Fall 2014.indd

Transcription

Fall 2014.indd

Volume 36, Issue 3, 2014
In This Issue
Promoting rest using a quiet time innovation in an adult neuroscience step down unit
By Tara Bergner, RN, BN, MHS, CNN(c)..........................................................................................................................................................5
Primary malignant brain tumours, psychosocial distress and the intimate partner experience: What do we know?
By Dr. Brenda Sabo RN, PhD..............................................................................................................................................................................9
Development of clinical practice guidelines for urinary continence care
of adult stroke survivors in acute and rehabilitation settings
By Andrea R. Fisher, RN, MSN, MSc, CNN(C), Infection Control Professional....................................................................................16
Clustered stroke patients on a general medical unit:
What nursing skills and knowledge contribute to optimal patient outcomes?
By Brenda Clayton, Athabasca University....................................................................................................................................................32
Retrospective analysis of phone queries to an epilepsy clinic hotline
By Anny Laforme, RN, BNI, Suzie Jubinville, RN, Micheline Gravel, RN, BScN,
Patrick Cossette, MD, PhD, FRCPC, and Dang K. Nguyen, MD, PhD, FRCPC...................................................................................41
Websites of interest
Canadian Association of Neuroscience Nurses and
Canadian Journal of Neuroscience Nursing website: www.cann.ca
Check this site often for updates on information.
Reports will be on the website.
Canadian Nurses Association: www.cna-nurses.com
Canadian Congress of Neurological Society: www.ccns.org
Please check out the web page to learn more about the
society to which we belong. CANN is an affiliate of this society.
Canadian Journal of Neurological Sciences: www.CJNS.org
World Federation of Neuroscience Nurses: www.WFNN.org
All CANN members are automatically members of WFNN.
Board of directors, committee chairpersons and associated
organization representatives 2014 / Conseil d’administration,
responsables des comités et représentants des groupes associés 2014
Councillors
British Columbia: Trudy Robertson
Alberta North: Andrew Kwan
Alberta South: Christianne Krassman
Saskatchewan: Jodi Copeland &
Michelle Jaspar
Manitoba: Jodi Dusik-Sharpe
Ontario West: Corbin Lippert
Ontario Central: Janice Williams
Ontario East: Aline Bourgoin
Quebec: Elizabeth Murphy-Lavallee &
Helen Fong
New Brunswick/PEI: Shelley Paul
Nova Scotia: Joan Pacione
Newfoundland: Jessica Dwyer Milley
2
Committee Chairs
Scientific Liaison: Nancy Thornton
Program Chairs (St. John’s,
Newfoundland 2015): Viola Finn &
Jessica Dwyer Milley
Scientific Chairs (St. John’s,
Newfoundland 2015): Jessica Milley
Communication & Marketing (Web
Administrator): Christianne Krassman
Communications & Marketing
(subscriptions): Jennifer Purkiss
Editor CJNN: Teri Green
Co-Editor CJNN: Corbin Lippert
Representatives
WFNN: vacant
Canadian Stroke Nursing Council:
Patti Gallagher
Canadian Alliance of Brain Tumour
Organizations (CABTO): Karen
Waterhouse
Professional Practice & Research:
Nancy Thornton
Program Liaison: Christianne
Krassman
Executive
President: Tara Bergner
Legislation & Bylaws: Cindy Hartley
Vice President/Secretary: Suzanne
Basiuk
Archivist: Betty Ross
Past President: Cindy Hartley
Membership: Janet White
Treasurer: Mark Bonin
Volume 36, Issue 3, 2014 • Canadian Journal of Neuroscience Nursing
Canadian Journal of Neuroscience Nursing
Le Journal canadien des infirmières et infirmiers en neurosciences
Volume 36, Issue 3, 2014
Editor/Rédactrice en chef
Theresa Green, PFB Room 2210, University of Calgary,
2500 University Drive NW, Calgary, AB T2N 1N4; [email protected]
For subscriptions, contact/Pour inscriptions :
Wendy MacGregor, 119 Innsmill Cr., Ottawa, ON K2T 1G6;
[email protected]
Co-Editor/Co-rédacteur
Corbin Lippert, [email protected]
•
•
•
•
Peer Reviewers/Réviseures
Sharon Bishop, Regina, SK
Jennifer Boyd, Toronto, ON
Andrea Fisher, Ottawa, ON
Sandra Ireland, Hamilton, ON
Lynn Joseph, Nepean, ON
Wilma Koopman, London, ON
Joanna Pierazzo, Ancaster, ON
Cydnee Seneviratne, Calgary, AB
Mina D. Singh, Toronto, ON
Nancy Thornton, Calgary, AB
Carole White, San Antonio, TX
Make cheques payable to: Canadian Association of Neuroscience
Nurses/Les chèques doivent être émis à : L’Association canadienne
des infirmières et infirmiers en neurosciences (ACIIN) : c/o Wendy
MacGregor, 119 Innsmill Cr., Ottawa, ON K2T 1G6.
Yearly subscriptions are included with a membership in CANN/ACIIN
($75.00 Member, $65.00 Associate) or they may be purchased separately.
L’abonnement annuel à le Journal canadien des infirmières et infirmiers
en neurosciences est inclus dans les frais d’inscription à l’ACIIN (75,00 $
pour les membres actifs et 65,00 $ pour les membres associés).
Canadian Journal of
Neuroscience Nursing
The Canadian Journal of
Neuroscience Nursing is the
p e er-re v ie we d j our nal of
the Canadian Association of
Neuroscience Nurses (CANN)/
Association canadienne des
infirmières et infirmiers en
neurosciences (ACIIN). The journal
is published three times a year. We
welcome the submission of original
manuscripts in the areas of practice,
research, theory, education, and
policy, which are of interest to the
neuroscience nursing community.
The views, statements, and opinions
expressed in the articles, editorials,
and advertisements are those of
the authors or advertisers. They do
not necessarily represent the views
and policies of CANN/ACIIN
and the editors and publishers
Canada: $65.00 (CAN)
United States: $65.00 (US)
International: $70.00 (US)
Single Copy: $15.00 (CAN)
disclaim any responsibility or
assumption of liability for these
materials. The Canadian Journal of
Neuroscience Nursing is indexed in
the Cumulative Index to Nursing
and Allied Health Literature,
International Nursing Index (INI)
and Nursing Citation Index.
ISSN 1913-7176 (Print)
ISSN 2368-2639 (Online)
Mission statement
The Canadian Association of
Neuroscience Nurses (CANN)
sets standards of practice and
promotes continuing professional
education and research. Members
collaborate with individuals, families, interdisciplinary teams and
communities to prevent illness
and to improve health outcomes
for people with, or at risk for, neurological disorders.
Copyright
No part of this publication can be reproduced, stored in a retrieval system or transmitted, in any form or by any means, without the prior
written consent of the publisher or a licence from the Canadian Copyright Licensing Agency (Access Copyright). For an Access Copyright
licence, visit www.accesscopyright.ca or call toll-free to 1-800-893-5777.
The Canadian Association of Neuroscience Nurses gratefully
acknowledges the funding provided to the Canadian Journal of
Neuroscience Nursing by the Social Sciences and Humanities
Research Council under the Aid to Transfer Journals program, to
support the operation and expansion of the journal.
Le Journal canadien
des infirmières
et infirmiers en
neurosciences
Le Journal canadien des infirmières et infirmiers en neurosciences est le journal de
L’Association canadienne des
infirmières et infirmiers en neurosciences (ACIIN). Cette publication est revisée par ses propres
membres. Le journal est publié
trois fois par année. Nous acceptons les manuscrits originaux se
rapportant à la pratique du nursing, de la recherche, de la théorie, de l’éducation, et de l’éthique
professionnelle, tous des sujets qui
suscitent l’intérêt de l’ensemble du
personnel en neurosciences.
Les opinions, les points de vue,
et les énoncés exprimés dans les
articles, éditoriaux et affiches
publicitaires sont ceux des auteurs
et commerçants. Ils ne reflètent
pas nécessairement les idées et
les politiques de l’ACIIN. L’éditeur
et la maison d’édition n’acceptent
aucune responsabilité reliée au
contenu du matériel publié dans
le journal. Le Journal canadien
des infirmières et infirmiers en
neurosciences est rattachée au
Cumulative Index to Nursing
and Allied Health Literature,
International Nursing Index (INI)
and Nursing Citation Index.
ISSN 1913-7176 (presse)
ISSN 2368-2639 (en ligne)
Énoncé de mission
L’Association canadienne des
infirmières et infirmiers en neurosciences (ACIIN) établit les standards de pratique de la profession
et fait la promotion de l’éducation
permanente et de la recherche. Les
membres collaborent avec les individus, les familles, les équipes multidisciplinaires et la communauté
en général dans le but de prévenir les maladies neurologiques et
d’améliorer la santé des gens qui en
sont atteints ou qui sont à risque
d’en souffrir.
Editorial
Well, it is time for me to come out from behind the scenes
and thank Dr. Theresa Green for welcoming me to the editorial
department of the Canadian Journal of Neuroscience Nursing.
It is a pleasure to be involved with an organization that is powered by sheer will and determination. As a previously somewhat
passive participant in CANN, I cannot believe the amount of
volunteer energy that is required, supplied and expended in
producing an annual conference and a specialty nursing journal.
Since joining Theresa, I have had the opportunity to be a part
of the editorial process. We have reviewed, edited, accepted
and rejected quite a few papers in the past year. I can assure
you that a lot of effort goes into producing a product that readers should find interesting, applicable and of a high scholarly
quality. Although the standards might be uncompromising,
the editorial process remains supportive of authors willing to
submit their papers for review. We are grateful to the volunteer
peer reviewers who take so much time to carefully read each
submission and make thoughtful comments. We know there
are many gems out there yet to be polished.
This journal and our organization is what we make it. We need
your submissions of original work to continue to fill our virtual pages. Be brave, seek out help from others, put yourself
out there, and share what you know. There is a huge amount of
knowledge locked up in neuroscience nurses across this country—share it! We will continue to support your efforts.
Best regards and best wishes for the holiday season.
Corbin Lippert, RN, MN, NP
London Health Sciences Centre, London, ON
Assistant Editor
Éditorial
On dirait qu’il est temps pour moi de sortir de l’ombre et de
remercier Mme Green de m’avoir accueilli au sein de la rédaction du Journal canadien des infirmiers et infirmières en neurosciences. C’est un plaisir de m’impliquer dans un organisme
qui repose sur une volonté et une détermination absolues.
Parce que j’étais autrefois un participant quelque peu passif
de l’ACIIN, je suis sidéré par la quantité d’énergie que doivent
déployer les bénévoles pour organiser une conférence annuelle
et publier un journal spécialisé. Depuis que j’ai rejoint Theresa, j’ai eu l’occasion de prendre part au processus éditorial. Au
cours de l’année, nous avons revu, corrigé, accepté et rejeté bon
nombre de documents. Je peux vous garantir que la conception
d’un produit que les lecteurs trouveront intéressant, applicable
et d’une grande qualité académique est le fruit de maints efforts.
Malgré des normes intransigeantes, le processus éditorial continue à soutenir les auteurs et auteures prêts à soumettre leurs
articles pour révision. Nous sommes reconnaissants du travail
effectué par nos pairs évaluateurs bénévoles, du temps qu’ils
passent à lire attentivement chaque article et de leurs observations judicieuses. Nous savons que de nombreuses perles rares
attendent encore leur heure.
Ce journal et cet organisme ne sont que ce que nous en faisons.
Il est indispensable que vous soumettiez vos travaux originaux
si nous voulons continuer à remplir nos pages virtuelles. Soyez
courageux, sollicitez l’aide des autres, faites-vous connaitre
et partagez ce que vous savez. Les infirmiers et infirmières en
neurosciences de ce pays sont les porteurs de nombreuses connaissances qui ne demandent qu’à être partagées. Alors, allez-y!
Nous continuerons à appuyer vos efforts. Mes meilleurs vœux
à tous pour cette fin d’année.
Corbin Lippert, RN, MN, NP
London Health Sciences Centre, London, ON
Assistant Editor
The Canadian Journal of Neuroscience Nursing is published by Pappin Communications /
La Journal canadienne des infirmières et infirmiers en neurosciences est publié par Pappin Communications
The Victoria Centre, 84 Isabella Street, Unit 2, Pembroke, Ontario K8A 5S5, email: [email protected]
Managing Editor: Heather Coughlin; Layout and Design: Sherri Keller
Advertising space is available/Disponibilité d’espaces pour messages publicitaires : For information, contact Heather Coughlin,
Advertising Manager, Pappin Communications, The Victoria Centre, 84 Isabella Street, Pembroke, Ontario, K8A 5S5; telephone:
613-735-0952; fax: 613-735-7983; email: [email protected] or visit our website at www.pappin.com
4
CLINICAL CORNER
Promoting rest using a quiet time innovation
in an adult neuroscience step down unit
By Tara Bergner, RN, BN, MHS, CNN(c)
Abstract
Sleep and rest are fundamental for the restoration of energy
needed to recuperate from illness, trauma and surgery. At
present hospitals are too noisy to promote rest for patients.
A literature search produced research that described how
quiet time interventions addressing noise levels have met with
positive patient and staff satisfaction, as well as creating a more
peaceful and healing environment. In this paper, a description
of the importance of quiet time and how a small but feasible
Une innovation au sein d’une unité de
soins courants en neurosciences pour
adultes : favoriser le repos à l’aide des
moments de calme
Résumé
Il est essentiel de dormir et de se reposer afin de récupérer
l’énergie nécessaire à se remettre d’une maladie, d’un
traumatisme ou d’une intervention chirurgicale. À l’heure
actuelle, les hôpitaux sont trop bruyants pour permettre aux
patients de se reposer. Une étude de la documentation a mis en
évidence des recherches décrivant à quel point les interventions
qui favorisent les moments de calme en réduisant les niveaux
de bruit ont reçu un accueil positif auprès des patients et du
I know that I will feel better when I go home, where it is
quiet, because there I can finally get some rest.
C.F., personal communication,
Patient in Adult Neuroscience Step Down Unit,
Health Sciences Centre (HSC), Winnipeg, Manitoba
Sleep and rest are fundamental for the restoration of energy
that is needed to recuperate from illness, trauma and surgery
(Fontana & Pittiglio, 2010). However, in the present state, hospitals are too noisy to facilitate this for patients (Mazer, 2006).
On average, an adult requires six to eight hours of uninterrupted
sleep each night to be able to function. In a hospital, a patient
might only receive eight minutes of continuous sleep (Lower,
Bonsack, & Guion, 2003). Adequate sleep has a positive influence on blood pressure, the pain experience and emotional
well-being (Gardner, Collins, Osborne, Henderson, & Eastwood,
2009). Conversely, sleep deprivation has been shown to cause
many adverse physiological changes including immune system
depression, respiratory changes, vasoconstriction of peripheral blood vessels, gastrointestinal motility changes, increased
muscular tension and increased heart rate and blood pressure
(Dennis, Lee, Knowles Woodard, Szalaj, & Walker, 2010). As
well, psychological changes including depression, delirium,
anxiety and confusion may affect recovery (Lower et al., 2003).
innovation was carried out in an adult neuroscience step
down unit in a large tertiary health care facility in Canada is
provided. Anecdotal evidence from patients, families, and staff
suggests that quiet time may have positive effects for patients,
their families, and the adult neuroscience step down unit staff.
Future research examining the effect of quiet time on patient,
family and staff satisfaction and patient healing is necessary.
Keywords: noise, hospital, quiet time, rest, patient satisfaction
personnel et ont donné lieu à un environnement plus paisible
et propice à la guérison. Dans ce document, nous décrirons
l’importance des moments de calme, ainsi que la façon dont
cette innovation modeste mais réalisable a été mise en place
dans l’unité de soins courants en neurosciences pour adultes
d’un important établissement de soins de santé tertiaires
canadien. Les témoignages des patients, des familles et du
personnel indiquent que les moments de calme ont eu des effets
positifs sur les patients, leur famille et le personnel de l’unité. Il
est nécessaire de mener de plus amples recherches concernant
les effets des moments de calme sur les patients, la famille, ainsi
que sur la satisfaction du personnel et la guérison des patients.
Mots-clés : bruit, hôpital, moment de calme, repos, satisfaction des patients
Since the time of Florence Nightingale, nurses have known
a quiet, restful environment is required for healing to occur
(Murphy, Bernardo, & Dalton, 2013). However, since the 1960s
this has been increasingly difficult to provide because of the
amount of noise within hospital units, especially with the constant evolution of technology and its incorporation into the
care of patients (Xie, Kang, & Mills, 2009). In this article, we
describe development, implementation and anecdotal feedback
related to a quiet time innovation implemented on an adult
neuroscience step down unit (ANSDU), undertaken to address
noise levels and the difficulty caused in relation to patient rest.
Background
In 1999, The World Health Organization (WHO) recommended that the average noise level in a patient’s room should
not exceed 35 dB (Berglund & Lindvall, 1999). Researchers have
found levels of noise in hospitals range from 50 to more than
100 dB (Darbyshire & Young, 2013; Konkani & Oakley, 2012;
Murphy et al., 2013; Ryherd, Waye, & Ljungkvist, 2008; Xie et
al., 2009). Comparatively, the noise level associated with normal
living, talking or having a radio play in the background is 50 dB,
while standing beside a running motorcycle, two-stroke chainsaw, or pneumatic drill measures 100 dB (Darbyshire & Young,
5
2013; Konkani & Oakley, 2012; Murphy et al., 2013; Ryherd,
Waye, & Ljungkvist, 2008; Xie et al., 2009). Hence, hospitalized
patients are theoretically subjected to three times the optimal
level of noise (Berglund & Lindvall, 1999; Darbyshire & Young,
Waye, & Ljungkvist, 2008; Xie et al., 2009).
2009; Fisher, 2008; Gardner et al., 2009; Kirkie, 2008; Ryherd et
al., 2008; McManis, 2008; Murphy et al., 2013; Shattell, Hogan,
& Thomas, 2005). The purpose of this paper is to describe a
quiet time innovation in one Canadian health care institution.
In the neuroscience patient population, the constant and excessive noise that decreases sleep and rest has potentially devastating physiological effects. Noise increases a patient’s intracranial
pressure which, if unaddressed, can lead to the patient’s death
(Hickey, 2009; Tymianski, Sarro, & Green, 2012). A fundamental nursing measure implemented when a patient exhibits signs
and symptoms of increased intracranial pressure is to decrease
stimulation and noise by caring for the patient in a quiet, darkened room, thus lowering the patient’s intracranial pressure
(Woodrow, 2000).
Motivation for innovation
After attending the Canadian Association of Neuroscience
Nurses (CANN) Annual Board and Scientific Session in Ottawa,
Ontario in 2011 it became apparent from discussions with neuroscience colleagues across Canada that the patients cared for
in our ANSDU would benefit from a quiet time intervention.
Two nurses who formed a quiet time working group developed and implemented this innovation in an ANSDU, which is
located in a large tertiary care facility in Winnipeg, Manitoba.
Synopsis of the literature related to noise in hospitals
Noise in hospitals has been reported as three times the recommended level (Berglund & Lindvall, 1999; Darbyshire & Young,
Waye, & Ljungkvist, 2008; Xie et al., 2009). We conducted a
review of the literature to determine what research disclosed
about the impact of noise in hospitals, as well as approaches to
mitigate these noise levels.
A study related to noise levels and perceived work environment
in a neurological intensive care unit was completed in 2008 in
Sweden (Ryherd et al., 2008). This research provided a thorough
description of noise levels in intensive care units and how that
noise could be disruptive to the occupants, but did not provide
any interventions to mitigate it (Ryherd et al., 2008). Research
from Australia described how noise was a barrier to sleep for
patients in an acute care hospital, and how a scheduled quiet
time intervention met with positive patient, visitor and health
professional satisfaction (Gardner et al., 2009). This research
demonstrated quiet time was a positive intervention with a
direct correlation to the noise level and the patient sleep/wake
pattern (Gardner et al., 2009).
Over the past nine years, researchers have indicated that hospital personnel in the United States have been aware of the negative impact on patient satisfaction caused by constantly high
noise levels and how some health care facilities have adopted
the philosophy of a quiet environment to promote healing
(Boehm & Morast, 2009; Fisher, 2008; Kirkie, 2008; Murphy et
al., 2013; Shattell, Hogan, & Thomas, 2005). Implementation of
quiet time programs has been described in the literature. While
the specifics of time of day differ depending on the hospital and
the patient population, the purpose is the same (Fisher, 2008;
Kirkie, 2008, McManis, 2008). Hospitals are too noisy to allow
patients the opportunity to rest and heal, and the provision of a
quiet environment promotes achievement of these goals (Fisher,
2008; Kirkie, 2008; McManis, 2008).
While literature from Sweden, Australia and the United States
describes the benefits of providing a quiet environment for
patients to heal, particularly patients with neurological issues,
no published research on the adoption of a quiet time or environment in Canadian hospitals is available (Boehm & Morast,
6
Quiet Time Innovation
Steps taken to gain innovation support
The two nurses who formed the quiet time working group
gained support for this innovation from the management and
administrative team by developing a project plan that was based
on the literature review and concerns expressed by patients and
families. This project plan was presented to the ANSDU clinical
manager, who found merit in the innovation and shared it with
the surgery director. The surgery director also believed this was
a worthwhile innovation and was successful in gaining executive
support from the chief nursing officer for a trial in the ANSDU.
Patient population
Patient characteristics. The patient populations cared for in
this ANSDU have a multitude of neurological issues including:
brain tumours, cerebral aneurysm, traumatic brain injuries,
spinal cord injuries and spinal cord tumours. They are critically
ill and require invasive intracranial pressure monitoring, as
well as frequent neurological and hemodynamic assessments.
Admission to the ANSDU is usually unexpected, often as a
result of an accident or medical emergency. Due to the severity
of the neurological issues and the unpredictability of patient
outcomes, the number of staff required to interact with the
patient is extensive. For example, a patient admitted to the unit
post surgically for a brain tumour removal will require assessments by nursing, physiotherapy, occupational therapy, nutritional services, and the cancer care social worker, as well as
the neurosurgical team who performed the surgery. This list of
individuals does not include other members of the health care
team who may be consulted or the patient’s support network.
One can see that the number of interactions for a patient is
numerous.
Setting
Physical environment. The unit targeted for the quiet time
innovation was an ANSDU. The unit is one large room with
the nursing station located in the centre. Eight patient beds are
placed around the central nursing station in a horseshoe shape.
Due to limited space, curtains separate patient beds. Two rows
of windows are situated next to six of the eight beds, which have
window coverings to decrease the sunlight coming through
them. Bedside and central nursing station lighting exist and
can be controlled independently of one another. A double door
separates the step down unit from the 20-bed general ward.
Noise level. Despite the small physical size of the unit, two
fire alarm bells are present. Each patient bed space has a
hemodynamic monitor, used to monitor the patient’s cardiac
rhythm, blood pressure, oxygen saturations, intracranial pressure, central venous pressure and respiratory rate. All of these
parameters require alarms associated with them and a hospital
executive directive states the alarm volume cannot be less than
60% of maximum at any time (C. Farmer, personal communication, September 6, 2011). Further alarms from intravenous
pumps, enteral feeding pumps and bed exiting alarms contributed to the noise level, as well as nursing interventions such as
the suctioning of patients. The step down unit has an occupancy
rate greater than 90%, meaning at least seven patients nursed
in the step down unit have invasive monitoring and require
frequent assessments and interventions.
The ANSDU is to provide the best possible environment and
opportunity for a patient to heal. However, the constant interactions between individuals (e.g., patients, staff, visitors) and
the alarms from the equipment make the noise level in the step
down unit deafening. With all this information in mind, the
quiet time working group developed a quiet time innovation
to address the noise and its impact on patients’ ability to rest.
Engagement of individuals involved in
the innovation
It was a priority of the quiet time working group that all individuals impacted by this innovation were aware of its implementation and its rationale (Langton, Robbins, & Judge, 2013).
To begin, nursing staff, ancillary staff, medical team, and allied
health professionals received education sessions focusing on
the impact of constant noise and stimulation on the neuroscience patient population and the detrimental effects of sleep
deprivation. These education sessions occurred in an informal
setting, often only taking 10 minutes in a location that was convenient for the staff. All members of the team were supportive
of the quiet time innovation and felt it would be beneficial to
the patient population in the ANSDU.
To educate other important members of the team including
the patient, families and visitors, the quiet time working group
developed posters and a brochure describing the purpose of
quiet time and what it was to look like. These posters were
placed at each patient’s bedside and the bedside nurse or unit
assistant distributed a brochure to each patient/family member/
visitor upon admission to the unit.
