Gun Violence: Insights From a Nurse Survey
Most nurses reported a firearm safety class would increase their comfort when accessing and educating patients.
A survey of 163 RNs reveals gaps in their knowledge about gun violence and comfort levels when asking patients about gun ownership or accessibility, findings that could guide hospital policies to enhance safety practices.
“Firearm Safety: Nurses’ Knowledge and Comfort,” in American Nurse, discusses gun violence in the U.S., noting that 48,204 people died from firearm injuries in 2022, according to CDC statistics. The 27-question survey at a large academic medical center in Massachusetts asked nurses about state and national firearm mortality rates, their comfort discussing firearms with patients, and educating patients about firearm safety.
Some notable results: Firearm knowledge: Incorrect or unsure responses ranged from 37% to 86%, indicating a need for firearm injury prevention education. “Nurses should have familiarity with firearm mortality statistics and state firearm laws so they can have informed discussions with patients about gun violence prevention,” the article notes.
Comfort level: Fewer than half of surveyed nurses (45.4%) felt comfortable asking patients about gun ownership or accessibility. Nurses with the least experience (up to four years) reported the most comfort, followed by those with 10 to 20 years of experience. Nurses employed five to nine years had the lowest comfort levels.
Barriers to patient assessment: Nurses cited a lack of firearm knowledge and patient educational materials, as well as not knowing what to do with information they collected. Some mentioned feeling unsafe or not having enough time.
Education: Most nurses (84%) reported a firearm safety class would increase their comfort when accessing and educating patients. Policies for documenting firearm assessments, self-education materials for patients and safety protocols were other popular choices.
A related article in Critical Care Nurse highlights best practices for treating patients with injuries from violence. Themes include identifying survivors of intimate partner violence or child abuse, collecting forensic evidence, providing emotional support, preventing further violence, and addressing challenges involving concurrent substance use disorders.
Quality Improvement Project Helped Prevent Pediatric Cardiac Arrest
Hospitals that maintained their risk rates tended to have more effective shared improvement models.
Hospitals that participated in a multicenter cardiac arrest prevention (CAP) quality improvement (QI) project maintained their improvement two years later.
“Sustained Performance of Cardiac Arrest Prevention in Pediatric Cardiac Intensive Care Units” [CICUs], in JAMA Network Open, notes that most of the 17 hospitals showed no increase in in-hospital cardiac arrest (IHCA) in their pediatric CICUs. “Importantly, hospital-level data suggest an association between CAP-specific processes (during and after implementation) and maintenance of IHCA prevention performance,” adds the observational cohort study.
“In brief, volunteer CICU teams formed a collaborative learning network led by QI specialists and physician and nurse faculty to implement a CAP bundle and engage in IHCA prevention-focused QI work.”
Comparing patient outcomes from the July 2018-December 2019 CAP project with those from the same units in the March 2020-February 2022 follow-up period, the study finds 12 hospitals maintained their risk reductions and five had IHCA rate increases of at least 1% (two with statistical significance), based on an online survey.
The hospitals that maintained their risk rates tended to have less transition of project leadership and more effective shared improvement models. One hurdle to sustainability is the burden of time and extra work, and future predictive models might focus on higher-risk patients in order to perform the CAP bundle more efficiently, the study adds.
The primary study limitation is inferred causation. “We cannot definitively rule out unmeasured clinical programmatic changes that may have influenced IHCA rates during the follow-up era. Additionally, other improvement initiatives may have had a direct and/or indirect influence on IHCA.”
CAP implementation considered long-term challenges by developing monthly recorded webinars with QI science education and easily accessible resources for clinicians. “Physician and nursing buy-in and engagement, leadership support, and local motivation, expertise, and organizational culture for QI change all represent contextual factors that are important considerations to foster a successful QI intervention.”
Ammonia Levels May Be Unreliable for OHE Diagnosis
Educational initiatives can help address the overuse of ammonia testing.
Ammonia testing for diagnosing liver-related brain conditions such as overt hepatic encephalopathy (OHE) is often problematic and unreliable, a study finds, emphasizing that diagnosis should be based on clinical factors rather than laboratory tests.
“Serum Ammonia Levels Do Not Correlate With Overt Hepatic Encephalopathy Severity in Hospitalized Patients With Cirrhosis,” in Clinical Gastroenterology and Hepatology, notes that despite current guidelines in the U.S. and Europe, ammonia testing is commonly used for patient assessment, resulting in additional costs and potentially delaying treatment.
The study involved 71 patients with cirrhosis and OHE randomly assigned to one of five treatment groups receiving varying doses of lactulose and either placebo or rifaximin. Lactulose dosing was adjusted to achieve two to three soft stools daily, with the option for rectal administration if needed.
Serum ammonia levels were tested in 44 patients on day one, revealing no clear connection between ammonia levels and the severity of both OHE and liver function scores. This lack of correlation held true across different ages and sexes (median age 63; 48% women).
In addition, no significant differences in OHE recovery time were observed among patients involved in first-day testing. However, in the full sample size of 71 patients, one treatment combination — rifaximin SSD 40 mg twice daily plus lactulose — showed improved recovery times compared with lactulose alone.
Despite the study’s small size, the findings align with previous data showing that initial ammonia levels don’t help predict OHE severity or resolution time, further reinforcing ammonia testing’s lack of utility as a diagnostic tool.
“These data, along with evidence that ammonia testing has been shown to have low diagnostic accuracy in patients with cirrhosis and OHE, warrant implementation of educational initiatives and/or tools that address and mitigate the overutilization of ammonia testing in select clinical settings,” the study concludes.
