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Clinical Rounds

doi: 10.1097/01.NURSE.0000552717.17329.2f
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Nurses with BSNs feel better prepared



Past research has identified quality and safety gaps between associate- and baccalaureate-prepared new nurses who graduated between 2004 and 2005. A new study assessed changes in nursing workforce quality and safety education preparedness among new nurses licensed in 2007-2008 (N = 324) and 2014-2015 (N = 803). The results revealed that the number of quality and safety educational gaps between bachelor's and associate degree nurse graduates more than doubled over 8 years. The authors write, “In the 2007-2008 cohort, RNs with a bachelor's degree reported being significantly better prepared than RNs with an associate degree in 5 of 16 topics. In the 2014-2015 cohort, bachelor's degree RNs reported being significantly better prepared than associate degree RNs in 12 of 16 topics.” They recommend improving accreditation and organizational policies requiring baccalaureate education for all nurses to safeguard quality of care and patient safety.

Source: Djukic M, Stimpfel AW, Kovner C. Bachelor's degree nurse graduates report better quality and safety educational preparedness than associate degree graduates. Jt Comm J Qual Patient Saf. [e-pub October 15, 2018].

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Enrollment for NHS3 is still open

Launched in 1976, the Nurses' Health Study (NHS) is an ongoing investigation involving about 280,000 participants to date. Affiliated with Harvard University and the National Institutes of Health, it is among the largest prospective investigations into risk factors for major chronic diseases in women.

Nurses' Health Study 3 (NHS3), the third generation of the study, is now underway to further investigate the long-term effects of nutrition, hormones, environment, and nurses' worklife on health. Researchers are currently recruiting male and female nurses (RNs and LPNs/LVNs) or nursing students between ages 20 and 46 who live in the US or Canada. Recruitment will continue until the goal of 100,000 new participants is reached.

NHS3 participants commit to completing a 30-minute online survey every 6 months:

  • Survey 1 collects demographic data, a medical history, and information about lifestyle and occupational exposures.
  • Survey 2 includes a detailed reproductive history and questions about current diet and physical activity.
  • Survey 3 updates the medical history and asks about lifetime physical activity. Nurses may also be invited to participate in optional studies on specific topics, such as fertility.

To learn more about contributing to the study, visit

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“Choosing Wisely” campaign gets results

Initiated in 2013 by The Joint Commission, the Choosing Wisely campaign is intended to reduce use of unnecessary or low-value healthcare, including overuse of diagnostic tests. A recent report describes a successful Choosing Wisely initiative implemented across 25 Kaiser Permanente Georgia medical clinics serving approximately 300,000 members during a 3-year period. Goals of the multifaceted intervention were to decrease unnecessary complete blood cell (CBC) counts and ECGs during routine physical exams, dual-energy X-ray absorptiometry (DEXA) osteoporosis screening for women who did not have an indication, and imaging for uncomplicated headaches. The initiative provided participants with guidelines selected by clinical leaders, continuing medical education for clinicians and training and education for clinic staff, an internal and external communication plan, and monthly reports.

The intervention achieved impressive reductions in all categories:

  • CBC use as a routine screening test decreased by 39.5%
  • ECG use as a routine screening test decreased by 15.5%
  • inappropriate DEXA scan use decreased by 23.4%
  • imaging for uncomplicated headache decreased by 3.9%.

All decreases were statistically significant and largely sustained even after physicians stopped receiving monthly reports about their use of these tests. The authors concluded that implementation of a comprehensive change management package led to sustained reductions in nonbeneficial services in ambulatory care.

Source: Pugel S, Stallworth JL, Pugh LB, et al. Choosing Wisely in Georgia: a quality improvement initiative in 25 adult ambulatory medicine offices. Jt Comm J Qual Patient Saf. 2018;44(12):699-707.

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Ignoring patient feedback leads to errors

Examining 184 patient- and family-generated reports of adverse medical events submitted from January 2010 to February 2016, researchers found that failure to consider the patient's perspective is a major contributor to diagnostic errors. An analysis of the data revealed “224 instances of behavioral and interpersonal factors that reflected unprofessional clinician behavior, including ignoring patients' knowledge, disrespecting patients, failing to communicate, and manipulation or deception.” They recommend that healthcare systems implement formal programs to collect patient experiences with diagnostic errors and use the data to develop a culture that encourages and supports positive, patient-centered communication behaviors.

Source: Giardina TD, Haskell H, Menon S, et al. Learning from patients' experiences related to diagnostic errors is essential for progress in patient safety. Health Aff (Millwood). 2018;37(11):1821-1827.