Components of the quiet time
innovation
Following recommendations described in the literature, the
time between 1400 and 1600 was designated as quiet time. This
time period corresponds with a natural low point in a human’s
circadian rhythm, which facilitates the body’s ability to naturally
rest (Dennis et al., 2010; Gardner et al., 2009; Olson et al., 2001;
Ruggiero & Dziedzic, 2004). Rest was promoted by ensuring
the patient was positioned comfortably and analgesia offered
so pain would not disrupt rest (Gardner et al., 2009). The level
of light in the step down unit during quiet time was reduced by
closing a minimum of 80% of the window coverings, as well as
dimming or turning off the lights at the patients’ bedsides and
dimming the lights at the central nursing station (Gardner et
al., 2009). The curtains between the beds were closed half way
so that the patient could not see the person in the next bed
or be impacted by neighbouring activity or light, but nurses
were still able to see the patients and determine if additional
assistance or interventions were needed (Gardner et al., 2009).
The double doors between the step down unit and the general
ward were closed. Families and visitors were encouraged to
allow the patient to rest and sleep, but were not required to
leave the bedside (Gardner et al., 2009). If the family member
or visitor wanted to stay, they were encouraged to be as quiet as
possible. Staff was encouraged to use the quietest voice possible
when communicating with patients and other team members
(Gardner et al., 2009). When appropriate, the amount of routine
nursing care, therapies, tests, consults and admissions were
reduced during this time (Gardner et al., 2009). This was not
always possible due to the high acuity and occupancy of the
step down unit. Scheduling of the operating room slate often
required the admission of patients during this time, but every
effort was made to do so as quietly as possible so as to not disrupt the other patients’ time of rest.
Feedback about the quiet time
innovation
While a formal evaluation of the quiet time innovation has not
been conducted, anecdotal feedback received six months after
innovation implementation suggests the quiet time has had a
positive impact. As the primary focus of the quiet time innovation was to improve the patient’s ability to rest by decreasing
the noise level in an ANSDU, the quiet time working group
spoke to patients about their feelings and experiences regarding quiet time. The statements received from patients have
included, “This is wonderful, what a great idea”, “I found the
noise overwhelming in here, but when the lights go dim I finally
have some relief from my headache” and “It gives my mom permission to leave for a little bit”. These statements imply that the
patients in the ANSDU appreciate the decrease in noise level
and stimulation that occurs during quiet time.
Visitors have responded stating, “It [quiet time] lets the patient
get the rest that they need”, and “Now I don’t feel guilty leaving
for a little bit, because I know that he is sleeping while I am
gone”. This, again, demonstrates that the individuals impacted
by the quiet time innovation believe it is a positive intervention
and one that is necessary for the patient to heal.
Surprisingly, the quiet time innovation also seems to have positively impacted nursing satisfaction. When the quiet time working group spoke to staff they said, “This is the best part of the
day”, “I finally have time to review my patient’s chart and ensure
that things are not getting missed”, and “We should have a quiet
time out of the ward as well”. This feedback received from the
staff replicates the positive staff satisfaction described in the
literature (Gardner et al., 2009). Staff, patients and visitors all
appear to appreciate a quiet environment.
7
Conclusion
Acknowledgements
Despite the known benefits, no published research about quiet
time innovations in the Canadian hospital setting exists. In this
paper, we describe the importance of quiet time and how a
small but feasible innovation was carried out in an ANSDU.
Anecdotal evidence from patients, families, and staff suggests that quiet time may have positive effects not only for the
patients, but also for their families and visitors and the adult
neuroscience step down unit staff. Future research examining
the quantitative and qualitative effects of quiet time will determine the impact of such innovations on patient, family and staff
satisfaction, as well as patient healing beyond the anecdotal
evidence presented here.
The author would like to thank “Quiet Time” team members
Jennifer Schneider, Wendy McDiarmid, Raj Mongru, and
all the staff (allied health, neurosurgery medical team and
nursing) on GA5 at the Health Sciences Centre, Winnipeg,
Manitoba, for their support, enthusiasm, and commitment to
the Quiet Time Innovation. Without all of you this innovation
would not be where it is today. A special thanks to the patients
and families in the GA5 step down unit.
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2014 CANN Conference Brain Tumour Foundation Award
Primary malignant brain tumours, psychosocial distress
and the intimate partner experience: What do we know?
By Dr. Brenda Sabo, RN, PhD
Abstract
From the time of diagnosis of a primary malignant brain tumour
(PMBT) and throughout the illness trajectory, the patient and
intimate partner face many psychosocial challenges ranging from
fear and uncertainty to hope and loss (Fox & Lantz, 1998; Janda
et al., 2007; Kvale, Murthy, Taylor, Lee, & Nabors, 2009). While
many patients diagnosed with cancer may go on to live with
cancer as a chronic illness, this may not be said of individuals
diagnosed with a PMBT, in particular those diagnosed with a
glioma, the most common form of brain tumour (Gupta & Sarin,
2002). Gliomas are associated with a short disease trajectory
and multiple deficits (functional, cognitive and psychiatric).
What makes the PMBT experience unique from other cancers is
that the intimate partner must not only deal with the diagnosis
of cancer in their spouse, but also the accompanying personality,
functional and behavioural changes wrought by the disease, as
La tumeur cérébrale maligne
primaire, la détresse psychosociale et
l’expérience du partenaire intime : Que
savons-nous?
Résumé
À partir du moment où on leur révèle le diagnostic d’une
tumeur cérébrale maligne primaire (TCMP) et tout au cours
de l’évolution de la maladie, les patients et leur partenaire
intime sont confrontés à de multiples défis psychosociaux qui
vont de la peur et de l’incertitude à l’espoir et au sentiment
de perte. Bien que de nombreux patients atteints d’un
cancer puissent continuer à vivre avec ce cancer comme s’il
s’agissait une maladie chronique, il n’en va pas de même
pour les individus chez qui on a diagnostiqué une TCMP,
en particulier ceux atteints d’un gliome, la forme de tumeur
cérébrale la plus répandue. Ce qui rend l’expérience d’une
Retraction
Please note: the article “Challenges in providing culturally-competent care to patients with metastatic brain tumours
and their families” printed in Volume 36, Issue 2, p.8, by
Longo and Slater, was not the 2013 Brain Tumour Foundation Award as indicated in the journal. The article “Primary
malignant brain tumours, psychosocial distress and the intimate partner experience: What do we know?” by Sabo is the
2014 Brain Tumour Award paper.
Please accept this apology to the authors and to readers for
any inconvenience this error may have caused.
Theresa Green, CJNN Editor
well as grieve the loss of the person they once knew (Sherwood
et al., 2004). These multi-dimensional deficits are thought to
place the intimate partner, as caregiver, at greater risk for
adverse psychosocial effects such as anxiety, depression and post
traumatic stress (Goebel, von Harscher, & Mehdorn, 2011; Keir,
Farland, Lipp, & Friedman, 2009).
The following discussion will provide an overview of the extant
literature on the experience of living with a PMBT from
the intimate partner (spouse) perspective with a particular
emphasis on how intimate partners cope. The intimate partner
is considered to be the heterosexual or same-sex, married
or common-law partner of the patient. Highlights from the
psychotherapy practice of the author will be used to further
strengthen the need for more research, education and enhanced
practice to more effectively meet the unique needs of this underresearched and supported population.
TCMP unique par rapport aux autres formes de cancer
est que les partenaires intimes doivent non seulement gérer
le fait que leur conjoint(e) est atteint(e) d’un cancer, mais
également les changements de personnalité, de fonctionnalité
et de comportement que provoque la maladie, ainsi que
faire le deuil de la personne qu’ils connaissaient jadis. On
pense que ces déficiences dans divers domaines exposent les
partenaires intimes, dans leur rôle de soignant, à des risques
d’effets psychosociaux tels que l’anxiété, la dépression et le
stress post-traumatique. Ce document de réflexion fait le point
sur la documentation actuellement disponible sur la réalité
de vivre avec une TCMP depuis la perspective du conjoint
ou de la conjointe, tout en mettant l’accent sur la façon dont
ces derniers gèrent la situation. Nous recourrons à des points
saillants issus du travail de l’auteure en psychothérapie
afin de renforcer davantage la nécessité d’effectuer plus de
recherches, d’éducation et de pratique en vue de répondre plus
efficacement aux besoins uniques de cette population qui fait
l’objet de trop peu de recherche et de soutien.
Setting the context: Primary malignant
brain tumours
Approximately 2,700 Canadians are diagnosed annually with
a PMBT. This equates to 8/100,000 people, but the numbers
increase to 32/100,000 when one takes into account metastases
to the brain (Canadian Cancer Society’s Steering Committee on
Cancer Statistics, 2011). The most common form is glioma with
a relative five-year survival of 23% (Canadian Cancer Society’s
Steering Committee on Cancer Statistics, 2011). Although Stage
I–III (low grade) may see median survival rates of 10 years, the
average survival for a Stage IV glioblastoma is approximately
1–3 years (Taphorne, Sizoo, & Bottomley, 2010) with many living less than 12 months. Approximately 1.4% of all new cancers
9
are PMBT with a median age at diagnosis of 57 years, although
the highest rate of occurrence ranges between 45 years to 75
years. Primary malignant brain tumours make up 2.4% of all
cancer deaths (National Cancer Institute, 2013). In the first year
after diagnosis, the average patient will make 52 visits to their
health care team (Brain Tumour Foundation of Canada, 2013)
suggesting a compromised quality of life and need to ensure
patients are supported not just physically, but also psychologically and emotionally. It would seem reasonable to think that
the frequent interactions with the health care team, whether
through appointments with their oncology specialist, imaging
team, or emergency department visits, would take a toll on the
psychosocial and physical health of the spouse.
interfere with the ability to cope with cancer” (National Comprehensive Cancer Network, 2010, p.DIS-2) may have deleterious physical and psychosocial effects on the intimate partner,
which can affect the health of the patient and entire family unit.
Factors associated with the variability of psychosocial distress
include the reality of day-to-day life, ability to adjust to life after
a diagnosis of cancer (coping style), treatment modality(s), and
change in prognosis (Hodgkinson et al., 2007; Ross et al., 2010).
Of concern is the limited understanding of psychosocial distress
experienced by intimate partners during the diagnosis to one year
early treatment phase (Goebel et al., 2011), as well as screening
for distress and referrals for psychosocial support despite effective interventions (Newell, Sanson-Fisher, & Savolainen, 2002).
PMBTs include all malignant tumours of the brain: frontal, temporal, parietal and occipital lobes; cerebellum; and, brain stem
(World Health Organization, 2010). Despite the severity of neuro-cognitive, neuro-functional and neuro-psychiatric symptoms
associated with a PMBT in many patients, there is a glaring
absence of research focused on the intimate partners’ concerns,
challenges and ability to cope with the changes in their partners
(Keir et al., 2009; Norton & Manne, 2007; Sherwood et al., 2004)
or the effect of a PMBT on the couple relationship, a second
major gap noted in the literature (Janda et al., 2008; Janda et al.,
2007; Strang, Strang, & Ternestedt, 2001). A recent search of the
research literature (CINAHL, PUBMED, PSYCINFOR) using the
key words primary malignant brain tumour, brain tumour, psychosocial, distress, couples, intimate partners and/or caregiver
reinforced the lack of attention given to this issue with less than
20 articles found. No articles explored preferred coping style, the
quality of the couple relationship and distress on adjustment and
overall quality of life for either spouse or patient.
As a psychotherapist, I have noticed an alarming number of
intimate partners of PMBT patients struggle with their inability
to cope with how and in what way this disease impacts their
life and health. A common refrain, “but it’s not about me”, highlights the isolation and lack of attention given to the caregiver,
who is generally the intimate partner. At the same time, the
health care system has come to rely heavily on the caregiver to
provide physical, psychological and emotional support without
routine assessments to determine the capacity to be able to provide such support. Although the need for family-based distress
screening and supportive care has been acknowledged, it has
yet to become a reality (Kim & Given, 2008). Intimate partners
frequently speak of the expectations tied to a caregiving role
despite their desire to “be the spouse” and not a health care
provider. Any suggestion that they focus on their own needs is
often met with resistance and/or perceived as a personal failure.
This expectation is likely the result of gendered, sociocultural
norms that assume women will take on the burden of caregiving with no questions asked (Armstrong & Armstrong, 2001).
In a study conducted by the author that explored caregiving
within the hematopoietic stem cell transplant population, one
spouse spoke of reflecting on the experience as a taking on of
roles, of coming to a realization that “you have to change… It
is not just the person dealing with cancer every day that has
to change, it’s everybody” (Sabo, McLeod, & Couban, 2012, p.
35). This population of cancer patients also experiences overall
poor prognosis and long-term side effects from the treatment
that can be debilitating, such as graft versus host disease and
the development of secondary cancers. What appears poorly
understood in both the PMBT and hematopoietic stem cell
transplant population is the effect such change has on the individual and the couple relationship over time.
Primary malignant brain tumours and
psychosocial distress
PMBT carries significant psychosocial distress (e.g., depression,
anxiety, stress) (Arnold et al., 2008; Kanter, Mammone D’Agostino, Daniels, Stone, & Edelstein, 2013) and lower quality of life
for patients and their intimate partners than other cancers (Gustafsson, Edvardsson, & Ahlström, 2006; Janda et al., 2007; Kvale et
al., 2009), yet the rate of unmet supportive care needs for both is
high (Hodgkinson et al., 2007). Although research has shown that
psychosocial distress changes over the disease trajectory for both
patient and partner, greater emphasis has been on the patient’s
level of distress with little attention given to the intimate partner
or the couple, as a unit (Badr, Carmack, Kashy, & Cristofanilli,
2010; Hodgkinson et al., 2007; Janda et al., 2007; Ross, Mosher,
Ronis-Tobin, Hermele, & Ostroff, 2010). Rather than respond
to the situation on an individual level, intimate partners, family
members and cancer patients react to cancer and its treatment
as one emotional unit leading to increased levels of psychosocial
distress (Fox & Lantz, 1998; Hagedoorn, Sanderman, Bolks, Tuinstra, & Coyne, 2008b; Segrin, Badger, Dorros, Meek, & Lopez,
2007) highlighting the need for research that takes into account
the effect cancer has on the intimate partner.
Increased psychosocial distress, defined as “a multi-factorial
unpleasant emotional experience of psychological (cognitive,
behavioural, emotional) social, and/or spiritual nature that may
10
More poignant are the intimate partners who describe “wanting more” yet, do not know what more is, or of feeling guilty
for wanting more. Intimate partners have shared personal stories of having lost their “best friend, partner and soul mate”
although the individual is still alive. Who they married or began
the couple relationship with has irrevocably changed; insight
around appropriate behaviours, judgement and, at times, the
ability to perceive the intimate needs of another through a hug
or caring word are slowly lost. The intimate partner may find
that life is now composed of uncertainty, of waiting for the
other shoe to drop, of fluctuations between hope and despair,
of grief and loss. How often do we, as health care professionals, recognize, acknowledge and validate the experience of the
intimate partner, of their needs and the psychosocial implications the devastating news of a diagnosis of a PMBT brings?
Should feeling uncomfortable about death and dying, of difficult news, be an excuse to avoid conversations? In one study,
it was noted that both patients and families were preoccupied
with existential thoughts (e.g., why me) and death anxiety, yet
these concerns were often not expressed directly (Adelbratt
& Strang, 2000). Patients and families are waiting for health
care professionals to bring up these very difficult topics. Not
infrequently, they wonder why health care professionals do not
address these concerns.
Research suggests that while health care professionals acknowledge 57% of socio-emotional cues, they only respond to approximately 22% of those cues (Kennedy Sheldon, Hilaire, & Berry,
2011). More concerning may be the blocking behaviour engaged
in by health care professionals when faced with addressing emotions, (Betcher, 2010), the tendency to focus on physical aspects
of care (Granek, Krzyzanowska, Tozer, & Mazzotta, 2013; Rask,
Jensen, Andersen, & Zachariae, 2009), or perceptions that conversations about death and end-of-life concerns will cause further distress and remove hope (Anselm et al., 2005). Research
has shown that conversations about end-of-life issues and
advanced care planning, when done in an empathic, supportive and humanistic way, actually can be beneficial in reducing
distress and uncertainty (Stajduhar, Thorne, McGuinness, &
Kim-Sing, 2010; Thorne, Hislop, Armstrong, & Oglov, 2005;
Thorne, Kuo, et al., 2005; Watts, 2012).
As the disease advances, patients and their spouses would benefit from conversations related to advanced care planning and
supportive/palliative care. Communication related to supportive/palliative care and end-of-life issues has been recognized
as sub-optimal by both health care professionals and patient/
spouse alike (Anselm et al., 2005; Friedrichsen, Strang, & Carlsson, 2000; Ronaldson & Devery, 2001; Stajduhar et al., 2010;
Thorne, Hislop, et al., 2005; Thorne, Kuo, et al., 2005). Effective
communication between the health care provider, patient and
spouse may be critical in the optimization of supportive/palliative care (Gilligan & Raffin, 1996), yet health care professionals
appear reluctant to engage in these conversations even when
training has been provided to enhance communication skills
(Beckman & Frankel, 2003; Ishikawa et al., 2002), or change
patterns of communication behaviour (Heaven & Maguire,
1996; Thorne, Hislop, et al., 2005). Despite good intentions,
effective communication remains a significant problem with
many patients encountering less than optimal communication
at some point during their illness (Ishikawa et al., 2002).
Perhaps, more concerning is the cultural shift from death as a
natural part of life to death-denying behaviour, as evidenced
in an emphasis on curative rather than supportive care. The
transition from the former to the latter may be perceived as
a “failure”. More compelling is the need to recognize and give
meaning to life through conversations about death (Bugental,
1965; Yalom, 1980).
In a 2008 stakeholder report, communication challenges were
identified as a critical source of concern for patients and families when considered within the context of palliative and endof-life care (Network for End of Life Studies: Interdisciplinary
Capacity Enhancement [NELS ICE], 2008). The report highlighted assumptions held by both patient/family and health care
provider alike. These assumptions included the perception of
giving up hope, or abandonment, a lack of willingness to talk
about palliative and end-of-life issues (e.g., send in “junior doctors”), and differences among health care professionals around
what constitutes quality end-of-life care. Striking a balance
between acknowledging that an illness is terminal while supporting hope can be challenging yet, if not undertaken, has the
potential to lead to compromised quality of care for the patient
and family. The need to understand the “intricate complexities
of what makes communication helpful or unhelpful … and the
mechanisms to ensure that what we do know is consistently
applied in practice” (Stajduhar et al., 2010, p.2045) is paramount
if optimal palliative care is to occur.
Primary malignant brain tumours, the
couple relationship and coping
A diagnosis of cancer can be an unexpected and devastating
event for the intimate partner, frequently resulting in elevated
levels of psychosocial distress (Goebel et al., 2011; Ownsworth,
Little, Turner, Hawkes, & Shum, 2008). Primary malignant brain
tumours are considered to be one of the most aggressive and
difficult cancers to treat (Graham & Cloughesy, 2004).
Furthermore, the disease trajectory includes progressive functional decline (Price, Goetz, & Lovell, 2002). Not only are these
tumours life-threatening, but also they carry the potential to
rob the patient of their mind and spirit (Fisher & Buffler, 2005).
Research has shown that at least 33% of patients diagnosed with
a PMBT exhibit high levels of anxiety, depression and poor quality-of-life outcomes (Ownsworth et al., 2008; Pringle, Taylor, &
Whittle, 1999). The rate of psychosocial distress for intimate partners has been shown to be as high as, if not higher than that of cancer patients in general (Hagedoorn et al., 2008b; Hudson & Payne,
2011; Langer, Yi, Storer, & Syrjala, 2010). Further, individuals (intimate partner and patient) vary in their ability to adjust to life after
a diagnosis of a PMBT. In one systematic review of the literature,
the authors concluded cognitive and behavioural function alone
could not adequately account for emotional adjustment and quality
of life (Ownsworth, Hawkes, Steginga, Walker, & Shum, 2009). The
review also noted that personal resources such as coping style and
self-perception (appraisal of circumstances), as well as socio-environmental factors (relationship, support networks) have largely
been ignored in research studies (Kraemer, Stanton, Meyerowitz,
Rowland, & Ganz, 2011; Ptacek, Peirce, & Ptacek, 2007).
Much of our understanding of the effect of cancer on intimate
partners has emerged from research within breast and prostate cancer populations. Findings suggest that the disruption
arising from the demands of cancer can undermine even the
most highly functioning intimate partner relationship (Fergus
& Gray, 2009; Merz et al., 2011). Common stressors for the
intimate partner include fear, loss, thoughts of mortality and
abandonment stemming from the diagnosis (Hagedoorn, Sanderman, Bolks, Tuinstra, & Coyne, 2008a; Maliski, Heilemann,
& McCorkle, 2002), renegotiation of family roles and responsibilities (Langer et al., 2010; Northfield & Nebauer, 2010; Sabo et
al., 2012), increased financial strain (Armstrong & Armstrong,
11
2001; Lauzier et al., 2005), and alterations in sexual intimacy
and social activities (Beck, Robinson, & Carlson, 2009; Belcher
et al., 2011; Manne & Badr, 2008). Research has found social
support, in particular close interpersonal relationships to be an
important factor in coping with cancer (Fergus & Gray, 2009;
Rodin et al., 2007). Studies suggest that the couple’s relationship
may be a stronger predictor of health outcomes than marital
status when considered within the context of cancer (Halford,
Scott, & Smythe, 2000; Northouse, Mood, Templin, & Mellon,
2000; Norton & Manne, 2007).
When one partner becomes distressed the other is likely to
become distressed as well (Gilbar & Zusman, 2007; Zwahlen,
Hagenbuch, Jenewein, Carley, & Buchi, 2011). The intimate partner may employ a variety of strategies to enhance adjustment
and coping. These include the capacity to engage in constructive
communication about their stress, demonstrate a supportive
response to stress, construct a shared meaning of illness (“our”
illness rather than the patient’s experience alone), and work
together to deal with the complexity of the cancer experience
(Badr et al., 2010; Fergus & Gray, 2009; Skerrett, 1998). Factors
that create dissonance or distance among intimate partners
and, thus, decrease the capacity for coping include personal
characteristics (patient and partner) such as anger/hostility,
counter dependency, emotion versus problem-focused strategies
to manage stress, and avoidance coping styles. Factors within
relationship dynamics that can increase tension and impede
coping include buffering (protecting partner by withholding
information), lack of shared illness belief, inability to accommodate change and changes in the intimate relationship (Badr
et al., 2010; Fergus & Gray, 2009; Morgan, 2009). It would be
reasonable to assume that similar stressors could be experienced
by intimate partners within the context of PMBT.
Implications for nursing practice,
education and research
Screening for distress has become the standard of care within the
cancer care system for several Canadian cancer centres. Health
professionals struggle to do that well, particularly when there
are limited resources to address the needs of those identified
as distressed, as is often the case (Bultz & Johansen, 2011). In
light of the significant symptom burden, poor overall prognoses
and decreased quality of life associated with a PMBT, strategies
that enhance knowledge and understanding and support deeper
reflection of the psychosocial implications of PMBTs may have
the potential to improve quality of care and outcomes for intimate partners.
Furthermore, such strategies may also serve to empower health
care professionals and reduce their own distress. The development and pilot testing of digital stories recounting the personal
experiences of caregiving may be an effective mechanism for
addressing research and clinical knowledge gaps such as those
related to the intimate partner experience, psychosocial distrust
and adjustment within cancers such as PMBT. Digital stories are
“short, personal narratives that use still images and music captured through the use of digital media… to merge the richness
inherent within traditional patient narratives with an ability
to focus, edit and reflect, to produce a story that is engaging,
12
powerful and directly accessible to others” (Christiansen, 2011,
p. 290). As such, digital stories have much to offer health care
professionals and students alike.
With greater emphasis on patient/family or relationship-centred care delivery, approaches to education that enhance awareness, empathy and the meaning of existentially important
experiences become imperative. Illness narratives afford the
nurse an opportunity to access the human experience (Kumagai, 2008; Sandelowski, 1991) discover knowledge, uncover
hidden meaning and support caring (Kumagai, 2008; Sandelowski, 1991) through “entry into the kingdom of the sick”
(Sontag, 1978). From a pedagogical perspective, stories can
make challenging information coherent, meaningful and easily
understood by situating complex concepts into practice and
practical situations (Lave & Wenger, 2002; Wenger, McDermott,
& Snyder, 2002). The use of storytelling through multimedia
approaches would foster active engagement in reflection by
nurses and nursing students alike through the use of real life
situations, thus promoting deeper learning from the experience
(Christiansen, 2011; Sandars, Murray, & Pellow, 2008), as well
as supporting the translation of knowledge (Scott, Hartling,
O’Leary, Archibald, & Klassen, 2012). Furthermore, integration
of digital stories as one aspect of continuing education may be
transformative by challenging the nurse’s existing world-view
(values, beliefs) through self-reflection (Brown, Kirkpatrick,
Magnum, & Avery, 2008; Kozubska & MacKenzie, 2012; Kumagai, 2008). The ability to look critically at one’s own practice,
to identify areas for improvement, and apply this new knowledge and awareness to one’s practice is considered an essential
element in continuing professional development (Johns, 2006).
