli. satisfaction with the status survey (October –.indd 38 3/25/2010 9:08:59 PM . and others interested in improv- ity trait underlying the adoption of new ideas. for Form B of the scale using the Constant Comment software that they use to (Table ). was formed in June 2005 with fund. vided by Constant Contacts confirmed that of the . processing” (Leavitt & Walton. & Nolan.%) members quality of acute health care and ending harm to patients. tentative approval was obtained from Beacon’s answer a survey. otherwise invited to participate in the survey. started answering the survey and  (. Thus. After the initial Leavitt and Walton’s innovativeness scale is used to predict findings were shared with the team and all concerns were an individual’s adoption of new services. The definition. the means scores for non- The use of a web-based survey vehicle to administer a innovators and innovators were reported to be . hospitals are ac. which is present in Leavitt and Walton’s Review Board of the University of San Francisco. and other directedness. However. respectively (Leavitt & Walton. Internal con- cient way to obtain important information. Over time ing patient outcomes. ). 1975. The study was approved by the Institutional their own use. The collaborative consists of physicians. The e-mails sent to members. It was decided to exclude the language of innovative- Processing ness from the consent letter because it was thought that the term may affect individual responses.. possessing the ability to transform informa- ton’s (. convening. ) and to address any issues with the Innovativeness: Openness of Information tool. e-mail began the survey and . The appeal of answered. but is somewhat inferred in Rogers by the use Beacon Leadership team (eight individuals) was initially of venturesomeness. e-mail ease of use (score is the sum of answers). Beacon Patient Safety Collaborative All the members of the Beacon collaborative were The Bay Area Patient Safety Collaborative. and scoring systems as the original survey the potential application of new ideas (Bearden & Nete- to allow for direct comparison. the survey completed it. Information pro- known as Beacon.% of members that opened the (e. The construct of addresses).” The survey utilized the same their own use. nurses. After sufficient to be innovators or early adopters than those who don’t discussion. The results were compared meyer. and operational practices. ) tool titled “Innovativeness: Openness tion about new concepts. title.g. . ideas. evidence. products.% of those that began celerating the implementation of high impact. novelty seeking.  were opened (. Nolan. and Walton’s () version and identified seven factors: The survey was distributed one time to the collab- new is wasteful. A confounder that was considered related to this proj- The leadership team of Beacon was approached to ect was whether those who answer surveys are more likely participate in the innovativeness survey. with Rogers’s percentages of innovators and early adopt- Based on one of the original samples using intercept ers in groups. risk orative members with a -week window to complete the aversion. and questionnaire has been shown to be an effective and effi- . social desirability.

Innovators are described as individuals open to new experiences and novel stimuli. The results of the survey will be accessed via the password of the primary investigator. and 5. Recruitment Procedure: Convenience sampling by utilizing the Beacon leadership team and potentially members of the entire Beacon collaborative. Agree. I would give a lot of weight to what others think of it. 4. If people would quit wasting their time experimenting. 3. Potential Benefits to Subjects: Findings from this study will contribute to the body of knowledge related to innovation personality types in patient safety collaborative. 7. Respondents are assured of confidentiality. IRB Application Study Title: Openness of Information Processing in a Patient Safety Collaborative 1. After the data are aggregated and analyzed. Survey of Members of Beacon Collaborative on Openness of Information Processing Primary Investigator: Juli Maxworthy. Often the most interesting and stimulating people are those who don’t mind being original and different. 6. An electronic survey with 24 multiple choice questions will be provided to participants through a URL link within the e-mail. 4. I would like a job that requires frequent changes from one kind of task to another. However. CPHQ Innovativeness: Openness of Information Processing Form A 1. this assessment has not been validated. addresses confidentiality. No demographic questions that would reveal the identity of the participants are included. Disagree.indd 39 3/25/2010 9:08:59 PM . 1988). we would get more accomplished. including work by students under your supervision. 2. one can determine whether they are innovators. 