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Minimally invasive surgery linked to higher mortality

Minimally invasive techniques to treat early stage cervical cancer are widely accepted despite a lack of rigorous research supporting their safety and effectiveness. Laparoscopy-based and robotic techniques are now the dominant methods of performing radical hysterectomy in the US. Two recently published studies call these approaches into question.

  • A cohort study was conducted based on a large patient sample drawn from the National Cancer Database. Over a median follow-up of 45 months, the 4-year mortality was 9.1% among women who underwent minimally invasive surgery and 5.3% among those who underwent open surgery. The researchers concluded that “minimally invasive radical hysterectomy was associated with shorter overall survival than open surgery among women with stage IA2 or IB1 cervical carcinoma.”
  • In a second, smaller study, patients with early stage cervical cancer were randomly assigned to undergo minimally invasive surgery or open surgery. The primary outcome was the rate of disease-free survival at 4.5 years. The conclusion was similar: “Minimally invasive radical hysterectomy was associated with lower rates of disease-free survival and overall survival than open abdominal radical hysterectomy.”

In an accompanying editorial, Amanda N. Fader, MD, called these results “alarming” and urged surgeons to “proceed cautiously, counsel their patients regarding these collective study results, and assess each woman's individual risks and benefits with respect to minimally invasive as compared with open radical hysterectomy.”

Sources: Ramirez PT, Frumovitz M, Pareja R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. N Engl J Med. 2018;379(20):1895-1904. Melamed A, Margul DJ, Chen L, et al. Survival after minimally invasive radical hysterectomy for early-stage cervical cancer. N Engl J Med. 2018;379(20):1905-1914. Fader AN. Surgery in cervical cancer. N Engl J Med. 2018;379(20):1955-1957.

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Lower levels recommended for critically ill

An expert panel has issued a new clinical practice guideline recommending that oxygen saturation levels in critically ill patients be maintained at 96% or less. The guideline is based on recent research showing that administering supplemental oxygen in patients with normal oxygen saturation increases mortality.

The authors provide specific recommendations for certain patient populations. For example, no supplemental oxygen is recommended for patients with acute stroke or acute myocardial infarction whose SpO2 is 90% or more on ambient air. They write that 90% to 94% is a reasonable target for most patients; for patients at risk for hypercapnic respiratory failure, however, they recommend a target range of 88% to 92% using the minimum amount of oxygen necessary.

The recommendations apply to both hospital and prehospital care.

Source: Siemieniuk RAC, Chu DK, Kim LH, et al. Oxygen therapy for acutely ill medical patients: a clinical practice guideline. BMJ. 2018;363:k4169.

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“Sleep texting” is trending among college students



In a survey of 372 students in two midsized universities, nurse researchers asked students about hours of sleep (on a school night and over the weekend), and where they kept their cell phone while they slept. More than 25% admitted texting in their sleep and reported poor sleep quality, but most had no memory of what they said or whom they texted. Students who slept with their phone in bed were most likely to text in their sleep. Those with four or more technologic devices in their bedroom had significantly less sleep compared with those with three or fewer devices.

The researchers conclude that sleep texting is a growing trend among college students and that it has an adverse effect on sleep quality. Poor sleep quality has been consistently rated as a top impediment to academic performance in college.

Sources: Dowdell EB, Clayton BQ. Interrupted sleep: college students sleeping with technology. J Am Coll Health. [e-pub October 26, 2018]. New research findings from Villanova nursing professor show an increase in sleep texting. Villanova University. News release.

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Health literacy strongly affects patient outcomes



To investigate the impact of low health literacy on patient outcomes, researchers followed 3,000 patients hospitalized at Vanderbilt University Adult Hospital with acute coronary syndromes, heart failure, or both. They found that a patient with very low health literacy was about 13% more likely to die within a year than someone with very high health literacy.

Along with diagnosis and comorbidities, the study considered social and behavioral factors and perceived health competence, which was described as how confident patients felt about their ability to positively affect their recovery. Lead investigator Lindsay Mayberry, PhD, says that the effects of health competence or literacy on mortality were “sizeable, even alongside clinical predictors that we would expect to be really powerful.” According to Mayberry, the study illustrates the importance of screening for health literacy in hospitalized patients and making sure that health information is delivered in ways that patients can understand.

Source: Low health literacy associated with early death for cardiovascular patients. Vanderbilt University Medical Center. News release. November 7, 2018.

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