More research utilizing theoretical models such as the relational
intimacy model of couple psychosocial adaptation to cancer
(Manne & Badr, 2008), dyadic adjustment (Spanier, 1976) and
resiliency (Walsh, 2006) may be helpful in capturing a more
robust picture of the psychosocial implications of caregiving
by intimate partners within the PMBT population, leading
to effective strategies for distress management and relational
quality. Interventional research focused on implementing and
evaluating distress screening for intimate partners may lead to
more effective psychosocial support for the caregiver, as well
as help to normalize a natural consequence of caregiving, psychosocial distress.
What can nurses do to acknowledge and support both patient
and family? Nurses may start by opening discussions with other
members of the health care team around early referral to the
palliative/supportive care consultation team. In a system that
places greater emphasis on acute curative intent (Thorne, 2008),
health care professionals such as doctors and nurses have a
tendency to avoid or put off the challenging conversations
about death and dying. This may be for a variety of reasons
including: 1) fear that hope will be destroyed for patients and
their family members; 2) that such a conversation may result
in further distress; or 3) they do not feel adequately equipped
to enter into such discussions and/or respond to the emotions
that may ensue (Anselm et al., 2005). Failure to acknowledge
the need to transition to palliative/supportive care in a timely
way may erode the client/health care professional relationship,
decrease quality of life, autonomy and decision-making control, and heighten levels of anxiety and depression (Stajduhar,
2011; Stajduhar et al., 2010). Studies have shown that patients
would like to have conversations about advanced and endof-life care planning, but wonder why HCPs do not raise the
issue (Barnes et al., 2011). Furthermore, they would like these
conversations to occur in an empathic, humanistic and supportive manner (Thorne, Hislop, et al., 2005; Thorne, Kuo, et al.,
2005). Unfortunately, it is not uncommon for patients to learn
of the terminal nature of their illness on referral to palliative
care services (Ronaldson & Devery, 2001). Including education for both patients and families about the benefits of timely
referral to palliative care may go a long way towards decreasing
perceptions of abandonment and loss of hope among patients
and families (Barnes et al., 2011; Schofield, Carey, Love, Nehill,
& Wein, 2006; Stajduhar, 2011; Stajduhar et al., 2010; Thorne,
Hislop, et al., 2005; Thorne, Kuo, et al., 2005).
Another important step may be the acknowledgement and validation of the impact caregiving may have on the psychosocial
and emotional well-being of spouses and other family members.
Nurses should consider how and in what way screening for
distress might include the caregiver. Simple questions such as:
“How are you today?”; “What do you need?”; and “What have
you done for yourself lately?” may open the door to further
conversation about the spouse or family member’s level of psychosocial health and well-being. I vividly recall a spouse telling
me that not once did any health care professional ask her how
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Conclusion
While research is growing on psychosocial distress within cancer patient populations, little attention has been given to the
implications a diagnosis of cancer may have for the spouse,
particularly the spouses of PMBTs. Our understanding of the
role and quality of the couple relationship, ability to cope, and
level of distress on quality of life and ability to adjust following
a diagnosis of a PMBT is limited, highlighting a critical need
for more research on this subject.
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15
Development of clinical practice guidelines
for urinary continence care of adult stroke
survivors in acute and rehabilitation settings
By Andrea R. Fisher, RN, MSN, MSc, CNN(C), Infection Control Professional
Abstract
This study developed evidence-based clinical practice guidelines
for the urinary continence care of adult stroke survivors in acute
and rehabilitation settings. The research team conducted a
comprehensive review of the literature on urinary continence
interventions and outcomes. The team then developed a set of
recommendations outlined in the resulting clinical practice
guidelines titled Clinical Practice Guidelines (CPGs) for the
Urinary Continence Care of Stroke Survivors in Acute and
Rehabilitation Settings.
The evaluation of the CPGs consisted of a two-part assessment
and pilot implementation. An expert panel of 25 local and
regional experts in stroke and continence care assessed the
proposed CPGs. This assessment consisted of two stages: a)
evaluating the guidelines using the Appraisal of Guidelines
Research and Evaluation (AGREE) Instrument (http://www.
agreetrust.org); and, b) conducting focus groups to identify
barriers and facilitators to the implementation of the guidelines
L’élaboration de directives de
pratique clinique pour le traitement
de l’incontinence urinaire chez les
victimes d’AVC dans les services
de soins de courte durée et de
réadaptation
Résumé
Cette étude a permis de développer des directives de pratique
clinique fondées sur des données probantes en vue de
traiter l’incontinence urinaire chez les victimes d’AVC dans
les services de soins de courte durée et de réadaptation.
L’équipe de recherches s’est livrée à un examen exhaustif de la
documentation sur les interventions favorisant la continence
urinaire et leurs résultats. L’équipe a ensuite élaboré un
ensemble de recommandations décrites dans les directives de
pratique clinique en découlant et intitulées Clinical Practice
Guidelines (CPGs) for the Urinary Continence Care of Stroke
Survivors in Acute and Rehabilitation Settings (Directives de
pratique clinique [DPC] pour le traitement de l’incontinence
urinaire chez les victimes d’AVC dans les services de soins de
courte durée et de réadaptation).
L’appréciation de ces DPC se composait d’une évaluation en
deux parties et de la mise en œuvre d’un projet pilote. Un
groupe d’experts locaux et régionaux constitué de vingtcinq spécialistes du traitement de l’AVC et de l’incontinence
ont évalué les DPC proposées. Cette évaluation comportait
16
using the Ottawa Model of Research Use (OMRU). Results
from the expert panel assessments/feedback contributed to the
refinement of the CPGs as well as identification and construction
of implementation strategies.
Two sites conducted a three-month pilot implementation of three
recommendations from the CPGs as selected by each site. The
two inpatient sites were a rehabilitation setting and a mixed
acute and rehabilitation setting. The implementation of the
CPGs included the development of learning strategies tailored
to the needs of each site and in addition to the creation of an
online self-learning portal. This study assessed nurses’ knowledge,
attitudes, and beliefs regarding urinary continence challenges
using a survey before and after the pilot. Chart reviews before
and after the pilot implementation audited the nurses’ urinary
continence practices for patients and uptake of the selected
guidelines’ recommendations. Study findings suggested the
implementation of the CPGs’ recommendations improved nurses’
knowledge of the continence needs of stroke survivors.
deux étapes : a) évaluer les directives à l’aide de l’Appraisal
of Guidelines Research and Evaluation (AGREE) [Grille
d’évaluation de la qualité des recommandations pour la
pratique clinique] (http://www.agreetrust.org] et b) mener
des groupes de discussion afin de déterminer les obstacles
et les éléments facilitant concernant la mise en œuvre des
directives à l’aide de l’Ottawa Model of Research Use (OMRU)
[Modèle d’Ottawa d’utilisation de la recherche]. Les résultats
de l’évaluation/de la rétroaction du groupe d’experts ont
contribué à affiner les DPC ainsi qu’à déterminer et à concevoir
les stratégies de mise en œuvre.
Deux sites ont chacun choisi trois recommandations issues
des DPC, puis ont mis en œuvre un projet pilote de trois
mois. Le premier de ces deux sites hospitaliers offrait des
services de réadaptation, et le second, un mélange de soins
de courte durée et de réadaptation. La mise en œuvre des
DPC comprenait l’élaboration de stratégies d’apprentissage
adaptées aux besoins de chaque site, en plus de la création
d’un portail d’auto-apprentissage en ligne. Cette étude a évalué
les connaissances, les attitudes et les croyances du personnel
infirmier à l’égard des défis liés à la continence urinaire au
moyen d’une enquête réalisée avant et après le projet pilote.
L’examen des dossiers avant et après la mise en œuvre du
projet pilote a servi à vérifier les pratiques des infirmières et
infirmiers en matière de continence urinaire chez les patients
et l’application des recommandations choisies. Les résultats de
l’étude suggèrent que la mise en œuvre des recommandations
des DPC a amélioré les connaissances du personnel infirmier
au sujet des besoins en matière de continence chez les
survivants d’AVC.
Background
Urinary incontinence is the involuntary loss of urine and can be
defined by the type of storage and voiding symptoms (Abrams et
al., 2010). Urinary incontinence is common among stroke survivors and is associated with higher levels of mortality, disability and discharge to long-term care, as compared to survivors
without continence issues (Dumoulin, Korner-Bitensky, & Tannenbaum, 2007; Wilson, Lowe, Hoffman, Rudd, & Wagg, 2008).
Data from the National Stroke audits for England, Wales and
Northern Ireland from 1998–2002 reported urinary incontinence rates between 39% and 44% one week after stroke, which
remained an issue for 15% to 20% of stroke survivors at time
of discharge from hospital (Wilson et al., 2008). Stroke survivors can experience various types of urinary incontinence such
as stress, urge, overflow, functional, mixed and/or transient
incontinence. Table 1 shows questions that could help identify
the type of urinary incontinence and can be asked as part of a
patient history and physical (Registered Nurses’ Association of
Ontario [RNAO], 2005). Urinary retention has been less well
studied for stroke survivors. One study in a rehabilitation setting reported a prevalence of 21.5% (Wu & Baguley, 2005).
Addressing the urinary continence needs of stroke survivors
may prevent complications such as skin breakdown and urinary
tract infections, which may result in prolonged hospital stays.
A systematic review of outcomes for stroke survivors identified
urinary continence accompanied by cognition impairment as a
key factor for poor outcomes (Almenkerk, Smalbrugge, Depla,
Eefsting, & Hertogh, 2013).
Table 1: Types of urinary incontinence
Type of urinary Questions
incontinence
Stress
Is a loss of urine with coughing and/
or sneezing resulting in increased
abdominal pressure?
Urge
Is the involuntary passage of urine
occurring soon after a strong sense of
urgency to void?
Overflow
Is the involuntary loss of urine associated
with bladder over-distention? Total
incontinence is a continuous and
unpredictable loss of urine.
Functional
Is urinary leakage associated with
inability to access the toilet because of
impairment of cognitive and/or physical
functioning or an environmental barrier?
Mixed
Is urine loss having features of both stress
and urge?
Transient
Is urine loss resulting from causes outside
of, or affecting the urinary system such
as acute confusion, infection, atrophic
urethritis or vaginitis, medications,
psychological conditions, restricted
mobility or stool impaction?
However, studies identifying and evaluating interventions to
address urinary dysfunction among stroke survivors have failed
to yield comprehensive clinical practice guidelines (CPGs) for
this population. Clinical practice guidelines have been defined
by the Institute of Medicine (National, Heart, Lung, and Blood
Institute, 2011) as: “statements that include recommendations
intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits
and harms of alternative care options”. This article discusses
the development of CPGs to improve the urinary continence
care of adult stroke survivors titled Clinical Practice Guidelines
for the Urinary Continence Care of Stroke Survivors in Acute
and Rehabilitation Settings (See Appendix A), and provides an
overview of a pilot implementation of select evidence-based
recommendations. The study objectives were to: 1) conduct a
literature review to obtain information about urinary management for stroke and geriatric patients, 2) identify key factors
that may be barriers and facilitators to practice, and 3) develop
and implement CPGs in acute and rehabilitation settings. The
Ontario Ministry of Health and Long-term Care provided funding for this project.
Methods
Search strategy and literature review
The research team conducted a comprehensive literature
review. The overall topic was urinary incontinence care for
stroke survivors. To optimize the literature review process the
team generated a list of terms and key words in three categories: population, interventions and outcomes. The search
inclusion criteria were the specific populations and demographics relevant to the study: stroke patients, brain injury patients,
acute care patients, rehabilitation care patients, long-term care
patients, inpatient care patients, community care patients, geriatric populations, gender, class and cross-cultural characteristics. Literature pertaining to persons younger than 18 years
of age was excluded, because the population of interest was
adults. The inclusion criteria also comprised documentation
tools and clinical practice interventions, management techniques, self-managed care, complementary health care and
diagnostic tools.
Since the focus was on post-stroke care, interventions for the
following conditions were excluded: irritable bowel syndrome,
colitis, inflammatory bowel disease, urinary disorders, post-partum incontinence and bariatric surgery. Also excluded from the
search were pharmacological treatments or surgery interventions that were beyond the scope of the proposed CPGs. The
search strategies for outcomes included the search strings of
fecal incontinence, urinary incontinence, nurse-sensitive outcomes and techniques.
The literature search was performed in April 2007 and limited
to English and French publications between 1995 and 2007.
Databases searched included: CINAHL, Medline, PubMed,
Sage Publications; Embase, Nursing Abstracts and EBSCO. The
academic and scholarly publications in the searches were limited to peer-reviewed articles, clinical research, clinical practice
guidelines and best practice guidelines. In addition, members
of the research team contacted clinical experts in stroke and/
17
or continence care at Canadian acute and rehabilitation health
care facilities to identify further sources of information such
as grey literature that may have been pertinent for the CPG’s
content.
Initially, 1,329 articles were identified during the aforementioned databases with 370 duplications. The research team then
reviewed abstracts and removed 723 literature articles that did
not meet the inclusion criteria. The research team obtained
and reviewed the remaining 236 references (see Figure 1). The
quality of the literature was appraised using the RNAO’s Level
of Evidence hierarchy (see Table 2) and ranked accordingly.
During the review process seminal or influential articles from
earlier than the search timeframe were identified and included
in literature review.
Appendices B and C provide a summary of the key research
studies and systematic reviews the research team used in the
development of the CPGs. Expert opinion was often used when
research was not available. Appendix B contains nine references
for urinary retention, mostly with stroke and rehabilitation
patients, six studies and three systematic reviews. Systematic
reviews addressed catheterization practices in adult populations (Fernandez & Griffiths, 2006; Griffiths & Fernandez, 2007;
Niel-Weise & van den Broek, 2007). No published CPGs or
best practice guidelines were found for urinary retention in
stroke patients.
Appendix C provides a summary of 12 references for urinary
incontinence in mostly adult patients, three studies and nine
systematic reviews. Two stroke specific references are included,
Harari et al., 2004, and Thomas et al., 2005. Harari et al. (2004)
conducted a randomized controlled trial (RCT) with stroke
patients in the community and rehabilitation and demonstrated
the effectiveness of a bowel program. This level of evidence
supports the assessment of stroke survivors for constipation
by obtaining information about stool frequency, character and
consistency of bowel movements and fluid intake. This recommendation is supported by RNAO CPGs, Promoting Continence
Using Prompted Voiding (2005).
The second stroke reference is by Thomas et al., 2005. It is a systematic review in stroke adult patients to determine the optimal
methods for prevention and treatment of urinary incontinence.
The authors reported there was evidence that specialist professional input through structured assessment and management
of care and specialist continence nursing may reduce urinary
incontinence after stroke. This finding was supported by Borrie,
Bawden, Speechley, and Kloseck (2002) in an RCT in adults in
an outpatient clinic. The research team chose to recommend an
inter-professional team approach because of the wide range of
skills and knowledge required for urinary incontinence assessment diagnosis and treatment.
DuBeau, Simon, and Morris (2006) studied quality of life in
nursing home residents and found that urinary incontinence
was associated with worse quality of life in residents with
moderate cognitive and functional impairment. In a systematic review, Fader, Cottenden, and Getliffe (2007) report that
only one RCT recommended using continence management
18
products for women with urinary incontinence. These studies
provide evidence to support interventions promoting stroke
survivors’ dignity using products to manage incontinence.
Recent evidence suggests that conservative approaches for
managing incontinence and promoting continence involving
pads and toileting are most frequently used for residents in
care homes. (Roe et al., 2010). Habit retraining, and timed
and prompted voiding are common toileting practices used in
care home populations for residents with cognitive or physical
impairments, with limited evidence on effectiveness (Eustice et
al., 2000; Ostaszkiewicz, Johnston, & Roe, 2004). Clinical practice guidelines have recommended timed and prompted voiding although evidence ratings are low (Agency for Health Care
Policy and Research, 1996). The RNAO (2005) developed a best
practice guideline for promoting continence using prompted
voiding for adults. More research is needed to determine if
improved outcomes in urinary incontinence can be achieved
in non-stroke populations.
Figure 1: Literature search ﬂow diagram
Table 2: RNAO levels of evidence
Ia. Evidence obtained from meta-analysis or systematic
review of randomized controlled trials
Ib. Evidence obtained from at least one randomized
controlled trial
IIa. Evidence obtained from at least one well-designed
controlled study without randomization
IIb. Evidence obtained from at least one other type
of well-designed quasi-experimental study without
randomization
III. Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative
studies, correlation studies, and case studies
IV. Evidence obtained from expert committee reports
or opinions and/or clinical experiences of respected
authorities
A synthesis of recommendations for behavioural approaches
of internal CPGs by Dumoulin, Korner-Bitensky, and Tannenbaum (2005) reported consensus opinion for three CPGs that
timed voiding or prompted voiding should be implemented for
urinary retention or incontinence in cooperative and mobile
individuals with stroke. These guidelines are from the Agency
for Health Care Policy (1996); Research, Veterans Affairs/
Department of Defence (2004); and Health Publication, U.K.
(2002). Behavioural treatments to teach patients new skills to
control the physiologic responses of the bladder and pelvic
muscles such as pelvic muscle training exercises and strategies
to respond to urgency were not addressed in the CPG. The
research team believed that this work was preliminary (CPG)
and recognized that further work in this area would need to
be addressed at a future time. Studies have demonstrated that
behavioural procedures can be implemented in ambulatory settings (Burgio et al., 1998; McDowell, Burgio, Locher, & Rodriguez, 1992).
Development of draft clinical practice guidelines
Between 2007 and 2008 the research team synthesized findings from the systematic literature review. A draft set of evidence-based CPGs was developed for the continence care of
survivors after the hyper acute or acute phase of stroke care.
The intended domain of care is inpatient acute care or rehabilitation settings. The CPGs document was titled Clinical Practice
Guidelines for the Urinary Continence Care of Stroke Survivors
in Acute and Rehabilitation Settings. The CPGs included recommendations for assessment, interventions for continence management, education for health care professionals, organization
supports and policy (see Appendix A). Each recommendation
included a ranking of evidence. The CPGs also contained a glossary, medications linked to urinary retention and incontinence,
as well as information about continence assessment tools and
an intermittent catheterization protocol.
Evaluation of draft clinical practice guidelines
The research team identified experts and recognized leaders
involved in the provision of stroke and/or continence care
in acute and rehabilitation settings. The experts and leaders
include researchers, physicians, advanced practice nurses, clinical nurses, physiotherapists, occupational therapists, administrators and stroke survivors and one family member. These
participants constituted the expert panel for the evaluation of
the draft CPGs.
Table 3: Key questions addressed by World Café
participants
1. What are the barriers to the implementation of
continence care guidelines for stroke survivors?
2. What are the facilitators to the implementation of
continence care guidelines for stroke survivors?
3. What strategies do you feel will assist with the
implementation of continence care guidelines for stroke
survivors?
The Ottawa Model of Research (OMRU) provided an important framework for the implementation of the guidelines. The
OMRU identifies six factors that impact the implementation
and uptake of innovations in clinical practice: a) the practice
environment; b) the potential research adopters (administrators
and clinical staff ); c) the evidence-based innovation; d) strategies for transferring the innovation into practice; e) adoption/
use of the evidence; and, f ) health and other outcomes (Logan
& Graham, 1998). The systematic assessment and evaluation
of these six factors is central to the OMRU.
The OMRU (Logan et al., 1998) guided the research team to
identify barriers and facilitators to the implementation of CPGs
in the acute and rehabilitation settings. The researchers, with
the expert panel, applied the OMRU in two stages. The first
stage involved the assessment of the content, presentation,
and applicability of the clinical practice guidelines using the
Appraisal of Guidelines Research and Evaluation (AGREE)
Instrument (http://www.agreetrust.org). The AGREE Instrument provides a framework for assessing the quality of CPGs.
It consists of 23 key items organized in six domains: scope and
purpose, stakeholder involvement, rigour of development,
clarity and presentation, applicability, and editorial independence. High scores suggested recommendations were feasible
for implementation and evaluations. This assessment helped
researchers appraise the quality of the CPGs. The second stage
involved examination of the practice environment and potential
adopters using a “World Café” focus group process to identify
barriers and facilitators for the CPGs’ uptake.
The “World Café” (http://www.theworldcafe.com) is a process
for bringing people together around questions that matter and
is founded on the assumption that people with diverse perspectives have the capacity to construct knowledge through
dialogue. The study team obtained written consent from Café
participants to participate in the focus groups. A Learning and
Development Officer, employed at The Ottawa Hospital, facilitated the World Café process. The Café agenda, addressed in
a half-day workshop, included an introduction followed by an
overview of the study and activities for the group. Participants
dedicated the majority of their time to dialogue and gave their
input into three key questions listed in Table 3.
The researchers organized the participants into five tables with
five or six participants in each group. One person at each table
acted as host and one as recorder, with each question allocated
approximately 15 minutes of discussion. Participants changed
tables for each question while the host remained. Each table
had five minutes to present its discussion findings to its peers.
Pilot site implementation
In addition to developing CPGs for urinary continence care of
stroke survivors, the study team implemented the guidelines in
a short-term pilot. The pilot included preparation of educational
materials, pre and post chart audits and a knowledge, beliefs and
attitudes survey. The Clinical Practice Guidelines for the Urinary Continence Care of Stroke Survivors in Acute and Rehabilitation Settings was piloted for three months at two sites: a)
rehabilitation setting, and b) mixed acute care and rehabilitation
setting. Respective research ethics boards approved this phase
of the study. Members of the research team met with hospital
19
administrators to ensure a high level of support and engagement
during the implementation. The research team collaborated with
the clinical managers of the two pilot sites to facilitate a meeting
with clinical nurses. The team held three staff meetings with clinical nurses on the stroke rehabilitation unit, two with day shift
nurses and one meeting with the evening nurses. The meetings
included an educational session about the CPGs, a discussion
about potential barriers and facilitators to guideline implementation and finally the researchers asked the clinical nurses to
identify the three most important recommendations from the
guideline for implementation on their unit. Nurses based their
decisions on past experiences and an overall understanding of
their clinical environment. The research team selected only three
recommendations to implement on each site for several reasons:
1) feasibility to achieve in the short timeframe, 2) most relevant to
particular area, and 3) focus on achieving success with a smaller
number of interventions. Researchers believed that limiting the
number of implemented interventions would facilitate adoption
and acceptance. Each meeting with clinical nurses addressed
questions and concerns about the three-month pilot implementation roles, responsibilities and expectations. The meetings also
acknowledged possible impediments and supports and, when
necessary, suggested actions to mitigate impediments to optimize
the implementation.
Pilot implementation delays at the combined acute and rehabilitation setting occurred due to unanticipated concurrent clinical
priorities. The research team developed a chart audit tool to
audit charts over a two-week period pre and post implementation to identify changes in nursing documentation that would
indicate adoption of the three piloted recommendations. The
study team hired and trained a research assistant to conduct
the chart audit.
Education approach
The research team developed educational materials that
included the following topics: a) a general presentation on
continence issues for the post stroke survivor; b) a reference
manual with an overview of the clinical interventions linked to
the selected recommendations; and c) an online self-learning
portal. The study team created an online self-learning portal to
support the implementation of clinical practice guidelines for
the urinary continence management of stroke survivors in acute
and rehabilitation settings. The portal consists of interactive
learning modules including: a) evidence-based recommendations; b) instructional videos; c) interactive care scenarios; d)
learning assessments; and e) supplementary materials such as
assessment tools and clinical algorithms. A blogging platform
(i.e., Wordpress) was the architecture and template system for
the website, which allowed for interactivity.
The research team developed education strategies tailored for
each site based upon the recommendations selected for implementation. Hence, each site used different material and strategies. The rehabilitation setting employed a combination of
group educational sessions using PowerPoint presentations,
skills fair day, posters and pocket cards on timed and prompted
voiding differences. The mixed acute and rehabilitation setting
used structured group education sessions with short PowerPoint presentations.
20
Nursing knowledge, attitudes and beliefs
The nurses completed the Knowledge, Attitudes and Beliefs
Survey (KABS) (Evaluation of IC5: Improving Continence Care
in Complex Continuing Care, Report for the Ontario Women’s
Health Council, 2006). The researchers intended to help raise
awareness about continence care, highlight knowledge deficits
and determine the beliefs held by the nurses using this survey.
The true-false KABS survey was developed previously, as part
of the IC5 Collaborative Project; Improving Continence Care
in Complex Continuing Care Hospitals in Ontario, Canada.