2. I don’t like to talk to strangers. The 24 basic questions (either Form A or B) are attached. Description of Sample: The subject population will initially be the Beacon Patient Safety Leadership team and may be expanded to include the entire Beacon Collaborative membership. Each statement of the survey is evaluated in terms of “how well it fits the respondent’s own view” the 5 place scales associated with each statement are labeled as follows: 1. Minimization of Potential Risk: See above. Background and Rationale: Innovativeness: Openness of Information Processing (Leavitt & Walton 1975. 4. The unusual gift is often a waste of money. 8. Signature of Applicant Date Signature of Faculty Advisor* Date *Your signature indicates that you accept responsibility for the research described. 11. CNL. MBA. 3. has been redefined to be termed “openness of information processing” (Leavitt & Walton 1975. TABLE . Reimbursements/Compensation to Subjects: None. MSN. 1988). The quality and patient safety challenges health care is currently addressing are often led by individuals who appear to be innovators by their embracement of various ways to improve patient care and ensuring positive outcomes. The findings of this survey can shed light on assumptions made about the types of people associated with the patient safety movement in health care. (Continued) Evaluating “Innovativeness Quotient” 39 Article_09. 7. will monitor the research. Confidentiality of Records: All records will be kept in a secure file in the home of the Primary Investigator. as involved in the research on which the following measures are based. and will notify the IRPBHS of any significant problems or changes. as possessing the ability to transform information about new concepts. and as having a low threshold for recognizing the potential application of new ideas. After review of initial results. RN. 9. I enjoy looking at new styles as soon as they come out. Both positively and negatively worded statements along with several social desirability filler items are included in each form. It further attests that you are fully aware of all procedures to be followed. Undecided. In the original form. Buying a new product that has not yet been proven is usually a waste of time and money. If I got an idea. I like to take a chance. 8. Procedures: The procedure will be to send e-mail requests to contacts provided through convenience sampling. Subject Consent Process: The survey will be e-mailed initially to members of the Beacon leadership team. which includes individuals throughout the San Francisco Bay Area. products. The survey (Survey Monkey) will have a cover page with a letter that explains the need for the survey. The construct. Potential Risks to Subjects: The study presents no risk or inconvenience to subjects other than the inconvenience of time spent answering the survey. Strongly Agree. the data set will be destroyed. 10. and addresses consent to participate. 5. or services for their own use. ideas. Strongly Disagree. Construct: Innovativeness is assumed to be a personality trait underlying the adoption of innovations. Costs to Subjects: None. By assessing basic personality traits of individuals who participate in a patient safety collaborative. 2. 3. 6. 9. 5. it will be determined whether to expand the survey to the entire Beacon collaborative. item scores are summed to form an overall index. and there may be several “filler” questions added.

I like to see what my friends and neighbors think of a product before I try it. I would rather be safe than sorry. I like to fool around with new ideas even if they turn out later to be a total waste of time. I often buy it just to see what it is like. IRB Application (Continued) 10. especially in clothes. I enjoy being with people who think like I do. 12. evidence to make it clear that adoption was worthwhile. 3. 9. I don’t like to take chances if I don’t have to. Although not specified by the original authors. are a waste of money. A sensitivity analysis assumed that all subjects that that their results could be compared to those who took opened but did not complete the survey (334-127 = 207) the survey voluntarily. especially those that are really different. stimulating. it is usually a good idea to look at the situation from a completely different angle—one that wouldn’t occur to someone. I like to experiment. 20. Recording these items would reflect a higher level of innovativeness. Note. thereby becoming more of an expert. 24. 6. since it would be unethical to mandate that those who vator/early adopter category according to the validated tool chose not to take the survey would be forced to take it so utilized. 20. TABLE . 3. I like new styles in clothes. the usual ways of doing things are the best. 10. 19. I start up conversations with strangers. I take chances more than others do. 12. The findings of the study indi- cate that the patient safety collaborative consists of a higher Survey Findings proportion 28. 20. I usually pass right by. The Rogers model. 7. In the sensitivity analysis the per- validity of late adopters waiting until there is adequate centage of innovators/early adopters was 28. 