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This article reports a meta-analysis of 84 studies of quality of life (QOL) in cardiac patient populations published in the 5-year period 1987-1991. Selected methodologies and substantive characteristics of the studies are described. An overall effect size of .31 indicated a small but significant positive effect of pharmacologic, mechanical, surgical, nursing, or other treatment on QOL. No negative effect of treatment was found for any cardiovascular diagnostic category. Homogeneity analysis revealed eight potential moderators of the overall effect size: quality of study, gender of sample, time dimension, sampling method, intervention, marital status of subjects, quality-of-life dimension measured, and sample size.

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The Recruitment and Enrollment Assessment in Clinical Trials (REACT) was a National Heart, Lung, and Blood Institute (NHLBI)-sponsored substudy to the Cardiac Arrhythmia Suppression Trial (CAST). Two-hundred-sixty (260) patients who enrolled in CAST and 140 partially or fully eligible patients who did not enroll were compared across several parameters, including demographic variables, disease severity, psychosocial functioning, health beliefs, recruitment experience, and understanding of informed consent procedures used in CAST. Significant predictors of enrollment included several demographic variables (e.g., being male, not having medical insurance), episodes of ventricular tachycardia, and health beliefs (e.g., extra beats are harmful, a higher degree of general health concern). Enrollment was higher for those who read and understood the informed consent and those who were initially recruited after hospital discharge, particularly nondepressed patients. In the multivariate model, the key variables that emerged were the patient's reading of the informed consent form and the patient's lack of medical insurance. These results suggest that (1) the clinical trial staff's interaction with the patient and the time when recruitment is initiated contribute significantly to the decision to enroll; and (2) it may be a greater challenge to motivate patients to enroll in future clinical trials if health care reform improves access to medical insurance coverage. Some of the significant variables are modifiable, suggesting interventions that may increase enrollment rates in future trials.

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BACKGROUND: Pain assessment and management are recognized as major problems in critical care settings. However, little is known about pain management practices related to medical procedures performed in the ICU, particularly removal of chest tubes. OBJECTIVES: To describe practices related to chest tube removal in the United States, with an emphasis on pain assessment and management. METHODS: A survey instrument was developed and mailed to 995 members of the American Association of Critical-Care Nurses who cared for patients with chest tubes. They were asked about chest tube removal practices in their institutions. RESULTS: Chest tubes are removed primarily by physicians and house staff, although 11% of respondents reported that specially trained nurses removed the tubes. Only 16% indicated that a prescription for pain medication was routinely available before chest tube removal. The drug administered most frequently was intravenous morphine sulfate, but the dose varied considerably. Nurses were generally satisfied (65.6%) with practices related to chest tube removal in their unit; nurses who were not satisfied (34.4%) wished to see better pain management practices (45%), removal of tubes by the patient's assigned nurse (17.8%), a protocol for tube removal (13.9%), notification of the nurse before removal (12.2%), and other changes (10%). CONCLUSIONS: Practices associated with chest tube removal, especially pharmacologic management of procedure-related pain, vary in critical care units. Caregivers are advised to develop practice policies to guide decisions about management of acute pain in this patient population.

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Quality of life is a construct of intense interest to researchers and clinicians and is especially important with cardiovascular patients in recovery settings where the goal of care is to return the patient to a life style not diminished by illness or treatment. This article presents a discussion of a number of issues related to assessment of quality of life in recovery settings, including definition and dimensions of the construct, measurement, and design. Model development and testing is recommended as a crucial step in increasing the understanding of quality of life in this patient population.

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BACKGROUND: Critically ill patients have received little attention in the caring literature and yet are a population for whom caring behaviors are particularly important. OBJECTIVES: To describe patients' perceptions of caring exhibited by professional nurses in a critical care unit and to describe the meaning to the patients of these demonstrations of caring. METHODS: We used a phenomenologic approach for this descriptive study, which was conducted on 13 patients hospitalized in a critical care unit for at least 48 hours within 48 hours of their transfer from the unit. We asked them to respond to two open-ended questions and recorded all interviews on audio tapes that were transcribed verbatim. RESULTS: Caring in a critical care unit is attentive, vigilant behavior on the part of the nurse. This vigilance embodies nurturance and incorporates highly skilled, technical practices, as well as basic nursing care and beyond. Caring is a healing process of which lifesaving actions by the nurse are a part. Identifying the characteristics of the individuals involved in this healing process was one way of describing caring. Personal attributes of nurses, family members, and patients themselves are important in the descriptions of the caring process. These attributes are incorporated into the concept of mutuality. CONCLUSIONS: Caring is descriptive of a mutual process in which intentions are joined to form a shared experience. In this mutual process, healing is an outcome that might otherwise be elusive.

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The primary goal of nursing research is to develop a scientific knowledge base for practice. Postanesthesia nurses are expected to critique nursing research before applying findings to clinical practice. As consumers of research, postanesthesia nurses must be able to employ critical evaluation skills to judge the merit and relevance of research to their clinical practice. This article presents criteria for critiquing clinical nursing research reports to determine their relevance to practice.