Results
Guideline evaluation
Eleven expert panel members evaluated the Clinical Practice
Guidelines for the Urinary Continence Care of Stroke Survivors
in Acute and Rehabilitation Settings using the AGREE Tool. Of
the 25 panel participants, 11 completed written evaluations,
which were reported to take one hour to perform. The less than
50% completion rate could possibly be explained by the fact
that the tool can take one hour to complete and that frontline
clinicians, including staff nurses, may not have any experience
or training conducting AGREE Tool evaluations. Participants
scored the evidence-based recommendations and also provided
qualitative comments on the scope, content, and presentation
of the guidelines. All of the participants strongly recommended
(n=3) or recommended with revisions (n=8) the evidence-based
recommendations. Participants recommended the guidelines
for further evaluation. Table 4 summarizes The AGREE Tool
domain scores and overall assessment. Because the development of the clinical practice guidelines was in an interim stage,
there was insufficient information available to score certain categories. The AGREE Tool scores were, consequently, low in several sub-categories, such as stakeholder consultation and pilot
implementation. The evaluation nonetheless identified areas
that needed further revisions, including the overview of the
methods, stakeholder consultation, and overall presentation.
Informal feedback from the participants demonstrated support
for the development work and recognized the importance of
Table 4: AGREE tool scores
AGREE Tool Evaluations
CONTENT AREA
Aggregate Score
Scope & Purpose
78.8%
Stakeholder Involvement
47.7%
Rigour of Development
72.3%
Clarity & Presentation
70.5%
Applicability
40.4%
Editorial Independence
39.4%
Overall assessment
Recommended with revisions (n=8)
Strongly recommended (n=3)
implementing the guidelines. Comments from the expert panel
were positive and minor editing suggestions were made to CGPs
prior to implementation.
Table 5 summarizes the findings from the focus group participants at the World Café in relation to the three questions
the research team asked them to address. Participants identified three barriers for the implementation of continence care
guidelines: 1) lack of adequate resources, 2) attitudes of health
professionals, stroke survivors, and caregivers, and 3) a lack of
continuity of continence care. Participants proposed that clinical
practice champions, practice guidelines, and structured support could facilitate guideline implementation. In addition, the
focus group participants suggested three strategies to assist with
guideline implementation: using practice champions, developing a standardized educational program, and implementing the
guidelines in an incremental manner. The research team included
these suggestions into the planning for the pilot implementation.
Table 5: Findings from World Café focus group participants
Question 1: What are the barriers to the implementation of continence care guidelines for stroke survivors?
Lack of adequate resources: Participants identified that a lack of adequate resources was a significant barrier to the
implementation of clinical practice guidelines for the continence care of stroke survivors. Inadequate resources included
a perceived lack of nurses available to implement the guidelines, inadequate facilities, and insufficient time to follow the
suggested recommendations.
Attitudes of health professionals, stroke survivors and caregivers: Participants noted that the attitudes of health professionals
acted as a barrier to continence care of stroke survivors. Examples of negative attitudes include cultural and personal beliefs
regarding continence care; low priorities regarding continence care; resistance to practice changes among health professionals;
and the belief that continence challenges are acceptable.
Lack of continuity of continence care: Participants noted that there was a lack of continuity of continence care for stroke
survivors. Contributing factors included absence of clinical practice guidelines, lack of interprofessional communication, and
staff turnover.
Question 2: What are the facilitators to the implementation of continence care guidelines for stroke survivors?
Best practice guideline champions: Participants indicated that support and advocacy from guideline champions, such as
clinical managers and nurse educators, were key facilitators to the successful adoption of the CPGs for the continence care of
stroke survivors at implementation sites. The champions play a critical role as they encourage nurses to implement guidelines
and help other health professionals to support the use of guidelines in rounds.
Best practice guidelines: Participants indicated that clear, concise and easy-to-understand guidelines are necessary to facilitate
the adoption of clinical practice guidelines in the implementation settings. They encouraged the inclusion of clinical practice
guidelines and/or information sheets in educational and patient information packages.
Structures supporting guideline implementation: According to participants, existing systems may facilitate the implementation
of these clinical practice guidelines in acute and rehabilitation settings. These include the following: interprofessional teams,
policies supporting evidence-based practice changes, expert clinics, and multidisciplinary processes.
Question 3: What strategies do you feel will assist with the implementation of continence care guidelines for stroke
survivors?
Identify and capitalize upon practice champions: Participants stated the importance of identifying and capitalizing upon
the expertise and advocacy of practice champions. These may be existing continence care champions within the health care
system, or it may be possible to develop new champions through education and outreach.
Implement educational program: Implementing a strong, multi-tiered educational program targeting nurses, other health
professionals, stroke survivors, and caregivers was described as an important factor to effective implementation of CPGs.
Participants noted that the availability of high-quality presentation materials and self-learning packages may enhance nurses’
learning. Making educational materials available to stroke survivors and their caregivers increases awareness of post-stroke
continence challenges and may encourage the adoption of guidelines by nurses.
Implement practice changes incrementally: Participants indicated that incremental changes in practice might strengthen the
adoption of guidelines insofar as they would be manageable by nurses and participating implementation sites.
21
Pilot Site Implementation Findings
Clinical staff nurses at each site selected the three recommendations from the CPGs for their pilot implementation.
The researchers developed learning strategies tailored to the
needs of the pilot implementation sites. In the rehabilitation
setting, education included 20-minute training sessions done
five times on each recommendation—one recommendation
per month. Additionally, the team used posters on the various
types of incontinence in strategic areas of the unit. All nurses
received pocket cards defining timed versus prompted voiding
and a generic conversation script from the RNAO (2005) best
practice guideline on promoting continence care. Unit educators highlighted the selected recommendations at a previously
planned skills fair. Unit-based nurse experts encouraged staff
to discuss patients’ urinary continence needs during the weekly
interprofessional team rounds.
On the KAB surveys that evaluated nurses’ knowledge, attitudes, and beliefs regarding urinary continence challenges,
nurses demonstrated some knowledge regarding urinary continence management at baseline (see Table 7), identifying a
strong need for general and intervention-specific education.
The implementation of the CPGs improved scores on the KAB
surveys with knowledge scores improving 13.8 points and attitude scores improving 6.2 points.
The research assistant audited the pilot stroke survivor charts
one week prior to the start of the implementation. The week
following the end of the three-month implementation, the
research assistant conducted the post-implementation chart
audit. The rehabilitation unit experienced a decrease in the
number of stroke survivors with urinary continence issues
Table 6: Guideline recommendations selected by pilot
sites
Rehabilitation Unit
Acute and Rehabilitation Unit
• #3 “Assess contributing
factors to continence
management challenges
that may occur due to
stroke using data from
validated assessment
tools.”
#1 “Assessment of stroke
survivor’s continence history.
Identify pre-existing and
emergent comorbidities
and transient causes that
may contribute to urinary
incontinence and/or urinary
retention.”
• #9 “Assess the type
and severity of the
stroke survivor’s urinary
incontinence using a
validated assessment
tool.”
#2 “Conduct a baseline
assessment of post void residual
volumes and voiding patterns.”
• #11 “Initiate an
individualized timed
voiding schedule for
stroke survivors.”
#11 “Initiate an individualized
timed voiding schedule for
stroke survivors.”
22
during the post-implementation week of chart audits. The
implementation period was short (three months) to evaluate
changes in clinical practices. Small sample sizes prevented statistical analysis. However, the chart audits provided descriptive data and suggested continence needs were identified and
interventions were put in place both pre and post implementation. This preliminary data provided information to suggest
an awareness of nurses of the continence needs and the need
for interventions to address areas of concern. The pre and post
chart audits demonstrated minimal change in the documentation of continence management. The majority of documented
interventions noted both pre and post audit included the following: 1) toilet patient regularly Q2-3 hours, 2) push fluids,
and 3) the use of continence management products such as
pull-up briefs and pads.
Discussion
The literature review in urinary incontinence in stroke studies provided mostly Level III and IV evidence according to
the RNAO levels of evidence. Expert opinion contributed to
the development of the CPGs. Future research is needed to
address the effectiveness of interventions in urinary continence
in stroke populations.
The research team used information obtained from the expert
panel to revise the evidence-based recommendations, Clinical
Practice Guidelines for the Urinary Continence Management
of Stroke Survivors in Acute and Rehabilitation Settings. The
team also found this information valuable for developing key
education strategies to support the implementation of the clinical practice guidelines at the pilot implementation sites. The
researchers developed presentations that: a) dispelled urinary
continence management myths; b) identified types of urinary
incontinence; and c) could be delivered with limited resources.
Development of an online self-learning portal also supported
the implementation of the clinical practice guidelines (French
and English versions of the clinical practice guidelines). All educational material was publicly available via the online self-learning portal.
This study did not have strong measures to assess the degree
to which nurses implemented the selected recommendations.
Clinical outcomes such as resolution of urinary incontinence,
a reduction in the frequency of urinary incontinent episodes,
and patient satisfaction with their continence management regimen would have informed the research team about effective
implementation of the recommendations.
Table 7: Changes in KAB scores at two pilot sites
Site
Score
Knowledge
Attitudes
Pre-pilot implementation n=42
51.8%
72.9%
Post-pilot implementation n= 20
65.6%
79.1%
Change
+13.8
+6.2
The research team identified several possible reasons to explain
why the chart audits did not measure the uptake of the recommendations. The audit tool may have been too broad in
its scope and not specific enough to capture implementation
of the three recommendations piloted at each site. The format of the medical record at each clinical unit did not foster documentation of the specific elements of the selected
recommendations.
Other factors that may have negatively impacted the pilot
implementation were the turnover of staff involved with the
implementation, competing corporate demands, and time
pressures from increasing workload responsibilities. Other
researchers involved in the development and evaluation of nursing clinical guidelines (Gifford, Davies, Edwards, & Graham,
2006; Ploeg, Davies, Edwards, Gifford, & Elliott-Miller, 2007;
Francke, Smit, de Veer, & Mistiaen, 2008) have reported similar barriers to evidence-based guidelines uptake. This finding
reflects the reality of work experiences in many clinical practice settings. The demands on clinical nurses to implement evidence-based practice are high.
Limitations and strengths
Our study had several limitations. The Knowledge, Beliefs
and Attitudes survey tool from the Ontario IC5 Collaborative
Project that the researchers used to gather information from
frontline clinicians had not undergone widespread validation
testing. Therefore, the interpretation of the survey scores
would have been stronger if associated with other evidence.
The study team asked participants, as a group, to come to consensus about the most appropriate CPGs recommendations
for implementation in their practice setting. The selection
of recommendations could possibly have been prejudiced by
one or more informal leaders and not truly representative of
the group’s opinion. The sample size for the pilot implementation was only two inpatient units, each with less than 30
beds, reducing generalizability to other inpatient rehabilitation
facilities. Even with these limitations, the study provided preliminary exploration of the challenges for urinary continence
CPGs for this patient population.
A key strength of the study was the inclusion of stroke survivors
in the development of the CPGs. These individuals provided
a unique lived experience to discussions about priorities and
the proposed draft CPGs. Engaging an expert panel contributed to the development of the guidelines and supported the
implementation with information about barriers and facilitators. Nurses were provided with tools and resources to improve
continence management of their patients.
Conclusion
This study contributed to the body of knowledge on the management of urinary continence of stroke survivors by developing evidence-based recommendations and piloting selected
recommendations. Preliminary study findings demonstrated
an uptake of the evidence-based recommendations. A larger
study is required to determine the applicability of all the recommendations in the CPG. Additional research is needed to evaluate the sustainability of nurses’ knowledge and to determine
the impact of the CPGs on clinical outcomes. This research
team has subsequently conducted an evaluation of the online
self-learning portal in partnership with national and international nursing organizations. This study suggested that the
implementation of the guidelines improved nurses’ knowledge
of the continence needs of stroke survivors.
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APPENDIX A: Clinical Practice Guidelines for the Urinary Continence Care of Stroke Survivors in Acute and
Rehabilitation Settings Summary of Recommendations
URINARY CONTINENCE MANAGEMENT OF STROKE SURVIVORS
Assessment Recommendations
1. Assess stroke survivor’s continence history. Identify pre-existing and emergent comorbidities and transient causes that may
contribute to urinary incontinence and/or urinary retention.
Level of Evidence
IV, IIb
2. Obtain a baseline assessment of three post-void residual volumes and voiding patterns (i.e., amount voided and amount of
urine scanned in bladder).
Level of Evidence
IIb, III, IV
3. Assess contributing factors to continence management challenges that may occur due to stroke using data from validated
assessment tools. These include changes in medications, nutrition, dietary practices, mobility, cognitive status, and ability to
communicate.
Level of Evidence
Ia, III, IV
4. Discuss stroke survivor’s knowledge, beliefs, goals and cultural attitudes toward urinary continence management.
Level of Evidence
IV
5. Assess stroke survivors for the presence of urinary tract infections.
Level of Evidence
III
6. Assess stroke survivors for constipation by obtaining information about stool frequency, character and consistency of bowel
movements and fluid intake.
Level of Evidence
Ia
7. Identify environmental barriers to successful toileting.
Level of Evidence
IV
8. If urinary incontinence is detected, identify the type experienced by the stroke survivor and develop an appropriate
management plan.
Level of Evidence
III, IV
Intervention Recommendations: Urinary Incontinence
9. Assess the type and severity of the stroke survivor’s urinary incontinence using a validated assessment tool.
Level of Evidence
IV
10. Initiate an individualized prompted voiding schedule based on stroke survivor’s needs, as determined by a three-day
voiding record.
Level of Evidence
Ia, IV
11. Initiate an individualized timed voiding schedule for stroke survivors.
Level of Evidence
IV
12. Promote stroke survivors’ dignity by using continence management products, such as pads and pull-ups, to manage
incontinence. Product selection is dependent on the type of incontinence and amount of urine lost.
Level of Evidence
Ia, IV
25
Intervention Recommendations: Urinary Retention
13. Ensure optimal patient positioning to promote voiding, taking into account the stroke survivor’s preferences and
impairments.
Level of Evidence
IV
14. Establish an appropriate intermittent catheterization plan of care for the management of urinary retention using a voiding
record and monitoring intake and output of fluids.
Level of Evidence
Ia, Ib, IV
15. Use the smallest catheter size available to minimize the discomfort and risk of injury associated with catheterization.
Level of Evidence
IV
General Interventions
16. Implement a bowel protocol to ensure proper management, if the stroke survivor is experiencing constipation, and
encourage stroke survivors to have healthy intake levels of at least 1,500 to 2000 ml/day of fluid when medically appropriate.
Minimize the intake of caffeine, alcohol, and other bladder irritants.
Level of Evidence
IIa
17. Consult with the medical team to determine if a more detailed evaluation of lower urinary tract function is needed if
urinary retention and/or incontinence persist.
Level of Evidence
IV
18. Promote privacy for stroke survivors while toileting.
Level of Evidence
IV
Education Recommendations: Health Professionals
19. Nurse educators will conduct educational sessions with health professionals outlining types of incontinence, their
respective treatments and the association between stroke and urinary continence management. Self-learning materials will be
made available to augment educational sessions and provide those unable to participate with information regarding urinary
continence management of stroke survivors.
Level of Evidence
IV
20. Provide stroke survivors and their caregivers with information regarding urinary retention, urinary incontinence and
urinary continence management options.
Level of Evidence
IV
Organizational & Policy Recommendations
21. Ensure that the organization has the planning, resources and administrative support needed to implement these evidencebased practice guidelines.
Level of Evidence
IV
22. Establish an inter-professional team approach for the urinary continence care of stroke survivors.
Level of Evidence
IV
23. Ensure continuity of care for stroke survivors between acute, rehabilitation, and complex continuing care settings by
documenting management strategies and outcomes.
Level of Evidence
26
IV
APPENDIX B. Summary of Key Research Papers for Urinary Retention
Author, Year Topic
Borrie et al.
(2001)
Level of
Evidence, IIb
Dromerick
& Edwards
(2003)
Population
Geriatric
Risk factors for
urinary retention Rehabilitation
(UR) to determine Unit
prevalence and
assess validity of
use of bladder
scanner to
measure post void
residual (PVR)
urine volumes
Relation of PVR
to urinary tract
infection (UTI)
Stroke
Rehabilitation
Design
Sample Size
Comments
Prospective study;
prevalence of
UR, identified
risk factors for
UR and validated
use of bladders
scanner to detect
significant UR
167 patients
admitted to
service
11% (19 of 167) had UR. The risk of UR
was greatest in patients who are older, on
anticholinergic medication, long-standing
diabetes, and fecal impaction.
Prospective case
series
101
consecutive
admissions
underwent
an evaluation
that included
admission
urinalysis, PVR
determination
by ultrasound
and
medication
review
The risk of UTI increases when two or more
ultrasound PVR readings are more than 150
ml; the optimal PVR for initiating bladder
catheterization remains unknown.
A systematic
review on the
effect of duration
of catheterization
Eight
randomized
control trials
compared
various
duration of
catheterization;
741
participants
This review investigates and summarizes
the evidence for the removal of indwelling
urethral catheters. The authors report no
significant differences in patient outcomes but
suggest that the timing of catheter removal
is a balance between avoiding infection
(early removal) and circumventing voiding
dysfunction (later removal). Shorter duration
of indwelling catheter use appears to reduce
mean length of hospital stay.
Prospective
study to evaluate
bladder status by
postvoid residual
(PVR) sequential
catheterizations.
85 patients
enrolled in
the study; 79
were capable
of voiding at
the time of
admission and
included in the
sample
Patients were catheterized within 15 minutes
of voiding. A patient was defined as having
normal bladder emptying if each of the three
consecutive PVRs was less than 50cc; if any
one of the three PVRs remained above 50 cc,
the PVRs were continued twice a day until
the volume remained below 50 cc on three
consecutive samples.
Group 1: 37 patients (46.8%) with admission
PVRs of less than 50 cc; Group 2: 20 patients
(25.3%) with admission PVRs of more than 50
cc who advanced to three sequential PVRs of
less than 50 cc before discharged; and Group 3:
22 patients (27.8%) with PVRs of more than 50
cc from admission through discharge. 53.2%
of patients demonstrated incomplete bladder
emptying at admission and 27.8% at time of
discharge.
Level of
Evidence, III
Fernandez
& Griffiths
(2006)
Level of
Evidence, Ia
Garrett et al.
(1989)
Level of
Evidence, III
Effects of
duration of
short-term (1–14
days) indwelling
catheters
Trials evaluating
the effects of
various durations
of catheterization
prior to the
removal of shortterm indwelling
urethtral catheters
in all patients of
all ages and in any
settings
Bladder emptying Stroke patients in
assessment
a rehabilitation
centre
Ultrasound bladder scanners when used by
train nursing staff, provides conservative and
valid estimate of PVR of > 150 ml in people
undergoing geriatric rehabilitation.
Findings suggest bladder protocols be initiated
early and include serial PVR determinations.
Authors reported that one in six patients had
UTI on admission.
Incomplete bladder emptying or UR in stroke
patients with normal bladders is a frequent
problem, which should be addressed as part of
routine rehabilitation management.
27
Griffiths &
Fernandez
(2007)
Level of
Evidence, Ia
Strategies for
the removal
of catheters
from patients
with a shortterm indwelling
urethral catheters
Gross & et al. Effect of time of
day for urinary
(2007)
catheter removal
Level of
on voiding
Evidence, Ib
behaviours
Kong, K.H.
& Young, S.
(2000)
Incidence and
outcome of poststroke UR
Level of
Evidence, III
Randomized and
quasi-randomized
controlled trials
that compared
the effectors
of alternative
strategies for
urethral catheters
on patient
outcomes
A systematic
review that
compared
the effects of
alternative
strategies for
urethral catheters
on patient
outcomes
26 trials
involving a
total of 2,933
participants
Limiting how long an indwelling urethral
catheter was left in place was linked to
a shorter stay in hospital and less risk of
infection.
Stroke patients,
over the age of 18
years
A randomized,
comparative
design; 7 a.m. and
10 p.m. removal
45 patients
were enrolled;
19 in 7 a.m.
and 26 in 10
p.m.
No significant differences were identified
between the two groups with regard to
time to void, volume of first void, post-void
residual urine, or the number of subjects
requiring catherization. Authors conclude
monitoring bladder capacity and instituting
an intermittent catherization routine to
prevent over-distention remains an important
component of care.
Inpatient setting
of tertiary
rehabilitation
centre; first
ischemic stroke
Prospective study;
assessment of
residual urine
volume or PVR
using a portable
ultrasound
bladder scanner
was performed
on all patients
within 72 hours of
admission
80 consecutive 23 patients (28.8%) of patients had UR; 19
patients
(82.6%) had resolution or UR on discharge.
Authors recommend PVR screen be
performed for all patients immediately post
stroke, especially in those with aphasia,
cognitive impairment, a poorer functional
status and diabetes mellitus.
15 patients (19%) developed UTI during
rehabilitation
Randomized
trials comparing
catheter route of
insertion for adults
catheterization for
up to 14 days
A systematic
review to
determine the
advantages and
disadvantages
of alternative
approaches to
catheterization
for short-term
bladder drainage
in adults
17 trials
Level of
Evidence, Ia
Determine the
advantages and
disadvantages
of alternative
approaches to
catheterisation
for short-term
bladder drainage
in adults
Limited evidence that the use of intermittent
catheterization rather than indwelling
catheterization reduced the risk of bacteriuria
in patients with hip or knee surgery.
Wu &
Baguley
(2005)
Prevalence,
risk factors and
outcomes of UR
General
rehabilitation unit
Prospective,
observation study
278
consecutive
patients
Of the 278 patients transferred to
rehabilitation, 22 (7.9%) had symptomatic
urinary retention before their transfer; the
remaining 256 had clinical unsuspected UR in
55 (21.5%).
Niel-Weise
& van den
Broek (2007)
Level of
Evidence, III
28
PVR volumes in 297 patients were 150 ml
or more in 64 (21.5%) patients. The risk
of UR was greatest among male patients
who had lower admission FIM instrument
scores, neurologic disorders (stroke or
multiple sclerosis), cognitive impairment,
urinary incontinence, a history of previous
prostate, bladder or voiding problems, were
taking anticholinergic medications, or were
immobile.
APPENDIX C. Summary of Key Research Papers for Urinary Incontinence
Author, Year
Topic
Population
Design
Sample Size
Comments
Borrie et al.
(2002)
Level of
Evidence, Ia
Interventions led
by specialized
nurses with
training in
managing
incontinence
Patient who were 26
years of age or older
and suffered from UI in
an outpatient clinic
Randomized
controlled
trial; men and
women were
randomly
allocated to
receive either
counselling
from
specialized
nurses to
manage
UI using
behavioural
and lifestyle
modification
sessions every
four weeks for
25 weeks or
usual care
421 subjects were
randomized to the
treatment (n=210)
and control (n=211)
groups
Behavioural and lifestyle counselling
provided by specialized nurses with
training in managing incontinence
resulted in a statistically and
clinically significant improvement
in the treatment group at 25 weeks,
with a reduction in incontinent
events and pad use.
DuBeau, C. et al.
(2006)
Level of
Evidence, III
Determine
whether
nursing home
residents with
UI have worse
quality of life
than continent
residents
Older nursing home
residents
Retrospective
cohort study
using a
Minimum Data
Set database
to determine
crosssectional and
longitudinal
(six-month)
association
between UI
and quality of
life
Of 133,111 eligible
residents, 90,538
had consistent
continence status,
58, 850 (65%) were
incontinent
UI was significantly associated with
worse quality of life in residents with
moderate cognitive and functional
impairment. New or worsening UI
over six months was associated with
worse quality of life (OR= 1.46, 95%
confidence interval=1.36-1.57) and
was second only to cognitive decline
and functional decline in predicting
worse quality of life. These results
demonstrate the need to improve
continence care and quality in
nursing homes.
Dumoulin et al.
2005
Level of
Evidence, Ia
A comprehensive
review of the
literature to
assess the
scientific
evidence for the
effectiveness
of behavioural
therapies to treat
UI post stroke
In adult stroke
population is
a behavioural
intervention more
effective than no
intervention or
placebo/alternative
intervention in the
management of UI? In
adult stroke population
is a combination
of behavioural
interventions more
effective than no
intervention or
placebo/alternative
intervention in the
management of UI?
A systematic
review
Four RCT, one
cohort, eight major
stroke CPGS and
two major UI CPGS
Most international stroke guidelines
do not report specific comments
to manage UI. Evidence for the
treatment of UI remains extremely
limited.
29
Eustice et al.
(2007)
Level of
Evidence, Ia
Assess the effects UI in adults, with and
without cognitive
of prompted
impairment
voiding; a
behavioural
therapy to
improve bladder
control for
people using
verbal prompts
and positive
reinforcement
A systematic
review
Nine trials, 674
elderly people,
the majority were
women; randomized
or quasi randomized
trial of prompted
voiding for
management of UI
Prompted voiding is a behavioural
therapy used to improve bladder
control for people with or without
dementia using verbal prompts and
positive reinforcement.
The limited evidence suggested
that prompted voiding increased
self-initiated voiding and decreased
incontinent episodes in the shortterm. There was no evidence about
whether these effects are sustained
over a long period of prompted
voiding or persist after stopping
prompted voiding. No stroke
specific studies.
Fader et al.