7. I like to try new and different things. 13. In hunting for the best way of doing something. I dread having to start another new project. When I see a new brand on the shelf. 9. 14. 4.indd 40 3/25/2010 9:08:59 PM . At work. 21. 23. 18. People who are shocking are usually trying to impress someone. 15.5% (96/127) scored in the inno. 13. I like to try new products to see what they are like. 17. 15. 16. In the long run. 6. 21. 18. I like to wait until something has been proven before I try it.7% (96/334). 16. I like to look at strange pictures. 15. 13. 18. A limitation of the study was the were noninnovators. and 21 on Form A. I can enjoy being with people whose values are very different than mine. 12. 14. 5. Unless there is a good reason for changing. Of those who than Rogers found in the general populations (~16%). 75. 11. 13. concluded that the 2 sigma percentage of inno- Results vators/early adopters is 16%. I like to experiment with new ways of doing things. In hunting for the best way to do something. I feel that too much money is wasted on new styles. 19. Also. I would like a job that doesn’t require me to keep learning new tasks. 40 Maxworthy Article_09. I like a great deal of variety. 9. I feel that the tried and true ways of doing things are the best at work and in my life.7% to 75. 5. I generally like to try new ideas at work and in my life. When I see a new brand on the shelf. Form B 1. 8. and items 3. which is a broader cross-section of the population. it is usually a good idea to try the obvious way first. I like people who are a little shocking. 22. and 23 on Form B. Some modern art is stimulating 23. active life. I’m the kind of person who is always looking for an exciting. When it comes to taking chances. items requiring reverse coding apparently are items 2. I would not risk my position at work by putting into effect some new idea that might not work. 18. 22. 19. 24. I think everyone should work on only one thing. 22. 11. The changes in styles. Sometimes original and different people make me uneasy. New products are usually gimmicks.5% of innovators/early adopters The findings of the survey were dramatic. I often try new brands before my friends and neighbors do. 5. The completed the survey. Today is a good day to start a new project. 11. 16. I think we should continue doing things the way they are being done now. breakdown of other elements can be found in Table 2. 8. 17. 11. 2. I like to spend money on unusual gifts and toys. the “filler” items are not included in the above scales.

then response rate among actively engaged Beacon members is 127/1048 (. timely. makes it possible to put together quality improvement teams that will have a higher chance of success.2% of recipients would open any given Beacon e-mail. identifying activities because the right people are likely to be at the systems’ issues.5% Licenses of Survey Participants License MD Pharm PT RN RT None/Other 1/3 33.5% of innovators/early adopters than Rogers found in general populations (~16%). could provide a great deal of savings in preventive loss There are implications for the DNP working in a sys- of improvement team time.5% (96/127) of those that completed the survey scored in the innovator/early adopter category according to the validated tool utilized. Nurses should be prepared with so- ficiency when implementing performance improvement phisticated expertise in assessing organizations. and facilitating organization-wide changes table from the beginning. The likeli- Implications for Leadership hood of rapid change occurring. There is an element in Essential #2 “Innovativeness Quotient.0% Degrees of Survey Participants Degree Associate Bachelor Master Doctorate None/Other 7/8 87. concluded that the 2 sigma percentage of innovators/ early adopters is 16%.indd 41 3/25/2010 9:08:59 PM .2% of e-mails opened by recipients. 2006). The use of this tool function as highly collaborative teams for safe. ). efficient.1% response rate.3% 10/15 66. The time required to send the in practice delivery (AACN.7%– 75. Low response rate partially due to incorrect e-mail addresses (2.2% bounce back) and broad e-mail database targeting even those loosely associated with Beacon group (only 30.6% Note. which is a broader cross-section of the population. new ideas generated.9% 48/62 77.” Obtaining the information that suggests screening of other fields for new approaches about “Innovativeness Quotient” of an individual member to issues in health care. Discussion survey and analyze the results is small. a in the interprofessional dimension of health care allows This proactive assessment of individuals in a team the DNP to facilitate collaborative team functioning.0% 34/43 79. Health care professionals must sues are innovators or early adopters. • The findings of the study indicate that those involved in the patient safety collaborative consists of a higher proportion 28.5% 32/36 88. There are also savings in ef.4% 5/6 83. TABLE . This survey is inexpen- Benefits of Knowing Team Members sive to administer and easy to use.302) = 40. Because of its ease of Evaluating “Innovativeness Quotient” 41 Article_09. it zational and systems leadership for quality improvement would be beneficial to identify personnel with the highest and systems thinking.4% 1/2 50.3% 4/4 100% 1/1 100% 61/74 82.7% (96/334) assuming all who opened and did not complete survey are noninnovators. Survey Data Results Results • 75. ef- during the formation of performance improvement teams fective. outcomes (AACN. and patient-centered care in will likely have value for identifying the right people for complex environment (IOM. and quicker uptake and transfer of information is more likely The essentials of DNP education were defined by the if the Innovativeness Quotients of the individual team American Association of the Colleges of Nursing (AACN. equitable. • The Rogers model. tems leadership role. • No control group due to the inability to predetermine or define a select group of innovators or noninnovators in any field. ). Data from Participants of Survey 84 or greater 96/127 75. This assumes that only 30. Effective performance “Innovativeness Quotient” improvement teams need to be intraprofessional since Knowing the “Innovativeness Quotient” of individuals issues encompass many functions. DNP Essential #2 describes the need for organi- For the purposes of developing an effective team. particularly in rela- tion to the potential time savings. • Sensitivity analysis 28. ). or an entire team takes only a few minutes and can be DNP Essential # relates to the interprofessional col- done via a convenient on-line survey. e-mail in previous 3 months). The findings of the laboration for improving patient and population health survey indicate that many who work on patient safety is. Advanced preparation the team (innovators/early adopters). members are known.

Washington. Journal of the American Medical Association.. J. T. Oxford. for innovativeness. sociation for Consumer Research. MBA. Institute of Medicine. In L. MacFarlane. C. The International handbook Quotient” was considered intuitive and easy to complete. (1993)..pdf Leavitt. E. 289(15). M. V. Schlinger (Ed. dations of improvement. Journal of Psychology. Educational and Psychological Measurement. CA 94109. G. Handbook of Mar. Rogers. (2003). Assessment of inno- For respondents. 581–629. Advances in Maxworthy.aacn. 6. (1975). G. & Foxall. J. E. (2003). 555–562). Convergent validity of four innova- Quotient” tool could be used by a team leader to identify tiveness scales. Berwick. O. C. cessing as a moderator of message effects on behavior (Faculty keting Scales: Multi-item measures for marketing and consumer working paper). (2003). 82(4). (2004). R. C. W. The foun- American Association of Colleges of Nursing.. New York: Free Press. R.). the “Innovativeness Goldsmith. (1988). G.. Diffusion of innovation in service organiza- vativeness Quotient” may have value to organizations in. Some personality correlates of open pro- Conclusion cessing. the survey and the analysis of the results were Greenhalgh. E. E. innovativeness.).). use and the simplicity of the scoring. State University. individuals who have high “Innovativeness Quotients. the online survey of “Innovativeness vation. Memorial Hospital. edu/DNP/pdf/Essentials..nche. Bate. J. quick. from http://www. Determining the “Inno. CA: Sage. (1984). & Nolan. R. CPHQ. 2. (1975). University of San Francisco.indd 42 3/25/2010 9:08:59 PM . 2008.).. 81–87. on innovations (pp.. and inexpensive...The Milbank terested in building more effective teams. & Kyriaki- simple. 78–91. DC: National Academy Press. Knowledge of a Quarterly. dou. Thousand Oaks. pp. Disseminating innovations in health. Openness of information pro- Bearden. References Langley. J. health system for the 21st century. Advances in Consumer Research. R. MI: As. & Walton. Ann Arbor. 545–554. and sustainability Institute of Medicine. tions: Systematic review and recommendations. (1986). DNP. (2000)..” 46. Robert. An empirical test of a scale Correspondence regarding this article should be directed to Juli C. College of Business Administration. In M. 2. M. (2006). the potential for diffusion. Nolan. Saint Francis consumer research (Vol. (2001). R. L. M. Shavinaina (Ed. 116. Craig. D. S. Ohio behavior research (2nd ed. 59–66. MSN. R.net 42 Maxworthy Article_09. F. Crossing the quality chasm: A new of patient-centered initiatives and ultimately save lives. To err is human. UK: Elsevier’s. E-mail: withmax@comcast. Goldsmith. sentials for Doctoral Education for Advanced Nursing Practice. Goldsmith. R. Diffusion of innovations (5th ed.. dissemination. G. T. The Es. Quality Progress. care. (1999). & Ginter. As a tool. 321–333). O. San Francisco. DC: team’s “Innovativeness Quotient” could potentially increase National Academy Press. Development of a scale for Retrieved September 17. P. RN. Washington. Leavitt. & Netemeyer. CNL. K. J. W. & Walton. 1969–1975.