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To be useful, a frame of reference must enable an investigator to organize all components of a research study beginning with the literature review and problem statement and continuing through interpretation of findings. Careful conceptualization of the entire research process will move nurses closer to building an orderly system of scientific knowledge in which each investigation serves as a tool of nursing science.

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Recruitment and Enrollment Assessment in Clinical Trials (REACT), an NHLBI-sponsored substudy of the Cardiac Arrhythmia Suppression Trial (CAST), was conducted to assess factors associated with enrollment in clinical trials. We report on the relationships of institutional factors at CAST sites to patient enrollment. The proportion of CAST-eligible patients enrolling at each CAST site during the REACT study period was defined as the number of subjects enrolled divided by the sum of (1) the number enrolled plus (2) the number of eligibles who refused plus (3) the number of eligibles whose physicians refused to permit CAST personnel to attempt to enroll them. A questionnaire that included 78 questions regarding factors hypothesized to be associated with enrollment was completed between August 1988 and February 1990 by the nurse coordinators at all 112 CAST sites in the United States and Canada. Sixteen items were unanalyzable, and 37 of the remaining 62 were grouped into seven scales. The remaining items were analyzed individually. Enrollment proportions varied widely across the 112 CAST sites (mean 32.7% SD 22.6). Five variables or scales were included in the final multiple regression model (multiple R2 = .39). The most important of these was the proportion of eligible patients at a site cared for by medical staff other than private attending physicians (multiple R2 for this variable alone, .26). This proportion tended to be high in teaching hospitals. Other variables in this model that were associated with higher enrollment proportions included the number of days per week a nurse coordinator was present at the site, the number of nurse coordinator full-time equivalents at the site, fewer other clinical trials for which the nurse coordinator was responsible, and fewer perceived obstacles to enrollment. These findings indicate that enrollment was more successful at hospitals with higher proportions of eligible subjects cared for by fellows, housestaff, and service attending physicians and at institutions with the committed presence of a nurse-coordinator.

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Validation of nursing diagnoses is an essential step in developing knowledge for nursing practice and should be a major goal of the discipline. Nursing diagnoses must have clinical referents, that is, defining characteristics which appear in patient populations exhibiting specific nursing diagnoses. Selecting nursing diagnoses for patient populations, developing a list of defining characteristics and operational definitions for a nursing diagnosis, selecting a standard to discriminate among subjects and constructing an instrument to document the occurrence of defining characteristics in selected patient populations are preliminary steps in identifying clinical referents. Methodological concerns addressed in establishing clinical referents for nursing diagnoses included controlling confounding factors, determining sample size, conducting a pilot study, determining interrater reliability, selecting appropriate statistical tests, and identifying critical defining characteristics for a nursing diagnosis.

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Official labeling of phenomena that nurses diagnose and treat requires that researchers validate the existence of proposed diagnoses. One part of the validation process is the examination of content validity. The Delphi technique is a useful methodologic technique for such an examination. This article describes the characteristics, background, advantages, and disadvantages of the Delphi technique, as well as suggested strategies for using it to validate nursing diagnoses. In discussing strategies for using the Delphi technique to validate nursing diagnoses, the format, essential components, and steps of each round of the traditional and modified Delphi procedure are addressed. Round I of the traditional Delphi technique involves selection of a panel of content experts, developing and mailing questionnaires and content analysis, and generating a list of defining characteristics and operational definitions for a nursing diagnosis. Round II involves developing and mailing questionnaires, determining percentage of agreement, and providing statistical analysis. Round III includes developing and mailing questionnaires and providing statistical analysis of data. Round IV consists of developing and mailing the final report, which includes a statistical summary of individual and grouped responses in round III, as well as a minority report. The format and statistical analysis of the modified Delphi procedure is similar to rounds II, III, and IV of the traditional Delphi technique, except the modified technique usually will require only three rounds.

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Although much attention has focused on the validation of defining characteristics for nursing diagnoses, equal attention has not been devoted to the development of operational definitions for defining characteristics. Operational definitions, however, provide a reference for determining whether defining characteristics are present in patients who participate in clinical validation studies. Validation of nursing diagnoses emerges from occurrence of the diagnostic label in clinical practice. Operational definitions provide the bridge between incidental observation and scientific validation of nursing diagnoses.

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The purpose of this study was to evaluate three subcutaneous injection sites for low-dose heparin therapy (5,000 units). One hundred and one subjects were randomly placed in one of three groups. Group A received injections in the abdomen, Group B, in the thigh, and Group C in the arm. Each subject received three injections at the one site. Activated partial thromboplastin time (APTT) was measured prior to initiation of heparin and again four hours after the first injection. Bruising was measured at 48, 60, and 72 hours postinjection. There were no statistically significant differences among groups for either changes in APTT or bruising at 60 and 72 hours postinjection. Thus the clinical practice of utilizing the abdomen as the only or preferred site for subcutaneous heparin injections was not supported.

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