(2007)
Level of
Evidence, Ia
Assess the
effectiveness of
different types
of absorbent
product designs
for women with
light urinary
incontinence
Women with light UI
who used absorbent
products (disposable
insert pads, menstrual
pads, washable pants
with integral pad,
washable insert pads)
suitable for light
incontinence
A systematic
review
One trial, 85 women,
which compared
different designs
of the products;
randomized crossover design
Disposable insert pads are more
effective for leakage prevention than
the other designs; because they are
most expensive, providing choice of
designs (or combination of designs)
is likely to be cost-effective. There is
no clear benefit for skin health using
either washable or disposable design.
No stroke specific studies.
Harari et al.
(2004)
Level of
Evidence, Ib
Constipation
and fecal
incontinence
Stroke patients were
identified by screening
questionnaire
Randomized
122 stroke patients
controlled trial in community
and 24 stroke
rehabilitation
inpatients
A clinical/educational nurse
intervention effectively improved
symptoms of bowel dysfunction up
to six months later, changed bowelmodifying lifestyle behaviours up
to 12 months later, and influenced
patient-GP interactions and
physician prescribing patterns. The
intervention included an assessment
by a nurse leading to: (1) targeted
patient and carer education; (2)
provision of booklet; and (3)
diagnostic summary and treatment
recommendations sent to the
patient’s general practitioner, and
ward physician if in hospital.
Hay-Smith et al.
(2007)
Level of
Evidence, Ia
Assess the
effectiveness
of physical
therapies in
preventing
incontinence in
adults
Incontinence in adults
A systematic
review
Two trials in men
(155) and 13 trials
in women (4661);
randomized or quasi
randomized trials
There is insufficient evidence
to determine whether physical
therapies can prevent UI in
childbearing women or men
following prostate surgery. No stroke
specific studies.
Ostaszkiewicz, J.
et al. (2007)
Level of
Evidence, Ia
To assess the
effects of habit
retraining for
the management
of UI
Adults
A systematic
review
Three trials with 337 Habit retraining involves identifying
participants
an incontinence person’s toileting
pattern and the development of an
individualized toileting schedule
to pre-empt involuntary bladder
emptying. The review found there is
not enough evidence from trials on
which to judge the impact of habit
retraining on UI.
30
Adult population
with an alteration in
continence status as a
primary outcome
Timed voiding is characterized by a
fixed time interval between toileting
and aimed at people with or without
cognitive impairment.
The fixed schedule of toileting was
combined with other interventions.
Reductions in the number of
incontinence episodes were reported
in each trial. Insufficient evidence
on the effects of time voiding for the
management of UI.
A systematic
review
Two trials with 298
participants in aged
care homes and had
reduced cognition
and impaired
mobility
Comparison of
four Cochrane
systematic
reviews
on bladder
training
and voiding
programmes
for the
management
of UI using
metastudy
descriptive
techniques
Four Cochrane systematic reviews:
A synopsis of
bladder training, prompted voiding,
four Cochrane
habit retraining and timed voiding
systematic reviews
on behavioural
interventions,
including bladder
training and voiding
programmes, for the
management of UI
in adults.
Ostaszkiewicz et
al. (2007)
Level of
Evidence, Ia
To assess the
effects of timed
voiding (fixed
time interval
assistance
program) for the
management
of urinary
incontinence
in adults
who cannot
participate in
independent
toileting
Roe et al. (2006)
Level of
Evidence, Ia
A synopsis of
findings on
theory and
methods using
metastudy
techniques
Thomas et al.
(2005)
Level of
Evidence, Ia
To determine the Adult population with A systematic
review
optimal methods stroke
for prevention
and treatment
of UI
Seven trials with 399
participants; no two
trials addressed the
same comparison
There was suggestive evidence
that specialist professional input
through structured assessment
and management of care and
specialist continence nursing may
reduce urinary incontinence after
stroke. Data from trials of physical,
behavioural, complementary and
anticholingergic drug interventions
are insufficient to guide continence
care of adults after stroke.
Wallace et al.
(2004)
Level of
Evidence, Ia
Adults
To assess the
effects of bladder
training for the
treatment of UI
Three trials
including 159
women compared
The purpose of bladder training is
to restore normal voiding patterns
by progressively lengthening the
interval between voids.
The limited evidence suggests that
bladder training may be helpful for
the treatment of UI. The trials were
of variable quality and small sample
size.
A systematic
review
31
Clustered stroke patients on a general medical
unit: What nursing skills and knowledge
contribute to optimal patient outcomes?
By Brenda Clayton, Athabasca University
Abstract
The purpose of this paper is to explore the nurse’s role in caring
for adult stroke patients, both ischemic and hemorrhagic, who
are clustered on general medical units. There is evidence in the
literature that having patients cared for in a dedicated stroke
unit improves patient outcomes by decreasing disability and
mortality rates for stroke survivors. However, having a dedicated
stroke unit may not be practical or feasible because of the
population distribution, particularly for smaller urban and
rural communities. Therefore, training nurses on the general
medical units to provide care to clustered stroke patients
requires specific skill training. This will decrease hospital stays
and improve patient outcomes, as a result of specialized trained
health care workers. A review of the literature indicates that
there are specific skills and knowledge the nurse requires to
perform evidence-based best practice therapy and have optimal
patient outcomes when caring for patients on general medical
units.
Key words: organized stroke units, nursing care, acute stroke
care, clustered stroke care
Résumé
Le présent document a pour but d’examiner le rôle de
l’infirmière ou de l’infirmier dans les soins aux patients
adultes atteints d’un AVC ischémique ou hémorragique
qu’on a regroupés dans des unités de médecine générale.
La documentation prouve que soigner les patients dans
des unités spécialisées dans les soins de l’AVC améliore les
résultats des patients, car cela réduit les taux d’invalidité et
de mortalité chez les victimes d’AVC. Cependant, il n’est pas
toujours pratique ou possible de posséder une telle unité du
fait de la répartition de la population, en particulier pour
les collectivités urbaines ou rurales plus petites. Il est donc
nécessaire de donner une formation professionnelle spécifique
aux infirmiers et infirmières de ces unités de médecine générale
afin de soigner les groupes de victimes d’AVC. La présence
Stroke is the number one cause of adult disability in North
America (Canadian Stroke Network, 2011; Green & King, 2011;
Justice, Howe, Dyches, & Heifferon, 2008) and the third leading
cause of disability in the developed world (Stroke Unit Trialists’ Collaboration, 2013; Struwe et al., 2013). Stroke is a multifaceted disease and involves the skills, efforts and knowledge
from a coordinated interdisciplinary team in treating the stroke
patient (Kalra & Langhorne, 2007; Summers et al., 2009). There
is evidence in the literature that having patients cared for in a
dedicated stroke unit improves patient outcomes by decreasing
disability and mortality rates for stroke survivors (Saposnik et
al., 2011). Unfortunately, the percentage of patients who spend
any time on a stroke unit after being admitted with a stroke is
low, only 53%, which is undesirable in terms of optimal outcomes (Heart & Stroke Foundation, 2014).
While it is not feasible to have a dedicated stroke unit in every
community, how can these patients be best cared for at smaller
urban and rural centres with lower stroke admission rates?
According to the Heart and Stroke Foundation: Canadian
32
de fournisseurs de soins de santé ayant reçu une formation
spécifique réduira la durée du séjour à l’hôpital des patients et
améliorera leur état de santé. Une étude de la documentation
révèle que les infirmières et infirmiers doivent avoir acquis des
aptitudes et des connaissances particulières afin de fournir
des traitements optimaux qui soient fondés sur des données
probantes, et ainsi obtenir les meilleurs résultats possible chez
les patients hospitalisés dans des unités de médecine générale.
Mots-clés : unités d’AVC organisées, soins infirmiers, soins
de l’AVC aigu, soins de l’AVC regroupés
Stroke Best Practice Recommendations (2014), having four
patients in the facility at any one time defines clustered patients
on a general medical unit. What is not clear is the expertise necessary for acute care nurses located in these smaller centres to
provide best practice for optimal patient outcomes. Therefore,
the purpose of this paper is to determine and explain what acute
nursing knowledge and skills are required to achieve optimal
patient outcomes for adult stroke patients, both ischemic and
hemorrhagic, clustered on a general medical unit.
Methodology
Published literature on the topic of stroke and nursing care for
adult stroke patients while on an acute care unit was compiled.
Two search strategies were used. The first approach involved
using the following search terms, “organized stroke units”,
“nursing care”, and “acute stroke care”, by accessing academic
databases such as CINAHL, MEDLINE, Cochrane Library and
ProQuest Nursing & Allied Health for articles. The second
strategy involved reviewing the reference lists of key Canadian
government and non-government publications, which included:
Heart & Stroke Foundation: Canadian Stroke Best Practice Recommendations (2014), Canadian Stroke Network (2011), Stroke
Engine (2013), National Institute of Health Stroke Scale (2014)
and Alberta Provincial Stroke Strategy (2010). These are organizations that conduct and report current and credible evidence-based practice findings in stroke research.
The first step was to review the title of the article and then
the abstract. If deemed relevant for the purpose of this paper
the full text was reviewed. Criteria for inclusion in this paper
was that the articles were peer reviewed, published after 2004,
and contained information on nursing care beneficial to acute
stroke patients. This process generated more than 75 articles
of which 47 documents were deemed relevant. These articles
were utilized for the paper.
Review of the literature
Organized stroke units are recommended for caring for stroke
patients (Stroke Unit Trialists’ Collaboration, 2013). Admission
to a stroke unit significantly contributes to reducing the social
and economic aspects of the burden of stroke (Di Carlo et al.,
2011). A dedicated stroke unit is a unit where only acute stroke
patients are admitted and treated (Lindsay et al., 2005). The necessary acute care nursing skills and practices that are required
to produce optimal patient outcomes in caring for acute stroke
patients was identified in the literature review. Clustering stroke
patients alone does not translate into improved patient outcomes; instead it is the ability to apply the nursing skills and
knowledge in a timely manner that leads to favourable patient
outcomes (HSF, 2014). The Stroke Unit Trialists’ Collaboration
(2013) identified important components of organized inpatient
stroke units (p. 8). These include a coordinated interdisciplinary
rehabilitation team, (comprising nursing staff, physiotherapist,
occupational therapist, speech language pathologist [SLP], registered dietitian [RD], pharmacist, recreation therapist, social
worker and chaplain), neurologist or specialist on staff, involvement of the caregivers, and a regular education program for the
nursing staff are also key (Stroke Unit Trialists’ Collaboration,
2013).
Hyperacute care for the stroke patient predominantly involves
the emergency medical services (EMS) and the care delivered
in the emergency departments (ED) where blood work and a
CT scan are performed. Here the etiology of the stroke is determined, and treatment initiated in the first few hours of a stroke
(HSF, 2014). Acute care focuses on continuing to stabilize the
patient; preventing deterioration and medical complications
during the following days. Topics and information presented
below have been identified as best practice in the acute nursing
care of clustered stroke patients (Summers et al., 2009). In particular, education for nurses is crucial, as their nursing practice
reflects their knowledge and skill sets in all of the following
areas (Stroke Unit Trialists’ Collaboration, 2013).
Telestroke
Patients who have suffered a suspected stroke require an examination from a specialist, preferably a neurologist (HSF, 2014).
Telestroke (Telehealth) improves access to best care. It is an
excellent method for connecting with a Stroke Neurologist from
a comprehensive stroke centre who can expedite treatment for
patients (Jeerakathil et al., 2012; Rudd, 2011). Telestroke allows
the physician to visualize and examine the patient remotely
from a larger stroke centre (Rudd, 2011).
Stroke order sets
Physician stroke order sets are specific standing orders that
direct care for the patient and address lab work, diagnostic
imaging tests, cardiac tests and other items related to stroke and
assessment of the patient’s condition. Examples include monitoring of blood pressure (BP), level of consciousness (LOC)
changes, nutrition and swallowing, and standing orders for
certain medications (Summers et al., 2009). Stroke order set
guidelines were published by Heart & Stroke Foundation: Canadian Stroke Best Practice Recommendations (2014) and reflect
evidence-based best practice research for neurologists to consider when developing their own institutions stroke order sets.
Clinical pathways
Clinical pathways contain evidence-based recommendations for
plan of daily care (Struwe et al., 2013). They are used to guide
the nursing team in managing stroke patients and coordinating the care, discharge planning, lab work and DI tests (Summers et al., 2009). Use of these pathways results in a decrease
in hospital costs, decrease in readmission rates, reduction in
the length of stay (LOS), and enhanced usefulness of outcome
measurement and quality improvement (Summers et al., 2009,
p. 2922). Green et al. (2011) found that “nurses play a key role
in the implementation of evidence-based recommendations”
(p. 15) and clinical pathways ensure the recommendations are
followed daily.
Nursing care
Nurses monitor the patients on an ongoing basis: 24 hours,
seven days a week, and observe and report any variations in
the physiological and psychological status of the patient (Seneviratne, Mather, & Then, 2009). Nurses need to undergo specialized training in order to develop communication skills
that enable them to effectively converse with the patient who
has aphasia. Nursing feedback helps support decisions made
regarding management and treatment (Cowey, 2012). Assessments listed below were identified in the literature as knowledge
and skills that nurses require to care for the acute adult stroke
patient (Summers et al., 2009). By developing expertise in acute
stroke practice, the nurse can help to minimize or even prevent
many complications that may arise (Lindsay et al., 2008).
Neurological assessment
Knowledge. Detecting changes (even subtle differences) in neurological status is vital to understanding, managing and recognizing alterations in neurological function, as well as predicting
outcomes in patients who have experienced a stroke. Ongoing
neurological vital signs, head-to-toe assessment, and effective
use of the tools to determine the neurological status are important. The neurological assessment includes assessing the level
of consciousness (LOC) and cognitive status (arousal, alertness
and orientation) using the Glasgow Coma Scale (GCS) and by
applying the National Institute of Health Stroke Scale (NIHSS)
to determine stroke severity (NIHSS, 2014; Niemi, McErlane,
& Tillett, 2013).
33
The GCS, which has “three components: eye opening, verbal
response and motor response”, is widely used to assess and
record the LOC in patients (McNett, 2007, p. 69). The GCS
is a reliable predictor of outcomes in head injured patients,
including those who experience an acute stroke, when combined with the patient age and pupillary response (McNett,
2007). Cerebral edema, mass effect and seizures are some of the
complications screened for by observing the patient and taking
the vital signs and GCS on a frequent basis (Hickey, 2009). Level
of consciousness is the first change noted if a patient is deteriorating. By recognizing this variation in LOC early, the nurse can
notify the physician and the change can be addressed (Hickey,
2009). Performing a head-to-toe neurological assessment at the
beginning of each shift and at frequent intervals during the shift
allows the nurse to gauge any alterations in neurological status
(Hickey, 2009). The NIHSS provides the nurse with a “snapshot” of how the patient is faring at that particular moment in
time and allows for ongoing evaluation of progress (Jauch et al.,
2013; Gocan & Fisher, 2008). The NIHSS tests a number of the
cranial nerves and permits the nurse to identify where some of
the difficulties originate (Hickey, 2009).
Skill. GCS is performed in conjunction with vital signs and
neurological assessment at least every four hours in the initial
acute care phase (HSF, 2014). It is imperative that all nurses
working with acute stroke patients have their certification in
the NIHSS (NIHSS, 2014). The NIHSS is performed on the days
deemed important by the stroke orders, or as needed by the
nurse (HSF, 2014). Monitoring for any kind of seizure activity is
necessary, as seizures are only treated if observed (APSS, 2010).
Blood pressure (BP) assessment and management
Knowledge. Hypertension is the most important modifiable risk
factor for primary and secondary stroke prevention (Lindsay,
2008, p. S8). The use of anti-hypertensive agents and education
on lifestyle modifications are recommended to decrease the
risk of another stroke (Lindsay, 2008). Hypertension is often
observed during and following an acute stroke, normalizing
within a few days (Weiss et al., 2013). Continued hypertension
may be attributed to an increasing intracranial pressure (ICP),
pain, full urinary bladder, hypoxia, pre-existing hypertension
and cerebral hemorrhage (Hickey, 2009; Summers et al., 2009).
In the initial 24-hour period, BP reduction management in
ischemic strokes is required for BP greater than 220/120 mmHg
(Jauch et al., 2013) while guidelines for intracerebral hemorrhagic
strokes are to maintain the systolic BP less than 180 mmHg
(Qureshi, 2013). It is important to note that there is a risk of
increasing cerebral ischemia when the BP is lowered excessively
or too rapidly in the acute phase, as decreased blood flow to
at-risk cerebral tissue occurs (Jauch et al., 2013). The brain has
already been compromised by the stroke, therefore the BP has to
be lowered cautiously (<15%-25%) (Summers et al., 2009). After
the acute phase, target blood pressure parameters aim to keep the
blood pressure lower than 140/90 mmHg for non-diabetic individuals and 130/80 mmHg for patients with diabetes (HSF, 2014).
Skill. Measuring BP at least every four hours in the initial phase
(48 hours) identifies any hypertensive episodes that may need to
be treated (HSF, 2014). Knowledge about BP guides the nurse
in identifying potential problems.
34
Temperature assessment and management
Knowledge. “Hyperthermia (temperature greater than 37.50C)
is associated with poorer outcomes and is associated with more
severe neuronal injury” (Hickey, 2009, p. 603). Aggressive
treatment of an elevated temperature is essential, as neurological deterioration can occur (Hickey, 2009). A combination of increased ICP and cerebral ischemia can result from a
decreased oxygen (O2) supply, as a direct effect of hyperthermia (Hickey, 2009). Shivering, which can accompany fever, may
also cause increased ICP and should be prevented whenever
possible (Hickey, 2009). Searching for a cause of the fever is
recommended (Lindsay et al., 2008).
Skill. Frequent monitoring of temperature (every four hours
for the first 48 hours) and as needed (prn) in the post stroke
phase is vital (Lindsay et al., 2008). Treating the elevated temperature with antipyretics (eg. acetaminophen [Tylenol]) and
mechanical measures such as tepid sponge, light bed linen and/
or clothing and antimicrobial therapy (as required) may be
necessary to lower the temperature (Lindsay et al., 2008; Jauch
et al., 2013).
Respiratory management
Knowledge. Ensuring patency of the airway and adequate oxygenation of the patient, following acute stroke, is critical to
prevent hypoxia and further neurological injury to the cerebral
tissue (Hickey, 2009). Hypoxia is defined as oxygen saturation
levels “less than 96% for greater than five minutes within the
first 48 hours of a stroke” (Jauch et al., 2013, p. 888). Changing
position of the patient at least every two hours helps prevent
pooling of the secretions in the lungs on the dependent side,
which potentially leads to a hypostatic pneumonia (Hickey,
2009). An increase in oxygen needs (as evidenced by low oxygen saturation levels) indicates an adverse change in respiratory
function (Hickey, 2009).
Skill. The respiratory assessment includes: observing the
respiratory rate, taking the oxygen saturation levels with pulse
oximetry, administering oxygen to maintain optimal oxygen
saturation levels, (88-92% for patients with COPD [Austin et al.,
2010] and greater than 94% for hypoxemic individuals [Jauch
et al., 2013; HSF, 2014]), performing auscultation of the lung
fields and reporting any abnormalities heard (Hickey, 2009).
Swallow screen
Knowledge. Dysphagia is a major concern for the stroke patient
and is present in more than half of stroke patients (Martino et
al., 2008). Martino et al. (2008) devised the swallow screen,
Toronto Bedside Swallowing Screening Test (TOR BSST),
which is sensitive, simple, highly predictable and reliable in
detecting dysphagia in stroke patients (p. 559). The stroke
patient should be referred to an RD within 48 hours of admission to ensure nutrition and fluid needs are ordered. Different
textures may be ordered depending on the assessment from the
SLP (Lindsay et al., 2008).
If the patient fails the TOR BSST or swallow screen and can
have nothing by mouth (NPO), then meticulous oral care using
a suction toothbrush should occur every two to four hours.
This frequent oral care decreases the risk of aspiration pneumonia in patients with dysphagia. When the secretions are not
allowed to accumulate in the oral pharyngeal area, the bacteria
cannot collect and inadvertently enter the trachea and subsequent lungs.
Skill. All nurses working on a clustered stroke unit should be
certified in performing the TOR BSST. The TOR BSST should
be performed within 24 hours of admission (HSF, 2014) so any
swallowing difficulties that might lead to complications can
be detected early (Jeerakathil et al, 2012). Frequent oral care
using suction toothbrushes is required on all patients, but most
meticulously on those patients that are NPO (HSF, 2014).
Hydration and nutrition
Knowledge. Hydration and nutrition are both important for
recovery (Summers et al., 2009). If the patient is kept NPO
because it is unsafe for the patient to eat or drink, then an intravenous (IV) infusion of normal saline is recommended to help
maintain hydration (Summers et al., 2009; Jauch et al., 2013).
If a patient becomes dehydrated or hypovolemic, there is the
potential for hypotension to occur and the brain to receive
decreased blood flow and potentially exacerbate cerebral ischemia (Summers et al., 2009). At some point during the first few
days, enteral feeds must be initiated as a strategy to meet nutritional and recovery needs in patients who are NPO (Lindsay
et al., 2008). If the patient has a continued inability to swallow
safely, then a tube may be inserted into the stomach for longer
term feeding (Jauch et al., 2013).
Skill. Maintaining an IV is vital for the infusion of normal
saline to maintain adequate hydration. If the patient is unable
to swallow during the first few days, a nasogastric feeding tube
is inserted. The patient requires nutrients if they are going to
heal. The RD is responsible for calculating the nutritional needs
of the patient. The appropriate enteral feeding formula is chosen and monitored by the nurses and RD (Lindsay et al., 2008).
Blood glucose assessment
Knowledge. Diabetes mellitus is a major risk factor for stroke
and up to one third of all stroke patients admitted to hospital have diabetes mellitus (Laird, 2014). The acceptable blood
glucose parameters for a patient with hyperglycemia are levels
between 7 mmol/L and 10 mmol/L (Jauch et al., 2013). Hyperglycemia is also associated with increased risk of hemorrhagic
transformation (hemorrhage after t-PA or ischemic stroke), as
well as a risk of a future stroke (Laird, 2014). Hyperglycemia
is associated with the stress response, inflammatory response
and any pre-existing glucose abnormality (Jauch et al., 2013).
Administering glucose solutions is contraindicated in this
patient population, as high blood glucose levels have a detrimental effect on neural tissue following an acute brain injury
(Summers et al., 2009; Jauch et al., 2013). Similarly, hypoglycemia is undesirable, as it mimics stroke-like symptomology
(Summers et al., 2009). Measuring the patient’s hemoglobin
A1C (HbA1C) may help gauge blood glucose abnormalities
occurring in the three months prior to the stroke.
Skill. All patients admitted with a suspected stroke should have
their blood glucose checked immediately (Lindsay et al., 2008).
Hypoglycemic and hyperglycemic episodes should be avoided.
As a result, frequent blood glucose monitoring is necessary (Allport et al., 2006; Summers et al., 2009). Any hypoglycemic or
hyperglycemic episodes should be treated (Lindsay et al., 2008).
Lipid management
Knowledge. Fasting serum lipid levels should be measured on
all patients who experience stroke (HSF, 2014). High cholesterol levels lead to plaque build-up in the arteries (atherosclerosis), which causes narrowing of the artery lumen and leads
to elevated BP (Anderson et al., 2013). To maintain the LDL
cholesterol level below 2.0 mmol/L (the recommended level)
many patients require a lipid lowering medication, usually a
statin (HSF, 2014). The RD also educates the patient on dietary
changes that could be helpful in decreasing sources of ingested
cholesterol.
Skill. The nurse needs to ensure a proper fasting lipid test
occurs and that the patient receives the appropriate teaching about the lipid lowering medication and its potential side
effects.
Language and speech
Knowledge. Nurses need to develop effective expertise and
communication skills to assess the patient’s ability to communicate. This is especially significant when the patient has suffered a left hemispheric stroke, as the major language centres
are located in the left frontal (Broca’s area) and left temporal
(Wernicke’s area) lobes (Hickey, 2009). The type of aphasia
can vary from being specific to more global, depending how
much brain tissue is involved. Broca’s aphasia is when the person has problems converting thoughts into meaningful language (expressive aphasia), while an individual with Wernicke’s
aphasia has impaired comprehension of the language (receptive aphasia) and can pronounce the words, but they usually
make no sense (Hickey, 2009, p. 118). If the stroke is extensive,
with a large portion of the brain being damaged, the person
may suffer a global aphasia where both major language areas
are affected (Hickey, 2009, p. 118). Apraxia and dysarthria are
motor speech disorders characterized by disruptions or abnormalities of movement parameters (Duffy, 2008; Hickey, 2009).
Skill. Recognizing what area of the brain is involved and interacting with the patient allows the nurse to identify issues that
the patient is having with the understanding, translation and
expression of thoughts into speech. The clarity of the patient’s
speech aids the nurse in the accuracy of her assessment. Collaborating with an SLP assists the nursing staff to reduce
communication challenges: the use of gestures, augmentative
communication devices and eye movements can aid the health
care team in identifying the patient’s needs.