English speaking or English as second language (HRET. Number 1..3. quality indicator [QI]. The Institute of Medicine’s (IOM)  study of “To ISMP.S.43 Article_10. Medication Practices. Keywords: Beers criteria. As the geriatric patient population increases. acteristics: elderly. This is an increase of nearly 60% since 1995. The elderly. REF (Health Research & Educational Trust. and/or omission of drugs that are indicated. & MGMA.indd 43 3/25/2010 8:16:24 PM . the elderly. 1998). unemployed. that may indicate limited literacy include the following: Clinical Scholars Review. ). and e-prescribing) for maxi- The U. population aged  and older is estimated to mizing safety. non- in the elderly. it would be the fifth cause of death in the United and approaches for the clinician to consider (Beers cri- States (Lazarou et al. If medication-related problems were ranked as a disease by cause of death. and rational prescribing) of death. the Institute of Medicine (IOM) reported that medication errors are the most common error in health care. Volume 3. the National Committee on Quality Assur- cation. and Medical Group Management The aim of this review is to discuss factors affecting Association [HRET. minority ethnic group. Pertaining specifically to the Err Is Human: Building a Safer Health System” stunned elderly. low income. 2010 © Springer Publishing Company 43 DOI: 10. The need for geriatricians will increase. vision will impact health literacy. and . quality indicators Two out of every three patients who visit a health care Recognizing the growing problem of medication safety in provider leave with at least one prescription for medi. & MGMA]. and the number of those aged  and older will increase Factors Affecting Medication Safety in the Elderly from  million to . medication adherence. medication safety in the elderly (health literacy. functional deficits such as poor hearing and low many with its conclusion that between . it would be the fifth cause of death in the United States. The provi- sion of quality care requires that clinicians recognize and prevent drug-related problems in the elderly. Lindenberg University of Texas In . teria. which contains quality medication during a given week and 27% take at least five measures related to high-risk drugs for the elderly. _ BRIEF REPORT Medication Safety in the Elderly: Translating Research Into Practice Julie A. Behaviors and responses inpatients die each year from medical errors (IOM.1. less than nicians to enhance their knowledge of medication safety a high school education. medica- ication-related problems were ranked as a disease by cause tion adherence. the use of inappropriate drugs. 2008b). million (The American Geriatrics Health Literacy Society. ISMP. potentially inappropriate prescribing in the elderly (PIPE). rational prescribing. increase from  million in  to  million in .. If med. a rapidly increasing segment of the population. 81% of adults in the United States take at least one formation Set (HEDIS) in . there will added Key risk factors include patients with the following char- responsibility on Doctor of Nursing Practice (DNP) cli. In ance revised its Healthcare Effectiveness Data and In- fact. health literacy . Institute for Safe Research continues in this area. safety culture. ). are at greatest risk for adverse drug events.1891/1939-2095. 2008a). Suboptimal prescribing in the elderly may involve overuse (poly-pharmacy).