Strategic Deprescribing for Older Adults
The paper outlines a six-step deprescribing protocol.
Increased risks of adverse outcomes from polypharmacy are common among older adults with multiple chronic conditions, and appropriate interventions are essential to manage and streamline medications.
“Reducing Inappropriate Polypharmacy Through Deprescribing,” by ECRI, recommends that health systems consider inappropriate polypharmacy — simultaneously using five or more medications — as a root cause of potentially avoidable issues such as drug interactions, cognitive and emotional impairment, falls and mortality.
The paper outlines a six-step deprescribing protocol involving a patient’s care team, provider and pharmacist. In summary:
- Compile and verify the patient’s diagnoses and related health statuses.
- Reconcile their current medication list with clinical indication or reasoning.
- Evaluate overall risk of drug-induced harm to determine how much to reduce or stop medications.
- Compare current and future benefits and risks of each medication to determine which ones to stop. Consider using a deprescribing decision support tool.
- Focus on stopping or reducing the dosage/frequency of medications with the least benefit-harm ratio and lowest risk of withdrawal or disease rebound. Consider the patient’s willingness to stop taking them.
- Implement the plan to stop or reduce medications, and monitor the patient for outcome improvements or adverse effects.
Deprescribing should be an ongoing strategy with engagement from patients, their families and caregivers, the paper adds. Establishing mutual motives for deprescribing involves asking patients what they think about their medication list, responding with empathy and education, and highlighting how deprescribing could benefit them.
The paper outlines various intervention methods and tools, including a case study highlighting the ALIGN intervention, a pharmacist-led telehealth program and an example of how to optimize patient and family engagement. The paper also covers the emerging use of artificial intelligence in polypharmacy management, noting potential applications such as enhanced diagnostic accuracy, personalized treatment plans and improved patient monitoring.
Nurse-led Interventions May Reduce Incidence of Delirium
Nurse-led, non-pharmacological interventions may reduce in-hospital delirium and mortality.
Nurse-led non-pharmacological interventions – including risk assessment, preventive measures, identification and rehabilitation – may reduce delirium in hospitalized adults and reduce mortality compared with usual care.
“Effectiveness of Nurse-led Non-pharmacological Interventions on Outcomes of Delirium in Adults: A Meta-Analysis of Randomized Controlled Trials,” in Worldviews on Evidence-Based Nursing, notes that multicomponent strategies proved more effective than single components, but burdens placed entirely on nurses can lead to excess workload and burnout. “To optimize the effectiveness of multi-component interventions for delirium, nurse-led multidisciplinary team care should be considered, including the involvement of a physician, physical therapist, and family members to participate in daily care,” the review adds.
The review involved 32 randomized clinical trials covering 10,122 participants and notes the interventions did not have a significant effect on duration or severity of delirium or hospital length of stay. “Therefore, for delirium-positive patients, treatment strategies including pharmacological or non-pharmacological interventions should be developed and validated to effectively reduce the duration and the severity of delirium and shorten the length of hospital stay.”
In trials where nurse-led interventions reduced the incidence of delirium, with a risk ratio of 0.74, only those with multicomponent strategies performed better than control groups receiving usual care. “The reason may be that delirium is caused by a multiple combination of factors, and single-component interventions only target a certain factor that causes delirium, so the effect is not significant.”
The review includes seven trials that showed reduced in-hospital mortality, leading to a recommendation to use these interventions in clinical practice and expand the research. “Medical personnel should carry out nurse-led, non-pharmacological interventions based on existing research protocols to effectively change in-hospital mortality in the future.”
Benefits of Animal-Assisted Therapy for Nurses
There were 64 study participants from critical care and medical-surgical units (41 were nurses).
Nurses with regular opportunities to engage in animal-assisted activities during their shifts reported improvements in mood afterward but experienced minimal long-term benefits on measures of stress, burnout and work engagement.
“The Impact of an Animal Assisted Activity on Healthcare Worker Well-Being in the Inpatient Hospital Setting” in International Journal of Complementary & Alternative Medicine, notes that volunteer groups of healthcare workers (HCWs), predominantly nurses, had opportunities to spend time with therapy dog teams up to three times a week across all shifts. “Our results suggest that this type of worksite intervention is acceptable to HCWs and may provide immediate benefits to HCW mood that may translate to improved patient care and satisfaction,” the study notes.
The study included 64 participants from critical care and medical-surgical units (41 of them nurses) who were divided into an intervention group and a control group that later received the same animal therapy. Both groups reported mood increases that persisted beyond the therapy time, but there were limited long-term impacts in other measurable areas.
One limitation of the results could be the time period of the study, during which COVID-19 cases remained high: October 2021 to March 2022. “For HCWs who have been working throughout the pandemic and who continue to work within very challenging inpatient environments, these findings may reflect a general feeling of distress that worksite interventions, even those that are well-intentioned and offer brief periods of distraction during the work day, may not be able to counteract,” the study adds.
AACN resources on this therapy include a journal article on animal-assisted interventions for delirium and a blog post about infection prevention related to therapy animals. In addition, a nurse story interview describes how a nurse’s rural background led to a passion for animal interaction and pet therapy in her professional life.
President’s Column: Hope. Unity. Belonging
As we welcome a new year and new hope, AACN President Jen Adamski shares a renewed sense of positivity from nurses’ desire to be heard, valued and celebrated.
Vision for Change: Elevating Diversity and Voice
AACN’s 2024 Pioneering Spirit Awardee Danielle McCamey is the founder, CEO and president of DNPs of Color. She is resolute in her work to amplify voices that have been historically excluded. “Use nursing as your superpower. We have a voice and we should use it.”