Urinary continence care
Knowledge. Establishing a baseline for urinary continence
begins on admission by determining the patient’s urinary
function prior to the stroke, including issues with dribbling,
incontinence or difficulty starting their stream (Woodward,
2013a). Between 40% and 60% of all people admitted to hospital following a stroke experience urinary incontinence and 15%
continue to experience incontinence at one year (Thomas et
al., 2009; Woodward, 2013a, p. 31). The problem is either with
the storage of urine (incontinence) or emptying of the bladder (retention) (Woodward, 2013a, Woodward, 2013b). If the
patient is unable to void on their own, intermittent catheterization every six hours may be required to help stimulate normal
physiological filling and emptying of the bladder (Summers et
35
al., 2009). The bladder scanner, a non-invasive handheld ultrasound device, is useful in determining the amount of urine in
the bladder, both before voiding or post-void residuals (Lindsay,
2008). Nurses need to be taught how to properly use a bladder
scanner. The use of indwelling urinary catheters is discouraged,
as they contribute to urinary tract infections (Lindsay, 2008;
Summers et al., 2009).
Skill. To deal with these issues, patients can be taught pelvic floor exercises, and encouraged to participate in bladder
training, either through prompted voiding or timed voiding
(Woodward, 2013b). Pharmacological interventions are available if the bladder training and pelvic floor muscle exercises
are not effective alone (Woodward, 2013b). Bladder scans and
intermittent catheterizations are performed as indicated on
the stroke order set if the patient is unable to void or has a high
post-void residual (greater than 150 mL) (APSS, 2010; Lindsay
et al., 2008; Woodward, 2013a).
Bowel care
Knowledge. Harari et al. (2004) studied constipation and fecal
incontinence over the 12-month period following stroke; they
found that encouraging daily pelvic floor exercises, the use of
suppositories (instead of laxatives), bulking agents (rather than
stool softeners to avoid anal leakage), increased fluid intake, and
diet all contributed to improved bowel function. Constipation,
which causes straining while having a bowel movement, results
in increased intra-abdominal pressure and ICP and should be
avoided (Hickey, 2009).
Skill. Identifying when the patient had their last bowel movement helps establish any problems. Use of a bowel routine
for constipation or fecal incontinence is suggested for stroke
patients (Lindsay, 2008). Incorporating this knowledge, when
educating the patients and families, is necessary so that
improved bowel function can return over time.
Visual and spatial neglect
Knowledge. Unilateral spatial neglect (USN) is a term used to
describe the inability of the patient to respond, report or orient
with any sensory modality to stimuli that is presented to the
hemibody opposite to the side of the brain lesion (more often
the right brain) (Menon-Nair et al., 2006). Menon-Nair et al.
(2006) report that the incidence of USN is found in approximately 30% of all stroke patients. USN makes it difficult for the
patient to focus on their needs in their personal space (e.g.,
combing hair), near extrapersonal space (within arms’ reach)
and far extrapersonal neglect (beyond arms’ reach) (MenonNair et al., 2006).
Skill. Nurses could use a simple test to check for USN by using
the comb and razor test to evaluate for personal space neglect
(Stroke Engine, 2013). Other recommended tests are the single letter cancellation for near extrapersonal neglect, and the
NIHSS for testing personal and near extrapersonal neglect
(Menon-Nair, Korner-Bitensky & Ogourtsova, 2007; Stroke
Engine, 2013). A member of the interdisciplinary team should
test for USN on their initial assessment.
Cognitive assessment
Knowledge. All stroke patients with hypertension, hyperlipidemia, diabetes, and older than 65 years of age are at a high risk
36
for cognitive and perceptual impairment (Lindsay et al., 2008).
For every patient who exhibits stroke symptoms, there are up
to nine people who have covert strokes that exhibit cognitive
impairment (Bayley et al., 2008). Screening for cognitive impairment using validated assessment tools should be completed to
investigate the cognitive status of the patient (Lindsay et al.,
2008). Areas addressed include: “arousal, alertness, attention,
orientation, memory, language, agnosia, problem-solving, planning, insight and judgement” (Lindsay et al., 2008, p. S17). Two
tests utilized include: Montreal Cognitive Assessment (MoCA)
and Mini-Mental Status Examination (MMSE) (Lindsay et al.,
2008; Hickey, 2009).
Skill. An abbreviated bedside assessment can be done to evaluate the patient’s cognitive function (Hickey, 2009). Higher level
deficits may be more difficult to detect, as the patient may have
devised methods to compensate for any deficiencies (Hickey,
2009). Nursing staff can collaborate with other members of
the interdisciplinary team to identify and implement strategies
that assist the patient and their family members to manage any
cognitive limitations.
Mobility
Knowledge. Regaining mobility is a vital part of the rehabilitation process following a stroke (Lindsay et al., 2008). Activities
involving moving the patient in bed, transferring the patient
from bed to chair, sitting in a chair and walking constitute
mobilizing the patient (Lindsay et al., 2008). To decrease the
complication of pneumonia, venous thromboembolism (VTE),
pressure sores and dislocation of the shoulder, nursing care
needs to focus on skin integrity, careful positioning and handling of the patient when turning and mobilizing, and pressure area risk evaluation (Ringelstein et al., 2013). Falls pose
a considerable safety risk post stroke and it is every health
care professional’s responsibility to assess the patient’s abilities and need for assistance to minimize this risk (Summers
et al., 2009).
Skill. Safely mobilizing the patient as soon as possible for
chair sitting and walking is crucial. Changing the patient’s
position at least every two hours while they are in bed or
in the chair decreases the chances of the patient developing
pneumonia, pressure area or a VTE. Identifying the patients
who are at risk for falling and using appropriate precautions,
mobility aids and levels of assistance are part of the mobility
assessment.
Venous thromboembolism (VTE) prophylaxis
Knowledge. Stroke patients are considered to be at high risk for
developing a VTE because they are paralyzed on one side and
may be immobile (Lindsay et al., 2008; Summers et al., 2009). To
avoid deep vein thrombosis (DVT) and pulmonary embolism
(PE), all patients should be mobilized as soon as possible, be
adequately hydrated, and started on prophylactic subcutaneous
(sc) anticoagulation medication, either low molecular weight
heparin (acute ischemic strokes) or unfractionated heparin
(renal failure) (HSF, 2014, section 4, p. 17; Lindsay et al., 2008).
If the patient has experienced a hemorrhagic stroke, the physician needs to monitor the size of the bleed with additional CT
scans; this ensures no stroke expansion after the patient has
been started on heparin (HSF, 2014, section 4.2.2).
Skill. Daily assessments for deep vein thrombosis (DVT) occur
along with sc heparin or low molecular weight heparin injections, as ordered. This is in addition to encouraging the patient
to mobilize and adequately hydrate.
Post stroke depression (PSD)
Knowledge. Post stroke depression is a frequent and significant
complication following a stroke, affecting both patients and
families (HSF, 2014; de Man-van Ginkel et al., 2013). One third
of all stroke patients exhibit depression at some point during
their recovery period. Therefore, all patients should be screened
during the first few days following a stroke and treated for PSD,
if required (HSF, 2014, section 7.1). Patients with PSD are noted
to have poorer functional recovery and cognitive function; they
have decreased social participation and are at an increased risk
for becoming dependent, rather than independent members of
the community (HSF, 2014). Families and caregivers of stroke
patients are also at risk for depression and as many as 30% to
60% of caregivers experience depression symptoms (HSF, 2014,
section 4.0).
Skill. Recognition of depression in both the patient and families is vital. Communication with team members regarding
depression concerns is important; various members of the team
can perform the depression screen using a depression scoring
test. Education on recognition and management of PSD for all
nursing staff is necessary (HSF, 2014).
Cardiac monitoring
Knowledge. ECG and Holter monitoring are standard assessments following a stroke. These investigations may identify any
arrhythmias that may have gone undiagnosed and need to be
treated (Jeerakathil et al, 2012). Atrial fibrillation is associated
with cardioembolic ischemic strokes. Once identified, patients
are most commonly prescribed anticoagulant therapy for stroke
prevention. The newer oral anticoagulants (dabigatran, rivaroxaban and apixaban) are as effective as warfarin (Coumadin);
however, the risks and benefits for each individual should be
considered when prescribing them (Coppens, Hart & Eikelboom, 2013).
Skill. Observing and reporting the regularity of the pulse when
taking the vital signs and ensuring the Holter monitor and ECG
are completed is necessary to assess for any abnormalities. Providing patient education regarding ongoing anticoagulant use
is important.
Diagnostic Imaging Tests (DI)
Neuroimaging and diagnostic investigations include: CT scan,
cerebral angiography, MRI, carotid Doppler and echocardiogram. These tests are critical to the diagnosis and determining
the etiology of the stroke (Jeerakathil et al, 2012; Summers et al.,
2009). Explaining each of the tests to the patient and family is
important and contributes to developing a trusting relationship
with the patient and family.
Nurse’s role in education of patient and family
The sudden signs and symptoms of a stroke are considered a
medical emergency (HSF, 2014). It is essential that patients
and families are educated about stroke and are able to recognize and respond to the signs and symptoms of acute stroke.
Understanding the modifiable risk factors associated with
stroke is important for secondary prevention (Cameron, 2013;
Dombrowski et al., 2013; Justice et al., 2008). This is especially
important in improving public awareness and ensuring a quick
response if symptoms recur (Cameron, 2013; Dombrowski et
al., 2013; Justice et al., 2008). The risk factors to be discussed
include: hypertension, diabetes, dyslipidemia, cardiac disease,
smoking, excessive alcohol consumption, drug abuse, obesity
and physical inactivity (Graham, 2008; Jeerakathil et al, 2012).
Interactive discussion with the patient and families is desirable
to review the risk factors related to stroke and to ensure transfer
of knowledge about the patient’s progress; the goal is to lessen
the occurrence of another stroke (Cameron, 2013; Lindsay et al.,
2008). It is necessary to educate the patient and family regarding
the current medications (benefits and side effects) the patient
is taking (Graham, 2008).
Rehabilitation
Discharge planning and rehabilitation begin on admission on
the clustered stroke unit with the use of an interdisciplinary
team (Lindsay et al., 2008). The smooth transition from the hospital to home involves effective discharge planning (Summers et
al., 2009). Improved patient outcomes are dependent on having
support systems, both family and community, in place for the
patient when discharged (Summers et al., 2009). For patients
not needing in-hospital rehab, the Early Supported Discharge
(ESD) program is valuable; an interdisciplinary team treats the
patient in their home environment for five days a week (HSF,
2014, section 5.4.2). This program has shown to be a cost-effective method of discharging the patient to their home with
therapy supports (Langhorne et al., 2013).
Palliative care
In the initial phase, all stroke patients should have access to
acute stroke care, whether on a dedicated or clustered unit
(Burton & Payne, 2012). When it is identified that the patient
experiencing stroke is not going to survive the devastating
event, palliative care then becomes necessary (Burton & Payne,
2012; Cowey, 2012; Payne et al., 2010). Palliative care needs
to be integrated within the acute stroke care model (Burton
& Payne, 2012). Palliative care encompasses the time period
months before death, while end-of-life is the component of palliative care when death is imminent (Cowey, 2012). Planning
for palliative care with patients who experience a sudden acute
stroke and die within the first 30 days is difficult to prepare for,
as it is such an unexpected event for the patient and family
(Payne et al., 2010). In 2011–2012, the 30-day mortality rate
post-stroke was 17.9% in Canada (HSF, 2014). According to the
qualitative study by Payne et al. (2010), families want their loved
ones to die in peace and with dignity. In order for nurses to be
effective in palliative care treatment, education and training has
to be provided that incorporates the integration of palliative
care on an acute stroke unit (Burton & Payne, 2012).
Discussion
Patients who experience stroke take a high-priority status in
treatment requiring a skilled nursing and interdisciplinary team,
as the sudden signs and symptoms of a stroke are considered
a medical emergency (HSF, 2014). The majority of patients do
not present early enough to receive the clot buster (t-PA) drug.
Therefore, care provided on an acute designated stroke unit or
37
clustered within a general medical unit can significantly impact
the survival and reduction of disability and length of stay (LOS)
for patients (Stavem et al., 2011). Acute care focuses on stabilizing the patient, as well as preventing deterioration and medical
complications during the first few days following for either an
ischemic or hemorrhagic stroke (HSF, 2014).
Improved patient outcomes occur when proper acute stroke
care is provided (McCann, Groot, Harnley & Gardner, 2009;
Saposnik et al., 2011). It is the responsibility of the nursing staff
to apply the nursing skills and knowledge in a timely manner to
ensure patient outcomes are optimised (HSF, 2014). All nurses
require certification in the NIHSS and TOR BSST (swallow
screen) as part of their qualifications to work on a clustered
stroke unit. To be effective, medical units providing care for
clustered stroke patients need skilled nursing staff who collaborate closely with an interdisciplinary team (Brooke & Walia,
2013; Langhorne et al., 2013). The focus of this interdisciplinary
team is early rehabilitation and incorporation of a number of
complex interventions, management of physiological variables
such as vital signs (BP, pulse, respiratory function and oxygenation), hydration and nutrition, early swallow screen, and early
mobilization (Brooke & Walia, 2013; Langhorne et al., 2013).
An awareness of the complications that can occur following
a stroke is necessary; care is directed towards preventing or
reducing those complications. Jeerakathil et al. (2012) states
that the most common complications include: “pneumonia,
urinary tract infections (UTI), falls, seizures, decubitus ulcer
and VTE” (p. 54). The factors that contribute to variations in
outcome, reduced hospital stay, rehabilitation in hospital, early
supported discharge program and death require specialized
training and expert knowledge to prepare the nurse to deal
with these type of outcomes. Knowledge and skills requisite for
optimal care of the clustered stroke patient are extensive and
described under the review of the literature.
In addition, admission to a stroke unit significantly contributes to reducing the social and economic aspects of the burden
of stroke (Di Carlo et al., 2011). The financial burden is high
with both direct costs (costs around hospital and rehabilitation
care) and indirect costs (loss of productivity and future earnings) (Summers et al., 2009). Having dedicated stroke care has
been found to be cost effective, primarily due to the decrease
in length of hospital stay, improvement in patient outcomes
and decrease in long-term care costs (Jeerakathil et al., 2012;
Langhorne et al., 2013). Alternatively, a clustered stroke care
model (providing care to four or more patients “clustered” on a
medical unit), may also impact that financial burden by decreasing costs with skilled nursing staff and a dedicated interdisciplinary team.
Keeping the communication open with the patient and family
by being honest and transparent in all areas of the care is crucial. Stroke is such an unexpected and devastating event for
both the patient and family; effective communication with the
patient and family impacts the overall experience. Palliative and
end-of-life care are areas where nurses specialized in stroke
care can greatly assist the family in dealing with the death of
their loved one.
Dedicated and organized stroke unit care is ideal, but it is
not always possible. Having well trained and skilled nursing
staff specialized in stroke care improves patient outcomes
following stroke. Whenever possible, having stroke patients
clustered on a general medical unit with nurses who have the
specialized nursing knowledge and skill sets, improves patient
outcomes, decreases LOS in hospital and has the greatest
opportunity of returning the patient home as a functioning
member of their community. The hope is a positive outlook
for such a devastating disease.
Funding
No funding was received for this review.
Conflict of Interest
There is no conflict of interest to declare.
Acknowledgements
An earlier version of this manuscript was completed as part of
the Master of Nursing program.
Many thanks to the interprofessional team members who
reviewed their areas of expertise in the paper:
Laura Sansom, Respiratory Therapist
Simon Kruithof, Physiotherapist
Victoria Christiansen, Registered Dietitian
Kari Granlund, Speech Language Pathologist
Conclusion
Based on the literature review, clustered stroke patients on
general medical units with nursing staff trained in stroke care
would likely improve patient outcomes over what is achievable on general medical units with nurses with no specialized
training. When patients are treated on either a dedicated stroke
unit or clustered stroke unit, they are more likely to survive the
stroke, regain independence and return home compared with
those patients who are not treated with specialized care (Stroke
38
Unit Trialists’ Collaboration, 2013). Some of the areas of particular importance include: NIHSS certification, TOR BSST (or
similar swallow screen certification), neurological assessment,
preventing complications by providing hydration and nutrition,
monitoring hypertension, temperature, blood glucose, ensuring
mobility and proper positioning, educating the patients and
families on the disease process, treatment, rehabilitation processes and patient progress. Having a dedicated stroke unit may
not be practical or feasible because of population distribution,
particularly for smaller urban and rural communities. Therefore, educating nurses on the general medical units to provide
care to clustered stroke patients requires specific skill training.
Leah McCorkill, Speech Language Pathologist
Tamsen Prochnau, Pharmacist
Joanne Angelstad, Registered Nurse
Dr. Donald Holmes, Radiologist
Dr. Jennifer Bestard, Neurologist
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Retrospective analysis of phone queries to an
epilepsy clinic hotline
By Anny Laforme, RN, BNI, Suzie Jubinville, RN, Micheline Gravel, RN, BScN, Patrick Cossette, MD, PhD, FRCPC, and Dang K.
Nguyen, MD, PhD, FRCPC
Abstract
We undertook a retrospective study of 5,189 telephone calls
made between January 2004 and June 2011 through our adult
epilepsy clinic hotline to a single epileptologist initially and two
epileptologists from June 2010 onwards. The majority of calls
were made by patients themselves (72%), followed by family
members (16%) and health care providers (11%). Half of the
calls originated from outside the city limits. Most were related to
Analyse rétrospective des questions
posées au service d’assistance
téléphonique d’une clinique d’épilepsie
Résumé
Nous avons entrepris l’étude rétrospective de 5 189 appels
téléphoniques effectués entre janvier 2004 et juin 2011 par
l’intermédiaire du service d’assistance téléphonique d’une
clinique d’épilepsie à un seul épileptologue d’abord, puis à deux
épileptologues à compter de juin 2010. Les appels ont été faits
Introduction
Epilepsy is a chronic condition characterized by recurrent,
spontaneous seizures resulting from abnormal and excessive neuronal discharges (Engel & Pedley, 2008). Long-term
drug therapy is the most common treatment form, but finding
antiepileptic drugs that provide adequate seizure control with
minimal or no side effects may warrant several drug modifications or dose adjustments. This is especially true for a subset
of patients, labelled as pharmaco-resistant or drug-refractory,
who have failed at least two adequate trials of antiepileptic
drugs and for whom the chances of complete seizure control
with additional drug trials are relatively low (Kwan & Brodie,
2000). For these patients, alternative treatments, such as epilepsy surgery or vagus nerve stimulation, may be considered.
Uncontrolled seizures are not only a major personal handicap,
but also represent a considerable public health burden due to
high use of health-care resources and high numbers of disability days or unemployment (Tellez-Zenteno, Pondal-Sordo,
Matijevic, & Wiebe, 2004; Wiebe, Bellhouse, Fallahay, & Eliasziw, 1999). Furthermore, chronic epilepsy generally impairs
cognition, most severely in patients with early onset in life and
poor seizure control (Elger, Helmstaedter, & Kurthen, 2004).
The presence of an epilepsy nurse can significantly improve the
care of epileptic patients, notably by enhancing the communication of information, providing advice on lifestyle issues, making
drug therapy adjustments, ensuring empathic listening and augmenting treatment compliance (Mills, Bachmann, Campbell,
Hine, & McGowan, 1999; Mills, Campbell, & Bachmann, 2002;
Ridsdale, Robins, Cryer, & Williams, 1997; Scambler, Scambler,
medication (25%), notification of seizures (23%), appointments
or tests (12%), and side effects (9%). Half of the workload was
generated by 10% of patients. The hotline service appears to
respond to needs, with most calls requiring rapid intervention.
It is desirable to develop novel approaches to address the needs
of high-frequency callers.
Key words: epilepsy, clinic, nursing, telephone, hotline
majoritairement par les patients eux-mêmes (72 %), puis par
les membres de la famille (16 %), suivis des fournisseurs de
soins (11 %). Un appel sur deux provenait de l’extérieur de la
ville. La plupart d’entre eux portaient sur la médication (25 %),
puis la manifestation d’une crise (23 %), les rendez-vous et les
examens (12 %) et les effets secondaires (9 %). La moitié de la
charge de travail était occasionnée par 10 % des patients. Le
service d’assistance téléphonique semble répondre aux besoins,
en notant que la majorité des appels nécessitent une intervention
rapide. Il est souhaitable d’élaborer des approches novatrices en
vue de répondre aux besoins de ceux qui appellent fréquemment.
Ridsdale, & Robins, 1996; Taylor et al., 1994). The epilepsy nurse
also enables the clinic to operate an efficient epilepsy hotline. In
other specialties, the telephone has been used for several purposes: a) to follow up on patients with chronic illness (Azzolin et
al., 2013; Schneider, Adams, & Gosselin, 2014; Smits et al., 2014),
patients who have recently been discharged from the medical
(Miller & Schaper, 2014), surgical (Darcy, Murphy, & DeSanto-Madeya, 2014) or obstetrical ward (Dennis, 2014; Dennis et
al., 2009); b) to provide education related to the patient’s specific
condition (Chan et al., 2014; Jarl, Tolentino, James, Clark, & Ryan,
2014); c) to reinforce adherence to treatment (Aliha et al., 2013;
Lourenco et al., 2014); and d) to support caregivers (Kwok et al.,
2013; Martindale-Adams, Nichols, Burns, Graney, & Zuber, 2013).
As seizures and side effects are unpredictable, the epilepsy clinic
hotline can respond with rapid at-home medication changes, thereby reducing the need for clinic or emergency room visits (considering the well-known difficulty of obtaining a clinic appointment
on short notice) (Foley, Oates, Mack, & Fox, 2000). Furthermore,
the epilepsy nurse may also address various call issues, such as
prescription refills, test scheduling or results, management of
non-seizure-related problems such as co-morbidities (e.g., anxiety,
depression) or other conditions (e.g., change in contraception, pregnancy issues, surgical interventions), information on the disorder
and its treatment. Prompt interventions are likely to reduce the
risk of complications (e.g., unwanted pregnancy, breakthrough
seizures) and improve quality of life. To our knowledge, however,
the reasons for calls to epilepsy nurses have not previously been
examined. In this study, we retrospectively analyzed all phone calls
made to our epilepsy clinic over a period of seven years to identify
user profiles and the reasons for their calls.
41
Methods
We retrospectively reviewed all telephone calls received
between January 1, 2004, and June 4, 2011, at a tertiary academic epilepsy centre. Although the clinic is run by four epileptologists, only calls placed to a single epileptologist (DKN)
initially and then to two epileptologists (DKN, PC) after June
2010 were analyzed, because messages had not been systemically documented and stored by the others. Messages received
from 2004 to 2010 were collected as written note-messages by
phone clerks. From June 2010 to June 2011, calls were directed
to the epilepsy nurse. The epilepsy clinic hotline is open Monday through Friday from 8:30 a.m. to 4:30 p.m. Outside working hours or when the line was busy, the patient could leave
a message on the nurse’s voice mail. These calls were documented on a standard nurse sheet and stored in the patient’s
electronic chart. The general mode of operation of our epilepsy clinic hotline is as follows: contact information for the
epilepsy clinic hotline (telephone and fax numbers) were usually
provided to all patients attending the clinic (and/or accompanying family members/caregivers) in the form of a business
card with instructions to call for any breakthrough seizures or
drug side effects. Messages are generally taken and answered
within 24–48 hours, depending on the level of urgency. When
the issue could be easily resolved by the nurse (e.g., questions
related to driver’s licence, referrals to community resources
or support groups, general questions on seizure triggers, and
lifestyle issues, etc.), the attending physician was only briefly
notified during weekly working sessions. If the caller’s problem
required the input of the epileptologist, the nurse gathered the
pertinent information (e.g., number of seizures, type of seizure, circumstances of seizure, current medications, treatment
compliance, abuse of drugs or alcohol, drug information including side effects, etc.) and discussed the case with him. Once a
course of action was determined, the nurse would then inform
the patient of the proposed plan and the follow-up process, if
necessary. New prescriptions were faxed to the patient’s pharmacy when drug changes were required.
For each call (when possible), one of the authors (AL) determined the caller’s identity, the patient’s identity (if different),
his/her age, place of residence by geographic region, call date,
call time and reason for call. Reasons for calling were classified
in seven categories (established based on prior personal experience): a) notification of seizure(s); b) notification of side effects;
c) general questions on epilepsy or epilepsy surgery; d) questions about antiepileptic drug therapy other than notification
of side effects (e.g., general information on drugs, timing of
drug administration, rapidity of titration, dosage, possible
drug interactions, renewal of expired medication prescription, reporting of self-medication changes, trouble paying for
drugs, generic substitutions, etc.); e) requests to fill in medical forms; f ) appointment or test scheduling or results; and
g) miscellaneous.