patients identi. applicability to most or lowest in the group that used both a medication schedule all practice settings. other measures include: drug levels. enhance and communicate safety concerns. and/or timing of medication administration tion effectiveness. alcohol use. all clinicians and non- feedback. 2008). these values ( Jones et al. sess the reason(s). act to pre- fied several barriers to medication adherence: these in. as- inaccurate registration forms. Compliance was higher when become an important resource for implementing medica- subjects took medication via blister packaging. charts had a higher medication compliance and medica. The average score in the medication safety cognitive capacity to organize. Patient Safety Organizations (PSOs). ISMP. confidence. For all patients on a prescribed medica- ments. on their ability to reduce potential for serious harm. 2008b). The best organizational) behavior based on lessons learned from predictors of nonadherence are the number of psychiatric mistakes. errors should be in place and is supported by a culture % were associated with increases in medication adher. inability to name medications. full implementation of action items related to medication tion knowledge than those that received counseling only. 2001). monitor the patient with each encounter for follow-through with laboratory tests. or re. and understanding to actively learn. Simplification of dosing regimens increased clinical personnel should be included in the educational adherence %–% (Schroeder et al. All available. adapt. ). In addition to simpli- health literacy issues (HRET. 2001). 2007). and be rewarded in a manner consistent with disorders and the complexity of dosing regimens. Subjects tion-safety best-practices. medication adherence. If the patient intentionally misses doses. number of barriers identified negatively correlates with a it refers to the extent to which individuals and groups will patient’s level of adherence. On average. When the PPSA was piloted. Compliance in older adults was (PPSA) provided data for designing web-based tools for higher with dose simplification and unit-of-dose packag. safety scored lowest (%) when compared to other patient The clinician should assess the patient’s or caregiver’s safety measures. commit to personal responsibility for safety.. & MGMA. established ance. ). Groups of patients that received reminder a large capital investment. It should was ineffective as a sole strategy. Tool topics were selected based with a written medication card had both higher knowl. however. 2007). and non- adherence to medication regimens has shown to be associ- Culture of Safety ated with 10% of hospital admissions and 23% of admissions to nursing homes ( Vermeire et al. frequently missed appoint. ). suggests that once-a-day dosing enhances daily compli. Effective communication involves assessing adherence at Medication Adherence each visit and developing a reminder system. strive clude efficacy. pro- edge and increased compliance.. ISMP. lack of tion regimen. imaging tests.indd 44 3/25/2010 8:16:24 PM . response.. 44 Lindenberg Article_10. and patient compli. noncompliance with medication regimens. A system for reporting In a systematic review of adherence interventions. and modify (both individual and the provider instructions ( Vermeire et al. serve. and administer domain was % (HRET. Evidence effort ( Jenkins & Vaida. patient education the practice (HRET. medication safety that will target outpatient practices and ing (Schroeder et al. If applicable or tions on a prescription bottle ( Jenkins & Vaida. and ability to be implemented without and organizer. and patient self-monitoring. noting a treatment that 42% of patients could not understand simple instruc. The Physician Practice Safety Assessment with prescribed therapy. 2006). Adherence increased be made clear to the staff that errors will be considered most consistently with behavioral interventions that re. Factors related Safety culture is the enduring value placed on worker and to nonadherence should be identified and addressed. 2006).. One study found methods such as: asking the patient. & MGMA. Dose simplification to single-pill . under the Patient Safety and Quality Improvement Act of ance with scheduling. lab work ferrals to consultants. Measures of adherence include practical (HRET. what (as appropriate) for prescribed medications. ISMP.. that allows for open collection and sharing of data within ence (McDonald et al. involving the family or significant others is a strategy to increase adherence (Haynes et al. Adherence with medications approximates 50%. remember. ISMP. fying regimens. have the primary mission of improving patient safety vs. & MGMA. reluctance to read materials at the practice. and attendance at appointments. results in fewer missed doses. and when duced dosing demands and involved monitoring and errors or near misses do take place. two-pill dosage significantly increased the persistence and quality.. The public safety by everyone at every level of an organization.. Omission errors were the mote positive behavioral change. ). opportunities for education. incomplete or medications. and medica- they are for. medication side effects. & MGMA. c). pharmacy practice staff should be trained to recognize and manage refills. not punishment.

According to the WHO. and chlorpropamide.. rational use of older than 65. 2001). In 2001. Other studies have (Aparasu & Mort.. ). with the storage area(s) well-organized and with delineating drugs to always avoid. Drugs must be sepa. a potential contributor to poly-phar- macy. it was revised to apply to community electronic. ). societal factors. 82% of nurse practitioners believed that to plan interventions for decreasing drug-related costs their choices of medications were influenced by the avail. 2008). Likewise. falls. have been associated with adverse out- tioner clinical practices (Figueiras et al. muscle relaxants.indd 45 3/25/2010 8:16:25 PM . The frequently cited Research also indicates that the greater the prescribers’ drug-related problems that required hospital admission connection with the pharmaceutical industry. dwelling elderly (Stuck et al. confusion. inappropriate and those that are inappropriate if recom- nity” ( WHO. are intended to reduce inappro. indometha- Evidence-based practice and the concept of “rational pre. Several studies have shown that 34% mended dosages or durations are exceeded. The Beers crite- (HRET. drugs that are rarely ap- controlled access ( Jenkins & Vaida. in 1997. 2007). ). and practi. safer alternatives exist ( Jenkins & Vaida. rated. and at the lowest cost to them and their commu. and dosing frequency errors (27%). medication orders Beers Criteria are to be read back. Drug marketing can influence practitioners directly. & MGMA. such prescribing in practice include: changing institutional as non-steroidal anti-inflammatory drugs (NSAIDs) and policies. propoxyphene. as recommended by the IOM by .000 person-months. Label. propriate and high-risk drugs which that may have some indications (Zhan et al. Preventable adverse drug events (pADEs) are estimated psychologically. 1994). & Mort. Researchers have consistently reported linked to preventable problems in elderly patients. ).. and educationally (Monagan et al. Interventions for improving found that patient-initiated medication (PIM) use. amitrtrip- scribing. because the risk is unnecessarily high and medication requires that “patients receive medications ap.. problematic abbreviations should be avoided. identifying inappropriate medication use assists clinicians 2004). at 14. dipyridamole.. Clinicians can refer to the Beers list of priate prescribing and improve patient care (Crigger & 48 individual medications or classes to avoid in patients Holcomb. Poly-pharmacy (the use of multiple About % of hospital admissions in elderly patients medications and/or administration of more medications may be linked to drug-related problems or drug toxic ef- than are clinically indicated) is a consequence of irratio. Clinical Approaches to Enhancing Medication Safety in cation is critical to medication safety. effective communi. 2000). and minimize drug-related problems (Fick et al. there should be an awareness of similar drug Beers and colleagues developed criteria to guide clinicians names (studies have shown that % of medication errors when prescribing medication with the potential for ad- are a result of drug names that look alike or sound alike) verse affects in the ambulatory elderly. ). and ideally. comes and increased costs (Smalley & Griffin. such as that patients receiving a large number of medications depression. the pharmaceutical industry has been shown to promote The application of the Beers criteria and other tools for inappropriate prescribing in studies of physicians (Angell. comprised medications that are generally time. benzodiazepines. several of the of the prescriptions in the United States are unnecessary medications were deemed inappropriate because there are (Farrell et al. An office culture that fosters open. and are at higher risk for receiving inappropriate medications hip fractures (Bootman et al. 2003). the prescribing system should be patients. Information should the Elderly be shared among all team members.. developed through literature and consensus own individual requirements. to name several (Aparasu (WHO) in the 1970s. (37%). The origi- propriate to their clinical needs. ability of samples. cin. This agent-specific list was revised in 2002 to include: long-acting benzodiazepines. for an adequate period of methodology. 2001). marketing strategies. in doses that meet their nal criteria..9 per 1. The influence of drug sampling by safer alternatives (Aparasu & Mort. patient nonadherence the denial of its influence. the greater were inadequate monitoring (45%). constipation. ). Rational Prescribing short-duration barbiturates.” as begun by the World Health Organization tylline. ). immobility. Zhan devel- ing and storage may be problematic. 2010). 2000). fects (Hanlon et al. 2000). propanolol. In office-based Medication Safety in the Elderly 45 Article_10. ISMP. oped criteria for drugs that contraindicated in the elderly. handwriting should ria were developed in 1991 and applied to nursing home be legible. Direct-to-consumer advertising is widely used in the United States and exerts a major effect on medication- Quality Indicators seeking behavior. Adverse drug events have been nal prescribing.