Results
Between January 1, 2004, and June 4, 2011, we received 5,189
calls from 1,232 patients with a mean of 58 calls per month. The
number of calls per month varied throughout the year, with
the fewest calls received during holiday seasons. The busiest
calling time window was between 10 a.m. and 12 noon. While
some patients only made one call over the six-year period,
others called up to 89 times during the same period. Almost
half the workload (n=2,375/5,189; 46%) was generated by 10%
of patients (n=117/1,232), ranging from 11 to 89 calls during
this 89-month period (Table 1).
Figure 1: Histogram of callers’ ages. Age groups (in years)
are plotted on the x-axis and frequencies on the y axis
Table 1: Workload according to number of calls per person
Categories based on
number of calls during a
period of 89 months
Number of
patients per
category
Percentage of total
callers per category
Total number of calls
answered (workload)
per category
Percentage of
workload generated
per category
1
562
45.62%
562
10.83%
2-5
418
33.93%
1,226
23.63%
6-10
135
10.96%
1,025
19.75%
11-15
56
4.55%
714
13.76%
16-20
22
1.79%
391
7.54%
21-30
23
1.87%
565
10.89%
31-50
13
1.06%
499
9.62%
51 +
3
0.24%
206
3.97%
42
Caller characteristics
Caller identity was available for 3,704 of the calls (71%). The
majority of calls were made by patients themselves (72%), followed by family members (16%), health care providers (11%)
and others (1%). Mean age of patient callers was 39 years (determined from 991 patients), with 32% of patient callers being
20–30 years old and 22% 40–50 years old. Calls made by family
members and professionals mainly concerned patients in the
20–30-year-old age group (40.74% and 34.18%, respectively)
(Figure 1). Calls originated from 17 demographic areas, half
from the hospital urban area (49%) and the remainder from
the rest of the province.
Reasons for calls
Reasons for calling could be identified for 3,904 of the calls
(75%). Most of the calls were related to medication (25%) and
notification of seizures (23%), followed by questions about
appointments or tests (12%), notification of side effects (9%),
medical forms (8%) and general questions about epilepsy or
epilepsy surgery (3%) (Figure 2). The main reason for calling
differed, depending on the category of caller: while patients
and health care providers primarily called with questions
concerning medications (440/2,000; 22% and 166/282; 59%,
respectively), family members mainly called for seizure notification (27%) (Figure 3).
Discussion
Our study revealed that the epilepsy clinic hotline is a service
used by patients, family members and health care providers.
The majority of calls required rapid intervention (i.e., related to
seizures or medication). Half of the calls were made by patients
Figure 2: Histogram of reasons for hotline use by patients
(blue), family members (red) and health professionals
(green). Main reasons are plotted on the x-axis and
frequencies on the y axis
living outside the city limits. Finally, close to half of the hotline
workload was generated by 10% of patients. To our knowledge, this is the first time such a quantitative analysis of calls
made to an adult epilepsy clinic has been performed. A previous study explored 208 calls to a telephone nursing line over
a two-week period, but in the setting of a pediatric neurology
clinic (Letourneau et al., 2003). It is noteworthy, however, that
the most common patient diagnosis in that investigation was
epilepsy (63.5%), indicating that the particular nature of the
disorder (unpredictability of seizures, severity and frequency
of disease manifestations in some patients, high number of
treatment options, etc.) requires such a service. Using a questionnaire sent to 193 patients, another study looked at reasons
for contacting the epilepsy nurse service at a tertiary centre
(Hosking, Duncan, & Sander, 2002). Authors found that the
main discussion topics were medication side effects (59%), general epilepsy issues (45%), worsening seizures (31%), support
(23%), surgery (18%), pregnancy issues (9%) and employment
(5%). These findings, though obtained in a different way, are in
line with our observations.
In our study, the mean number of calls per month was 58. Considering that the study was limited to analyzing calls to a single
epileptologist for most of the study period, we can safely deduce
that the frequency of calls per month would have been much
higher had we recorded the calls made to other epileptologists
in the group. A significant numbers of calls came from outside the city limits, which could be explained by the tertiary
nature of our clinic, the lack of resources in rural regions, and
the convenience of long-distance calling by patients living far
from the clinic.
Implications for nursing practice
The high number of calls confirms the importance of an epilepsy clinic hotline and, indirectly, the importance of the epilepsy nursing specialist who directs it. Responding to telephone
calls is time-consuming, but vital to ensure continuous patient
care. Indeed, the task may require several actions such as
Figure 3: Pie chart of hotline callers’ identity
43
playing phone tag, obtaining the necessary information from
the patient or caretaker, discussing the problem at hand with
the treating physician, explaining to the patient or caretaker
the plan of action and communicating with the pharmacy to
modify the treatment. Several reports have already described
how epilepsy nursing specialists play an integral part in the provision of care to epileptic patients by making the link between
them and their epilepsy specialist, implementing medication
changes without undue delay between regular visits, educating
patients and family members on epilepsy in general, and helping them overcome the stigma of epilepsy (Bradley & Lindsay,
2001; Couldridge, Kendall, & March, 2001; Goodwin, Higgins,
Lanfear, Lewis, & Winterbottom, 2004; Helde, Bovim, Brathen,
& Brodtkorb, 2005; Hosking et al., 2002; Rajpura & Sethi, 2004;
Ridsdale, Kwan, & Morgan, 2003). Although this cannot be verified with these data per se, it is likely that the epilepsy clinic
hotline prevented some emergency room visits, patient hospitalizations or adverse events from prescription errors, considering that the main reasons given for calling were related to
seizures or medication requiring prompt intervention.
Limitations
The main limitation of our study lies in its retrospective nature.
Information collected was not obtained in a systematic manner. Hence, the data originated mainly from calls by patients
followed by only one of the epilepsy specialists running the
clinic. Furthermore, caller identification, relationship to patient
and reasons for calling were not available for some patients.
There was no documentation of the amount of time spent on
calls, the amount of work generated (sifting through patients’
medical charts, discussions with other health care professionals, writing letters, etc.), how many of these calls were subsequently discussed with the epilepsy specialist, or how many
outgoing calls these index calls generated. Finally, we did not
assess whether interventions prevented emergency room visits
or hospitalizations. While the retrospective nature of this study
is a limitation, we feel the data presented could still contribute to understanding the profiles and motives of adult epilepsy
clinic hotline users and the associated workload.
Future research
A prospective study is currently underway to confirm our
observations and answer additional questions that have
stemmed from this retrospective work, while addressing some
of the limitations mentioned above. Such work is bound to
help improve the organization of the clinic and our provision
of care to epileptic patients. For example, if one of the main
motives for calls by patients or caregivers is to obtain additional
information on the antiepileptic drugs that were prescribed,
this could change the way physicians provide information during clinic visits or push for the development of leaflets to be
given out at the end of the visit. If one of the main reasons to
call is related to comorbidities of epilepsy, this could promote
the more widespread use of self-report questionnaires such
as the Beck Anxiety Inventory or the Neurological Disorders
Depression Inventory for Epilepsy at the clinic. Understanding
the various motives and how frequently these motives lead to
a visit to the emergency room if not addressed in time could
lead to recommendations on response times for each of these
motives. One of the most interesting findings was that close
44
to half of the epilepsy clinic hotline workload was generated
by 10% of patients. Further work on this particular subset of
callers is necessary to identify factors associated with their
high calling frequency: is it related to disease severity (seizure frequency or type), psychiatric co-morbidities, socio-economic status, level of familial or social support, etc.? Such an
analysis could lead to more specific interventions designed
to address the needs of these patients. For example, it may
very well be possible that the main reason why some of these
patients call so often is related to a lack of social network, a
personality disorder, psychological distress, cognitive deficits,
poor compliance, financial issues or substance abuse problems
rather than the seizures themselves, and that addressing these
issues is more profitable than simply changing their antiepileptic regimen. Potential solutions could then include, among
other things, the involvement of support groups, home visits
by nurses or social workers and educational epilepsy nursing interventions. The fact that the main motive for calling
differed between patients, who called mainly with regard to
medications, and family members, who mainly used the hotline
mainly for seizure notification, may suggest that such educational interventions should be adapted to the particular target
audience. For example, patients may possibly require more
education on the treatment and day-to-day management of
their condition, while family members need more information regarding their relative’s condition. Ideally, the outcome
of measures that would be put in place and patient satisfaction
with the service would need to be assessed as well.
Conclusion
Our epilepsy clinic hotline is frequently used by patients, family
members and professionals for reasons generally related to
seizures and antiepileptic medications. A prospective study
is underway to confirm our observations and assess whether
interventions stemming from these calls can prevent emergency room visits or hospitalizations. It will also give us more
details on the small subset of high-frequency callers responsible
for a large portion of the hotline workload so that additional
strategies aside from medication adjustments can be put in
place to better address their needs, whether for further education, psychological support, home visits, day centre or other
measures.
About the authors
Anny Laforme, RN, BNI
Suzie Jubinville, RN
Micheline Gravel, RN, BScN
Patrick Cossette, MD, PhD, FRCPC
Dang K. Nguyen, MD, PhD, FRCPC, Centre hospitalier de
l’Université de Montréal (CRCHUM) – Hôpital Notre-Dame,
Montreal, Quebec
Address for correspondence: Dang Khoa Nguyen, 1560
Sherbrooke St. East, Montreal, QC H2L 4M1
Phone: 514-890-8237
Fax: 514-412-7554
Email: [email protected]
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45
Second call for abstracts
The theme for 2015 is Rock with CANN in Newfoundland
The Newfoundland and Labrador Chapter of CANN invites you
to share in our efforts to showcase the important work neuroscience nurses do every day across the health care settings. The 46th
meeting of the Canadian Association of Neuroscience Nurses
will be held June 23–26, 2015, in St. John’s, Newfoundland.
The conference will take place at the Sheraton Hotel Newfoundland
in historic downtown St. John’s. St. John’s is the provincial capital
and is the perfect combination of big-city luxury and small-town
charm. As the oldest and most easterly city in North America, this
is where heritage lives. Melded with culture, history, and personality, St. John’s has survived two World Wars, five centuries, countless
hardships and triumphs. It’s become a rare, old city full of character,
experience and charisma, with a contemporary, sophisticated edge.
We invite you to share with an audience from across Canada
and beyond, your:
• best practices
• successes
• original research
• case studies
• literature reviews
• quality improvement projects and
• proven treatment, nursing techniques.
Abstract guidelines and template are available on the CANN
website: http://cann.ca.
Additional notes
Please note the deadlines associated with these awards.
Requirements for preparing abstracts:
1. On a single page, the abstract must describe the central
theme of the paper, workshop or poster. Maximum length
200 words or fewer.
2. Type your name and the title of your poster or presentation
or workshop on the top of the page. The first author should
be the person presenting the paper, workshop or poster.
Submit a second copy of the abstract with the title only.
Do not include any names on this second abstract. A blind
review process is used for abstract selection.
3. Indicate the following on the abstract page:
i. Intended level of audience (basic, advanced, or all
participants).
ii. Intended subspecialty (e.g., pediatrics, neurology, neurosurgery, neuro-critical care, etc.).
iii.Preferred format of your session (plenary, concurrent,
workshop or poster).
4. Send the following via e-mail only:
Microsoft Word files:
i. One file of the completed abstract with title and author
ii. One file of the completed abstract with title only
iii.One file with curriculum vitae for each presenter
iv. One file with authors’ information and audiovisual
requirements
v. Your return email address
5. If you wish your abstract to be considered for one of the
awards available, please indicate this with your initial submission. Details of the awards available are at www.cann.ca,
or speak with your local chapter councillor.
46
Please forward the above to: NL Scientific Chair Jessica Milley
at: [email protected]
Acknowledgement of receipt of any files or communication will
be sent via email soon after receipt. If you do not receive this
acknowledgement, or if you need to communicate with Jessica
Milley, please contact her at the above email.
Deadline for abstract submissions:
January 1st, 2015: All abstracts for paper and workshop presentations must be received.
January 1st, 2015: All abstracts for poster presentations must
be received.
January 1st, 2015: Intent to submit an application for the Codman Award, Brain Tumour Foundation Award, or Medtronic
Award must be received (see below for further information on
requirements for these awards).
Additional Guidelines for Workshop Submissions: please
indicate
1. The desired length of the workshop (i.e., half a day or one
day);
2. The desired minimum and maximum number of workshop
participants
3. Learning objectives for the workshop (to be included in
abstract submission; please refer to Requirements for Preparing Abstracts or online www.cann.ca)
4. AV equipment, room set-up, and other logistic constraints
5. Refreshments and/or meals, name of sponsor(s)
6. Handouts and/or any learning materials required are the
responsibility of the workshop organizers.
Additional Notes and Award Guidelines
Canadian Journal of Neuroscience Nursing has the first right of
refusal for the publication of the Mary Glover, Codman Award,
Brain Tumour Foundation, and Medtronic Award papers presented at these scientific sessions.
All presenters must register for the conference, at least for the
day of their presentation, and pay the applicable registration
fee.
Award, Bursary or Scholarship
Guidelines Codman Award
$1,500.00 from Codman.
The Codman Award will be presented to the author or authors
of a written paper that demonstrates the achievement of excellence in the area of neuroscience nursing research. It is expected
that the money will be used for professional development.
ELIGIBILITY
1. At least one of the author(s) is a general/honorary member of the Canadian Association of Neuroscience Nurses
(CANN) and was a general/honorary member in the preceding year.
2. The author(s) stipulates in writing the intention to seek
the award by the call for abstracts deadline; the deadline is
November 1 each year.
3. The author(s) is prepared to present the paper at the CANN
Annual Meeting.
4. The paper contains original work by the author(s).
5. The paper may be an adaptation from a previous work by
author(s); this must be stated.
6. The award may not be presented to the same author(s) two
consecutive years.
CONTENT
1. The paper is written according to the manuscript guidelines
for publication.
2. The author(s) presents a logical development of ideas based
on scientific evidence.
3. The author(s) demonstrates creativity and originality.
4. The paper has implications for neuroscience nursing practice, education, administration or research.
5. The paper is relevant to current trends in neuroscience nursing.
6. The paper demonstrates comprehensive knowledge of the topic.
STYLE
for publication as established by the Canadian Journal of
Neuroscience Nursing.
SELECTION
1. The paper is selected by the Scientific Program Committee
through consultation with the scientific liaison and editor
of CJNN.
2. The Scientific Program Committee reserves the right to
withhold the award if no paper meets the specifications.
3. The Scientific Program Committee must receive papers for
consideration by February 15.
PRESENTATION
1. A representative of the Codman Company at the Annual
Meeting presents the award.
PUBLICATION
1. The completed paper must be submitted to the editor of
CJNN, or designate (e.g., peer reviewer) at the Annual Meeting for publication.
2. The monetary portion of the award will be withheld until
publication in CJNN.
Medtronic Award
$1,000.00 Travel Grant from Medtronic.
The Medtronic Award will be presented to the author or
authors of a written paper that demonstrates the achievement
of excellence in the area of neuromodulation or neuroscience
nursing clinical practice. It is expected that the money will be
used to assist the recipient with travel expenses to attend the
annual meeting to present their paper.
ELIGIBILITY
Annual Meeting.
6. The award may not be presented to the same author(s) in
two consecutive years.
CONTENT
for publication.
5. The paper is relevant to current trends in neuroscience nursing;
6. The paper demonstrates comprehensive knowledge of the topic.
STYLE
for publication as established by the Canadian Journal of
SELECTION
1. The paper is selected by the Scientific Program Committee
through consultation with the scientific liaison and editor
of CJNN.
3. The Scientific Program Committee must receive papers for
consideration by February 15.
PRESENTATION
1. A representative of Medtronic Ltd. will be on hand at the
Annual Meeting to present the award.
PUBLICATION
Brain Tumour Foundation Award
$1,500.00 from BTF of Canada.
The Brain Tumour Foundation Award is presented to a
member of the Canadian Association of Neuroscience Nurses
(CANN) who demonstrates excellence in neuroscience nursing
related to brain tumours. Established in honour of Pamela Del
Maestro, RN, BSc, CANN member and a co-founder of the
Brain Tumour Foundation of Canada, the award includes the
publication of the winner’s paper in the Canadian Journal of
ELIGIBILITY
47
Annual Meeting in the year the award is being presented.
6. The award may not be presented to the same author(s) in
two consecutive years.
7. The author may not be the recipient of any other CANN
awards in the same given year.
APPLICATION REQUIREMENTS
Guidelines:
1. These bursaries are open to registered nurses who have
worked in neurosciences and are members of CANN in
good standing for at least two years.
2. The program or course of study for the Jessie Young Bursary
must have a clear neuroscience focus or component.
3. Successful candidate(s) must agree to write a letter to be
published in the CJNN describing how completion of the
course will advance neuroscience nursing.
CONTENT
1. The paper is approached from a nursing perspective.
2. The paper is relevant to care of patients with brain tumour.
6. The paper is relevant to current trends in neuroscience nursing with brain tumour patients.
7. The paper demonstrates comprehensive knowledge of the
topic.
Application:
A complete application consists of:
1. A completed application form.
2. Proof of acceptance into the educational program or course
of study for which the bursary is being sought, or proof of
registration to write the certification exam.
3. Evidence of amount of registration fees.
4. Proof of current registration with provincial nursing
association.
5. One letter of reference from a person who has had the
opportunity to assess your work. Acceptable referees include:
• another member of CANN
• manager
• educator (institution or hospital).
STYLE
1. The paper is written according to established guidelines for
the writing of a manuscript as per Canadian Journal of Neuroscience Nursing (CJNN) guidelines.
2. The paper shall not exceed 20 double-spaced typed pages.
Application deadline:
1. The closing date for receipt of applications for the Jessie
Young Bursary is April 1 each year.
2. The closing date for receipt of applications for the Certification Award is May 31 of each year.
SELECTION
1. The Scientific Program Committee selects the paper in
collaboration with the editor of CJNN and the Scientific
Liaison.
3. Papers for consideration must be received by the Scientific
Program Committee by February 15 of each year.
Jessie Young Bursary
(Continuing Education) **
CRITERIA FOR THE JESSIE YOUNG BURSARY—
Continuing Education
Beliefs and purpose
CANN believes that post-basic programs/continuing nursing
education (with a neuroscience nursing focus) programs, help
to promote excellence in neuroscience nursing practice. One
of the organization’s main aims is to foster the continuing professional education of members. The Jessie Young Bursary for
study in a Canadian post-basic neuroscience nursing program
provides support for CANN members to pursue their professional growth and contribute to the achievement of excellence
in neuroscience nursing.
PRESENTATION
1. A representative of the Brain Tumour Foundation at the
Annual Meeting presents the award.
PUBLICATION
Jessie Young Awards
• Bursary
• Certification
• Abstract
The Jessie Young Bursary/Certification Award was established to promote continuing professional education in line
with the mission and vision of CANN. These bursaries provide
financial support to qualified nurses to pursue additional training in neuroscience nursing.
48
Program criteria
1. The Program must be offered at a recognized university or
college in Canada.
The participant must:
• be a registered nurse, eligible for registration in the province where the course is offered
• have a minimum of one year’s experience in neuroscience
nursing
• demonstrate acceptance into the recognized program
• clearly state the specific neuroscience nursing focus that
will be studied if in a continuing education program (i.e.,
Bachelor of Nursing)
• must remain a member of CANN for at least one year,
post completion of studies.
MASTER’S DEGREE IN NURSING OR EQUIVALENT
CRITERIA FOR THE JESSIE YOUNG BURSARY
Beliefs and purpose
CANN believes that a master’s degree in nursing or equivalent
with a focus in neuroscience nursing clinical practice, education, consultation, administration, or leadership helps to promote excellence in neuroscience nursing practice. One of the
organization’s main aims is to foster the continuing professional
education of members.
Program criteria
1. The program must be a recognized Master’s of Nursing (or
equivalent) program or a Doctorate in Nursing program
in Canada.
The Participant must:
• demonstrate acceptance into a recognized program
• clearly state the specific neuroscience nursing focus that
will be studied
• must remain a member of CANN for at least one year post
completion of studies.
Jessie Young Abstract Award
The Canadian Association of Neuroscience Nurses established
the Jessie Young Abstract Award to promote continuing professional education in line with the mission and vision of CANN
and to help facilitate the attendance of members at the Annual
Meeting and Scientific Sessions. This award provides funding
for one conference registration from the accepted abstracts for
the Annual Meeting and Scientific Sessions.
Marlene Reimer Research Award
The Marlene Reimer Research Award was established to promote neuroscience nursing research in line with the mission
and vision of CANN. This award provides financial support to
qualified nurses to pursue a research project focusing directly
on neuroscience patient care issues relevant to the scope of
nursing practice in Canada. The amount awarded is determined
yearly. The award may be awarded to one or more individuals
depending on available funds.
1. Research funds will be allocated yearly based on numbers
of requests.
2. Application deadline is November 1 annually.
3. The total Marlene Reimer Research Award be $2,000 plus the
net profit from the Run for Research of the previous year—to
be reviewed annually at the midyear meeting by the BOD.
4. Fundable projects will focus directly on neuroscience patient
care issues.
5. Projects will focus on issues within the scope of nursing
practice in Canada.
6. The primary investigator must be a nurse and an active
member of CANN in the preceding year.
7. A letter of request plus the proposal shall be sent to the
chairperson of the research committee (may be sent
electronically).
8. An additional two copies of the proposal will be mailed electronically to the research chairperson—one copy includes
identifying information (research team members, health
care setting) and the second copy does not include this
information.
9. A letter of support from management/clinical supervisor
describing the contribution of this neuroscience nursing
research study proposal should accompany the application.
10. The research proposal shall include the following:
• title of project
• names and qualifications of the principal and
co-investigators
• purpose of the project
• methodology (including sample, procedures and data
analysis plan)
• evidence of consent by the ethics committee of the institution/agency from which the research subjects will be
selected, if applicable
• budget and time frame
• amount of money requested from CANN.
11. The proposed budget should include the following headings:
• professional services
• supplies
• services
• travel (does not include funding for travel to present findings at annual CANN meeting)
• equipment.
12. Proposals should also include details about other funding
sources, including those confirmed and those pending.
13. The Research Committee will review proposals and notify
the Board of Directors on decisions about funding awards:
• the award will be given to the recipient at the time the
decision is made and official recognition will be given at
the annual meeting luncheon
• those who receive funding shall provide progress reports
to the Research Committee upon request
• the deadline for applications for research funds will be
November 1, and will be published in CJNN
• researchers are expected to publish their results in CJNN
and present them at the Annual Meeting
• researchers must submit a report of their research to the
Research Committee.
CJNN Author Awards
1. All authors who submit a paper that is published in CJNN,
who are not receiving another award (such as Codman,
Medtronic, or Brain Tumour Awards from CANN) are eligible for the New Authors’ Award or General Authors’ Award.
2. New Author is defined as an author who publishes in CJNN
for the first time.
3. Eligible authors’ names will be entered into the separate
draws that will be held at the June meeting.
4. Cheques for $200.00 will be presented to the winners of each
of the two authors’ awards at the Annual General Meeting
in June.
5. The successful authors do not need to be CANN members.
6. Successful authors who are not present at the time of
announcement of the awards will have their award(s) mailed
to them.
7. This reward will come out of the CJNN budget.
8. If there are no new authors in any given year, a second general author award will be drawn from the eligible authors
of the same year.
9. The award will be presented by the editor of CJNN or
designate.
49
Première demande de résumés
Le thème de 2015 est L’ACIIN à Terre-Neuve : à la fine pointe du pays en neurosciences
Le chapitre de l’ACIIN de Terre-Neuve-et-Labrador vous invite
à partager vos connaissances dans le cadre de nos efforts pour
mettre en valeur le travail important qu’effectuent quotidiennement les infirmières et infirmiers en neurosciences dans
divers environnements de soins de santé. Le 46ème congrès
de l’Association canadienne des infirmières et infirmiers en
neurosciences se tiendra du 23 au 26 juin 2015 à Saint-Jean,
à Terre-Neuve.
iv. Un fichier comprenant des renseignements sur l’auteur
ou l’auteure et ses besoins en équipement audio-visuel;
v. Votre adresse courriel.
5. Si vous désirez que votre résumé soit considéré pour l’un
des prix disponibles, veuillez l’indiquer lors de votre soumission initiale. Des informations sur les prix sont à consulter
à www.cann.ca, mais vous pouvez aussi communiquer avec
le conseiller ou la conseillère du chapitre de votre région.
La conférence aura lieu au Sheraton Hotel Newfoundland, dans
le centre-ville historique de Saint-Jean. Saint-Jean est la capitale
de la province et associe à la perfection le luxe des grandes villes
au charme des plus petites localités. Parce que cette ville est la
plus ancienne en Amérique du Nord et celle la plus à l’est, notre
patrimoine national y est omniprésent. Elle combine culture, histoire et personnalité et a survécu à deux guerres mondiales, cinq
siècles, ainsi qu’à d’innombrables épreuves et triomphes. Elle est
devenue une ville ancienne et rare, débordante de personnalité,
d’expérience et de charisme, agrémentée d’une touche contemporaine et sophistiquée.