Vaida. has the potential for improving health outcomes and was ter. Inc. analgesics. and standardizing height and weight measurements medication-prescribing decisions. If a vulnerable elderly patient is prescribed an tions. home health care) (HRET. with the same or similar names. nursing home. ment (Curtis. or high-alert medications that may require dose reduction discontinuation (Shrank et al. c). those who recommended to have an annual drug regimen review. Items related to high-alert ful interactions. all medications should be reviewed with the patient. betes mellitus. information between a prescriber. who received higher quality care had % higher survival Indicators related to patient information include: hav- over  years. as are not successful e-prescribers will receive reduced pay- this allows an opportunity for the discontinuation of un. approach will help to clarify whether a drug is meeting 2008b). four diagnoses may have a significant impact on people in a managed care setting applying ACOVE indi. medication monitoring (%).” in which pa. print prescrip- this time. Additional items related to medication reconciliation QIs can be applied in practice to identify areas of care include: the provision of an up-to-date list of all medi- in need of improvement and can form the basis of inter. kidney disease. ISMP.5% of pADEs: cardiovascular drugs.. supporting the validity of these QIs ( Wenger ing a system in place for a name alert process for patients et al. Starting in 2012. umentation of response to therapy is imperative. c). Those for renewals (HRET. ). Automation of the ambulatory adverse effects at each encounter. In of pharmacological care of community-dwelling elderly addition. Such a list E-prescribing may be defined as the transmission. define and eliminate inappropriate du. tients bring to the encounter all of their prescription and This act requires Medicare to provide incentive payments nonprescription medications. & MGMA. and education ric disease. documentation of medication response and any ventions to improve care. & MGMA. At each encoun.. They are dia- cators found substantial underuse of appropriate medica. or health plan directly (Centers for Medi- drug-disease interactions. pharmacy plication of therapies. These practices could benefit from the use of the therapeutic goal for which it was prescribed and pro- medication reconciliation and building staff awareness of vides a rational basis for its continuation. and conduct 46 Lindenberg Article_10. doc- ble for 86. Improvements for Patients and Providers Act of 2008. and frequency. modification. ). and streamline the regimen to care & Medicaid Services [CMS]. All vulnerable elderly are recommended to have an up-to-date medication list readily available in the medi- Electronic Prescribing cal record that is accessible to all health care providers and includes over-the-counter medications.. and/or medication monitoring. ISMP. adopted by Congress with the passage of the Medicare ideally utilizing the “brown bag method. correct dangerous drug-to-drug or benefit manager. of prescription or prescription-related of new symptoms. writ- The Assessing Care of Vulnerable Elders (ACOVE) ten indications for as-needed medications included on the project. as well as the addition of necessary A qualified e-prescribing system generates a com- drugs not currently prescribed. ISMP. a collaboration between RAND Health and prescription. To be a valid measure of quality. ). E-prescribing improve adherence (Shrank et al.. medication selection.indd 46 3/25/2010 8:16:25 PM . A system should be in place to highlight these (%). liver disease. All vulnerable elderly are to successful e-prescribers. the three following drug categories were responsi. transmit prescriptions electronically.. using makes it possible to identify potential drug-related causes electronic media. Overuse of inappropriate medications occurred conditions when medications are prescribed ( Jenkins & infrequently (%) (Shrank et al. necessary medications. Medications prescribed plete active medication list using electronic data and al- by other providers can be reviewed and documented at lows professionals to select medications. where (hospital. 2009). and establishing a list of high-alert medica- Pfizer. & MGMA. and communication prescribing process has the benefit of enhancing patient of all medications received when care is transferred else- safety through computerized transmission of legible pre. cations. ongoing medication for a chronic medical condition. This would also put a check in place if the medications include: a system in place to track all patients elder is utilizing more than one pharmacy. One quarter of the QIs involve gies. requiring a protocol at care process must be strongly linked to an outcome that each encounter that documents patients’ medication aller- is important to patients. dosing. Such an and hypoglycemic agents (HRET. dispenser. receiving warfarin therapy and monitoring of INRs. ). and psychiat- tions (%). scriptions directly to the pharmacy and checks for harm. seeks to develop a living set of QIs for the tions prescribed that require direct contact of the provider medical care provided to vulnerable older persons. 2008). A chart-based review in the metric system for accurate dosage calculations. a health. studies. especially in the elderly. ).

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