Faites parvenir les informations susmentionnées à : Jessica Milley, présidente scientifique de T-N, à [email protected]
Nous vous invitons à partager avec des collègues provenant du
Canada entier et d’ailleurs vos :
• pratiques optimales
• réussites
• travaux de recherche originaux
• études de cas
• analyses documentaires
• projets d’amélioration de la qualité
• traitements et techniques en soins infirmiers éprouvés.
Les directives pour la rédaction des résumés et des modèles
sont à consulter sur le site internet de l’ACIIN : http://cann.ca
Remarques supplémentaires
Règlements pour la rédaction d’un résumé :
1. Le résumé doit tenir sur une seule page et décrire le thème
central de l’article, de l’atelier ou de l’affiche. Longueur maximum de 200 mots.
2. Inscrivez votre nom et le titre de votre affiche, présentation ou atelier en haut de la page. Le premier auteur ou la
première auteure inscrit(e) devrait être la personne qui fera
la présentation de l’article, de l’atelier ou de l’affiche. Veuillez
envoyer un deuxième exemplaire de ce résumé en indiquant
seulement le titre. N’inscrivez aucun nom sur ce deuxième
exemplaire. Le choix des résumés se fera à l’aide d’un processus de sélection à l’aveugle.
3. Indiquez les éléments suivants sur la page du résumé :
i. L’auditoire visé (novice, avancé ou tous les participants);
ii. La spécialité visée (p. ex. pédiatrie, neurologie, neurochirurgie, soins critiques en neurologie, etc.);
iii.Le format souhaité pour votre session (plénière, simultanée, atelier ou affiche).
4. Envoyez le document par courriel seulement :
Fichiers Microsoft Word :
i. Un fichier comprenant le résumé avec le titre et l’auteur;
ii. Un fichier comprenant le résumé avec le titre seulement;
iii.Un fichier comprenant le curriculum vitae de chaque
présentateur ou présentatrice;
50
Un accusé de réception des fichiers ou de toute communication
vous sera envoyé par courriel peu de temps après réception. Si vous
n’avez pas reçu d’accusé ou si vous avez besoin de contacter telle ou
telle personne, veuillez les contacter aux adresses courriel ci-dessus.
Dates limites pour la soumission des résumés
1er novembre 2014 : Tous les résumés de présentations d’article ou d’atelier doivent avoir été reçus. Si vous désirez remporter
le prix Codman, le prix de la Fondation des tumeurs cérébrales
ou le prix Medtronic, veuillez le mentionner lors de la soumission de votre résumé.
15 octobre 2014 : Tous les résumés de présentation d’affiche
doivent avoir été reçus.
1er novembre 2014 : Toutes les soumissions pour le prix Codman, le prix de la Fondation des tumeurs cérébrales et le prix
Medtronic doivent avoir été reçues.
Directives supplémentaires en vue de soumettre un
atelier : veuillez préciser
1. La longueur souhaitée de l’atelier (c.-à-d. une demi-journée
ou une journée entière);
2. Le nombre minimum et maximum de participants à l’atelier ;
3. Les objectifs d’apprentissage de l’atelier (à inclure dans la
soumission du résumé; veuillez vous référer aux conditions
à remplir pour la préparation d’un résumé à la page 39 du
journal de l’ACIIN ou en ligne à www.cann.ca) ;
4. Équipement audio-visuel, arrangement de la pièce et autre
contraintes logistiques;
5. Rafraichissements et/ou repas , nom(s) du/des
commanditaire(s);
6. Les documents à distribuer et/ou tout matériel pédagogique
requis sont la responsabilité des organisateurs et organisatrices de l’atelier.
Remarques additionnelles et directives pour les prix
Le Journal canadien des infirmiers et infirmières en neurosciences a le droit de premier refus pour la publication des articles
présentés à ces sessions scientifiques et ayant reçu le prix Mary
Glover, le prix Codman, le prix de la Fondation des tumeurs
cérébrales ou le prix Medtronic.
Tous les présentateurs et présentatrices doivent s’inscrire à la
conférence au moins pour le jour de leur présentation et payer
les frais d’inscriptions applicables.
Prix, bourse ou bourse d’études
Directives
Prix Codman
1 500 $ décerné par Codman.
Le prix Codman sera décerné à (aux) l’auteur(s) ou à l’ (aux)
auteure(s) d’un travail écrit pour son excellence dans le domaine
de la recherche en sciences infirmières en neurosciences. Il est
attendu que l’argent sera utilisé à des fins de développement
professionnel.
ADMISSIBILITÉ
1. Au moins l’un des auteurs ou l’une des auteures est membre
général/honoraire de l’Association canadienne des infirmières et infirmiers en neurosciences (ACIIN) et en était
membre général ou honoraire l’année précédente.
2. L’(les) auteur(s) ou l’(les) auteure(s) doivent stipuler par
écrit leur intention d’obtenir ce prix à la date limite pour les
demandes de résumés. La date limite est le 1er novembre
de chaque année.
3. L’(les) auteur(s) ou l’(les) auteure(s) sont prêts à présenter le
travail au congrès annuel de l’ACIIN.
4. Le travail est un ouvrage original de l’ (des) auteur(s) ou de
l’ (des) auteure(s).
5. Le travail peut être l’adaptation d’un ouvrage précédent
de l’(des) auteur(s) ou de l’ (des) auteure(s); ceci doit être
mentionné.
6. Le prix ne sera pas présenté au(x) même(s) auteur(s) ou à la
(aux) même(s) auteure(s) deux années consécutives.
CONTENU
1. Le travail a été écrit selon les directives de rédaction de
manuscrit aux fins de publication.
2. L’(les) auteur(s) ou l’(les) auteure(s) présentent un développement logique d’idées s’appuyant sur des preuves
scientifiques.
3. L’(les) auteur(s) ou l’(les) auteure(s) font preuve de créativité
et d’originalité.
4. Le travail présente des implications pour des soins infirmiers
en neurosciences, notamment au niveau de la pratique, la
formation, l’administration ou la recherche.
5. L’article reflète les tendances actuelles en soins infirmiers
en neurosciences.
6. Fait preuve d’une grande connaissance du sujet.
STYLE
1. Le travail est écrit selon les directives de rédaction de
manuscrit aux fins de publication conformément aux directives du Journal canadien des infirmiers et infirmières en
sciences neurologiques (JCIIN).
SÉLECTION
1. Le document est sélectionné par le Comité du programme
scientifique après consultation avec l’agent ou l’agente de
liaison scientifique et le rédacteur ou la rédactrice en chef
du Journal canadien des infirmières et infirmiers en sciences
neurologiques.
2. Le Comité du programme scientifique se réserve le droit
de ne pas accorder de prix si aucun article ne répond aux
critères de sélection.
3. Le Comité du programme scientifique doit recevoir les travaux soumis pour le 15 février.
PRÉSENTATION
1. Le prix sera présenté par un représentant ou une représentante de la société Codman durant le congrès annuel.
PUBLICATION
1. L’article doit être soumis à l’éditrice du JCIIN ou à la personne désignée (par ex., le réviseur ou la réviseuse) lors du
congrès annuel afin d’être publié.
2. La portion monétaire du prix sera conservée jusqu’à la publication dans le JCIIN.
Prix Medtronic
Subvention de voyage de 1 000$ décernée par Medtronic
Le prix Medtronic sera décerné à l’(aux) auteur(s) ou à l’(aux)
auteure(s) d’un travail écrit pour son excellence dans le domaine
de la neuromodulation ou de la pratique clinique en soins
infirmiers en neurosciences. Il est attendu que l’argent sera utilisé afin d’aider le ou la récipiendaire à payer les frais de voyage
pour se rendre au congrès annuel et y présenter l’article.
ADMISSIBILITÉ
de chaque année.
3. L’(les) auteur(s) ou l’(les) auteure(s) sont prêts à présenter le
travail au congrès annuel de l’ACIIN.
4. Le travail est un ouvrage original de l’ (des) auteur(s) ou de
l’(des) auteure(s).
de l’(des) auteur(s) ou de l’(des) auteure(s); ceci doit être
mentionné.
CONTENU
1. Le travail a été écrit selon les directives de rédaction de
manuscrit aux fins de publication.
scientifiques.
en neurosciences.
51
STYLE
manuscrit aux fins de publication conformément aux directives du Journal canadien des infirmiers et infirmières en
SÉLECTION
scientifique après consultation avec l’agent ou l’agente de
liaison scientifique et le rédacteur ou la rédactrice en chef
du Journal canadien des infirmiers et infirmières en sciences
neurologiques.
3. Le Comité du programme scientifique doit recevoir les travaux soumis pour le 15 février.
PRÉSENTATION
1. Le prix sera présenté par un représentant ou une représentante de la Medtronic Ltd. durant le congrès annuel.
PUBLICATION
1. L’article doit être soumis à l’éditeur ou à l’éditrice du JCIIN
ou à la personne désignée (par ex., le réviseur ou la réviseuse) lors du congrès annuel afin d’être publié.
Prix de la Fondation des tumeurs cérébrales
1 500 $ décerné par la FTC du Canada.
Le prix de la Fondation des tumeurs cérébrales sera décerné
au membre de l’Association canadienne des infirmières et infirmiers en neurosciences (ACIIN) pour son excellence dans le
domaine des soins infirmiers en neurosciences liés aux tumeurs
cérébrales. Créé en l’honneur de Pamela Del Maestro, IA, Bsc.,
membre de l’ACIIN et co-fondatrice de la Fondation canadienne
des tumeurs cérébrales, le prix comprend la publication de l’article du ou de la récipiendaire dans le Journal canadien des
infirmiers et infirmières en sciences neurologiques.
ADMISSIBILITÉ
de chaque année.
3. L’(les) auteur(s) ou l’(les) auteure(s) sont prête(s) à présenter
le travail au congrès annuel de l’ACIIN de l’année où le prix
a été décerné.
4. Le travail est un ouvrage original de l’(des) auteur(s) ou de
l’(des) auteure(s).
52
de l’(des) auteur(s) ou de l’(des) auteure(s); ceci doit être
mentionné.
7. L’(les) auteur(s) ou l’(les) auteure(s) ne peuvent pas recevoir
d’autres prix de l’ACIIN au cours de la même année.
CONTENU
1. L’article a été écrit depuis une perspective infirmière.
2. L’article traite des soins aux patients atteints d’une tumeur
cérébrale.
scientifiques.
en neurosciences.
STYLE
manuscrit aux fins de publication, conformément aux directives du Journal canadien des infirmiers et infirmières en
2. L’article n’excédera pas 20 pages typographiées, à double
interligne.
SÉLECTION
scientifique en collaboration avec l’agent ou l’agente de liaison scientifique et le rédacteur ou la rédactrice en chef du
Journal canadien des infirmières et infirmiers en sciences
neurologiques.
3. Le Comité du programme scientifique doit recevoir les travaux soumis pour le 15 février de chaque année.
PRÉSENTATION
1. Le prix sera présenté par un représentant ou une représentante de la Fondation des tumeurs cérébrales durant le
congrès annuel.
PUBLICATION
1. L’article doit être soumis à l’éditrice du JCIIN ou à la personne désignée (par ex., le réviseur ou la réviseuse) lors du
congrès annuel afin d’être publié.
Prix Jessie Young
• Bourse
• Certification
• Résumé
La bourse/certification Jessie Young a été créée afin d’encourager la formation professionnelle continue dans le respect de
la mission et de la vision de l’ACIIN. Ces bourses procurent
une aide financière à des infirmiers et des infirmières diplomés
afin qu’ils ou elles poursuivent leur formation dans les sciences
infirmières en neurosciences.
EXIGENCES RELATIVES À LA DEMANDE :
Directives :
1. Ces bourses sont disponibles pour les infirmiers et infirmières diplômés qui ont travaillé dans le domaine des neurosciences et qui sont des membres en règle de l’ACIIN
depuis au moins deux ans.
2. Le programme de formation ou le cours pour la bourse Jessie
Young doit être clairement orienté vers les neurosciences ou
en avoir une composante.
3. Les candidats et candidates sélectionnés doivent accepter de
rédiger une lettre qui paraitra dans le JCIIN et qui décrira en
quoi le cours participera à la progression des soins infirmiers
en neurosciences.
Demande:
Une demande complète se compose de :
1. Un formulaire de demande rempli
2. La preuve que le demandeur ou la demandeuse a été accepté
dans le programme de formation ou le cours pour lequel il
ou elle a fait demande, ou la preuve de l’inscription à l’examen de certification.
3. Preuve du montant des frais d’inscription.
4. Preuve de leur enregistrement actuel au sein d’une association provinciale d’infirmières et d’infirmiers.
5. Une lettre de référence d’une personne ayant eu l’occasion
d’évaluer votre travail. Sont considérées des références
valables :
• Un ou une autre membre de l’ACIIN.
• Un administrateur ou une administratrice.
• Un formateur ou une formatrice (institution ou hôpital).
Dates limites pour la demande :
1. La date limite pour recevoir les demandes de bourses Jessie
Young est fixée au 1er avril de chaque année.
2. La date limite pour recevoir les demandes de certifications
est fixée au 31 mai de chaque année.
Bourse Jessie Young (Formation continue)
CRITÈRES POUR LA BOURSE JESSIE YOUNG—
Formation continue
But et croyances
L’ACIIN croit qu’un programme d’études post-diplôme/programme de formation continue en sciences infirmières (avec
une spécialisation dans les soins infirmiers en neurosciences)
aide à encourager l’excellence dans la pratique des soins infirmiers en neurosciences. L’un des buts principaux de l’organisme est d’aider à la formation professionnelle continue de
nos membres. La bourse Jessie Young vise à aider l’un ou l’une
des membres de l’ACIIN à étudier dans un programme post-diplôme en soins infirmiers en neurosciences canadien afin qu’ils
ou elles poursuivent leur croissance professionnelle et contribuent à rendre possible la réalisation de l’excellence dans les
soins infirmiers en neurosciences.
Critères pour le programme
1. Le programme doit être offert dans une université ou un
collège canadien et reconnu. Le participant ou la participante doit :
• Être un infirmier autorisé ou une infirmière autorisée,
admissible à l’inscription dans la province où le programme est offert.
• Avoir au minimum un an d’expérience dans le domaine
des soins infirmiers en neurosciences.
• Fournir la preuve de son inscription dans le programme
reconnu.
• Préciser clairement le domaine spécifique étudié dans le
cadre des sciences infirmières en neurosciences si il ou
elle est dans un programme de formation continue (c.-à-d.
Baccalauréat en sciences infirmières) Rester un membre
de l’ACIIN pendant au moins une année après la fin des
études.
DIPLÔME DE MAITRISE EN SCIENCES INFIRMIÈRES
OU ÉQUIVALENT
CRITÉRES POUR LA BOURSE JESSIE YOUNG
But et croyances
L’ACIIN croit qu’un diplôme de maitrise en sciences infirmières,
ou l’équivalent, avec une spécialisation dans la pratique clinique,
la formation, la consultation, la gestion ou le leadership des
soins infirmiers en neurosciences aide à promouvoir l’excellence
dans la pratique des soins infirmiers en neurosciences. L’un des
buts principaux de l’organisme est d’encourager la formation
professionnelle continue de ses membres.
Critères pour le programme
Le programme doit être un programme de maitrise en sciences
infirmières (ou équivalent) reconnu ou un programme de doctorat en sciences infirmières
Le participant ou la participante doit :
• Fournir la preuve de son inscription dans le programme
reconnu.
• Préciser clairement le domaine spécifique étudié dans le
cadre des sciences infirmières en neurosciences.
• Rester un membre de l’ACIIN pendant au moins une année
après la fin des études.
Prix du meilleur résumé Jessie Young
Le prix du meilleur résumé Jessie young a été créé par l’Association canadienne des infirmières et infirmiers en neurosciences afin d’encourager la formation professionnelle
continue dans le respect de la mission et de la vision de
l’ACIIN, et pour aider les membres à venir assister au congrès
annuel et aux sessions scientifiques. Ce prix accorde un financement pour l’inscription à une conférence et est accordé à
l’un des résumés approuvés pour le congrès annuel et les sessions scientifiques.
53
Bourse de recherche Marlene Reimer
La bourse de recherche Marlene Reimer a été créée afin
d’encourager les recherches dans le domaine des sciences infirmières en neurosciences et dans le respect de la mission et
de la vision de l’ACIIN. Cette bourse accorde un financement
aux infirmiers et infirmières afin qu’ils ou elles poursuivent un
projet de recherche portant directement sur les questions liées
aux soins des patients en neurosciences relatives aux pratiques
infirmières canadiennes. Le montant accordé est déterminé
chaque année. La bourse peut être accordée à un ou plusieurs
individus en fonction des fonds disponibles.
1. Les fonds de recherché seront alloués annuellement et fondés sur le nombre de demandes.
2. La date limite pour les demandes est fixée au 1er novembre
de chaque année.
3. L’intégralité de la bourse de recherche Marlene Reimer est
de 2 000 $, à laquelle s’ajoute le profit net du « Courir pour
la recherche » (Run for Research) de l’année précédente; à
examiner chaque année à l’exercice de milieu de bilan par
le conseil d’administration.
4. Les projets finançables portent directement sur des questions liées aux soins des patients en neurosciences.
5. Les projets porteront sur des questions relatives aux pratiques infirmières canadiennes.
6. Le chercheur principal ou la chercheuse principale doit
être un infirmier ou une infirmière et avoir été membre de
l’ACIIN durant l’année précédente.
7. Une lettre de demande et la proposition de recherche
devront être envoyées au président ou à la présidente
du comité de recherche (elles peuvent être envoyées
électroniquement).
8. Deux copies supplémentaires de la proposition de recherche
doivent être envoyées par courrier électronique au président
ou à la présidente du comité de recherche ; l’une doit contenir des données d’identification (membres de l’équipe de
recherche, milieu de soins) et la seconde ne les contient pas.
9. La demande devrait être accompagnée d’une lettre de soutien écrite par la direction/le superviseur ou la superviseuse clinique et décrire la contribution de la proposition
de recherche pour les sciences infirmières en neurosciences.
10. La de recherche doit contenir les informations suivantes :
• Titre du projet.
• Noms et qualifications du (des) chercheur(s) principal(-aux) ou de la (des) chercheuse(s) principale(s) et
des chercheurs et chercheuses adjoints.
• Objectif du projet.
• Méthodologie (notamment un échantillon, les procédures et un plan d’analyse des données).
• Preuve de l’accord du comité d’éthique de l’institution/l’agence d’où proviendront les sujets d’étude, le cas
échéant.
• Budget et délais.
• Somme d’argent demandée à l’ACIIN.
54
11. Le budget proposé devrait contenir les sections suivantes :
• Services professionnels.
• Matériel.
• Services.
• Voyage (n’inclut pas le financement pour voyager au
congrès annuel de l’ACIIN afin d’y présenter les résultats).
• Équipement.
12. La proposition de recherche devrait également contenir
des détails sur d’autres sources de financement, notamment
celles qui ont été acceptées et celles en cours de traitement ;
13. Le comité de recherche examinera les propositions de
recherche et avisera le conseil d’administration des décisions concernant les bourses de financement :
• La bourse sera accordée au ou à la récipiendaire le
moment où la décision aura été prise. Une reconnaissance officielle sera faite au cours du déjeuner du congrès
annuel.
• Les personnes qui recevront un financement devront
fournir des rapports au comité de recherche sur demande.
• La date limite pour les demandes de bourses de recherche
est fixée au 1er novembre et sera publiée dans le JCIIN.
• Les chercheurs et les chercheuses devront publier leurs
résultats dans le JCIIN et les présenter au congrès annuel.
• Les chercheurs et les chercheuses doivent soumettre un
rapport de leurs recherches au comité de recherche.
Prix des auteurs du JCIIN
1. Tous les auteurs et auteures des articles parus dans le JCIIN
qui n’ont pas reçu d’autre récompense (telle que le prix Codman, le prix Medtronic, le prix des tumeurs cérébrales de
l’ACIIN) peuvent recevoir le prix des nouveaux auteurs ou
le prix général des auteurs.
2. Un nouvel auteur ou une nouvelle auteure est un auteur ou
une auteure qui publie dans le JCIIN pour la première fois ;
3. Les noms des auteurs et auteures admissibles seront tirés au
sort durant le congrès de juin.
4. Les gagnants de chacun des deux prix recevront un chèque
de 200 $ durant l’assemblée générale annuelle de juin.
5. Les auteurs et auteures gagnants ne doivent pas nécessairement être membres de l’ACIIN.
6. Le prix des auteurs et auteures gagnants absents au moment
de l’annonce leur sera envoyé par courrier.
7. Le prix proviendra du budget du JCIIN.
8. S’il n’y a pas de nouveaux auteurs ou nouvelles auteures
durant une quelconque année, un second prix général des
auteurs sera tiré au sort parmi les auteurs admissibles de
cette année.
9. Le prix sera remis par le rédacteur ou la rédactrice du JCIIN,
ou la personne désignée.
Canadian Journal of
Neuroscience Nursing
Manuscript Guidelines
for Publication
10.The Canadian Journal of Neuroscience Nursing (CJNN) is
a peer-reviewed journal.
11.APA formatting is used for both the body of the paper
and the references. For further information, please refer to
the latest edition of: American Psychological Association
(2010). Publication Manual of the American Psychological
Association (6th ed.). Washington, DC: American
Psychological Association.
12.Papers must be word processed and submitted in Word
format. A hard copy and disk may be sent by mail or the
paper may be submitted by e-mail attachment to Theresa
Green, RN, PhD, Assistant Professor, University of Calgary,
Faculty of Nursing, Room 2210, Professional Faculties
Building, University of Calgary, 2500 University Dr. NW
Calgary, AB T2N 1N4, Canada or [email protected].
13.Two peer reviewers review all papers received for content.
The Editor appraises the paper for formatting, style,
grammatical accuracy, and appropriateness for publication.
This process usually takes five to eight weeks. Papers may
be: a) accepted as submitted, b) returned for revisions, or
c) rejected and returned with feedback.
14.Manuscript guidelines
Maximum length is 6,000 words or 20 pages
Margins 1", double spaced, Times New Roman, 12-point
font size
Title page with full title, name, and institutional affiliation
Abstract of fewer than 200 words
Left justified, paragraphs indented 5 spaces
Headings typically include: Introduction; Review of
the literature (conceptual and data based); Research
question/Objectives/Hypotheses/Clinical concern;
Methodology and method; Analysis/Findings;
Discussion including specific Clinical implications/
recommendations; Summary/Conclusions; and
References. (Please note, not all of these headings are
needed or may apply to all papers).
Abbreviations should always be preceded by the full term.
An example would be Traumatic Brain Injury (TBI).
Drug citations include the generic name in lowercase
letters and brand names in parentheses.
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Le journal canadien
des infirmiers et infirmières
en neurosciences
Réglements de publication
dans le JCIIN
1. Le Journal canadien des infirmiers et infirmières en neurosciences est une publication révisée par ses propres
membres.
2. APA est utilisé pour la rédaction du journal et pour les
références. Pour de plus amples informations, veuillez consulter la publication suivante : The American Psychological
Association. (2009) Publication Manual of the American
Psychological Association (6e éd.) Washington, DC.
3. Les manuscrits doivent être transcrits par traitement de
texte utilisant Word 6.0 ou Word Perfect. Une copie, sur
papier et disquette, peut être envoyée par la poste ou le
manuscrit peut être envoyé par courriel à Theresa Green,
rédactrice en chef, 1468 Northmount Dr. N.W., Calgary,
Alberta T2L 0G6 ou [email protected]
4. Le contenu de tous les manuscrits reçus est révisé par réviseurs puis adapté pour fins de publication par la rédactrice
en chef. Ce processus nécessite environ 5 à 8 semaines.
Les articles pourraient être acceptés tels quels, retournés
pour révision ou retournés accompagnés de commentaires.
5. Spécifications se rapportant à la rédaction du manuscrit :
Longueur maximale du manuscrit : 6 000 mots ou 20
pages.
Marges de 1 pouce, double interligne, « Times New
Roman », 12 lettres au pouce
Page titre avec titre complet, le nom et le lieu d’emploi
de l’auteur
Un résumé de moins de 200 mots doit être inclu.
Marge de gauche, laisser 5 espaces pour les nouveaux
paragraphes
Les entêtes peuvent inclure : introduction, revue de la
litérature, (concept et données), but de la recherche,
objectifs, hypothèses, aspect clinique, méthodologie et
méthodes, analyses et résultats, discussions avec implications d’ordre clinique, recommendations, résumé et
conclusion, références. Veuillez prendre note que toutes
ces entêtes ne s’appliquent pas nécessairement à tous les
manuscrits présentés au comité
Les abréviations doivent toujours être précédées du
terme complet, par exemple : Accident cérébrovasculaire (ACV)
Les médicaments sont nommés utilisant le terme
générique écrit en lettres minuscules et le nom commercial écrit entre parenthèses.
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Fall 2014.indd

Transcription

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