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INTRODUCTION: This study aimed to identify the symptoms used to assess angina, determine how emergency nurses make triage decisions for potential acute coronary syndrome, and determine emergency nurses' initial actions. METHODS: This was a cross-sectional, survey-based design. Emergency nurses were recruited through a posting on the Emergency Nurses Association website and through postcards. Measures included demographic data, assessment of angina, and the Nurses' Cardiac Triage Instrument. Data were analyzed using descriptive statistics and ordinal logistic regression. RESULTS: A total of 414 registered nurses with a mean age of 41.7 (SD = 12.0) years participated. They were predominantly female (80.7%), had a baccalaureate degree (60.1%), and worked as a registered nurse for a median 10.0 years. Common terms used to assess angina were chest pain (79.5%), chest pressure (77.3%), chest tightness (72.9%), and chest discomfort (72.5%). The severity of chest pressure (median 5.0, interquartile range 1.0) and nature of chest pain (median 5.0, interquartile range 1.0) had the highest overall median scores to support initial cardiac triage decisions. Associated symptoms of diaphoresis, fatigue, and shortness of breath along with health history contributed to decision making. DISCUSSION: Emergency nurses primarily used chest symptoms and health history when deciding to evaluate for acute coronary syndrome in the emergency department. Associated symptoms of diaphoresis, fatigue, and shortness of breath, along with health history, also contributed to decision making. Initial registered nurse actions were to obtain an electrocardiogram, prepare the patient for the cardiac catheterization laboratory, and notify the emergency physician of the patient's admission.

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BACKGROUND: The COVID-19 pandemic added challenges to patient assessment and triage in the emergency department (ED). OBJECTIVE: The aim of this study was to describe the effects of the COVID-19 pandemic on ED triage nurse decisions for patients with potential acute coronary syndrome (ACS). METHODS: This was a secondary analysis of data from a descriptive, electronic, survey-based study. Participants were asked 2 questions: whether the COVID-19 pandemic had affected their triage and/or assessment practices for patients with potential ACS and, if so, how. Descriptive statistics were used to compare the characteristics of participants. A qualitative descriptive approach was used to analyze responses to the open-ended questions about the pandemic's effect on the triage process. RESULTS: Participants from across the United States had a mean age of 41.7 (12.3) years; 358 (80.6%) were women. The participants had a median of 10.0 (interquartile range, 16.0) years of experience as a registered nurse, with a median of 7.0 (interquartile range, 11.0) years of ED experience. A total of 180 of 444 participants (40.5%) indicated that the COVID-19 pandemic affected their triage processes and assessment of potential ACS patients; 156 (86.7%) provided a response to the open-ended question. Responses revealed 4 themes: (1) delays in triage and treatment, (2) ambiguous patient presentation, (3) heightened awareness of COVID-19 complications and sequelae, and (4) process changes. CONCLUSIONS: Forty percent of ED triage nurses participating reported that triage processes for patients with potential ACS were affected by the COVID-19 pandemic. Most expressed barriers that resulted in delayed assessment and treatment of patients and often resulted from overlapping cardiac symptoms and COVID-19.

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BACKGROUND: Most women experience prodromal myocardial infarction (MI) symptoms, but more information is needed about the perception, attribution, and care-seeking behaviors related to these prodromal symptoms. OBJECTIVES: We aimed to describe women's perceptions, attributions, and care-seeking behaviors related to prodromal MI symptoms. METHOD: We used a qualitative, multiple case study approach, recruiting participants during summer 2019 from a large hospital in the Midwestern United States. Data were collected from interviews with the women who experienced MI and some of their family members, journals, and electronic health records. An inductive, comparative analysis procedure was applied. RESULTS: Ten women, ages 42 to 84, participated in the study. The women experienced a mixture of certainty and uncertainty related to their symptoms and engaged in several cognitive processes to conceptualize and act upon their symptoms. Although all the women retrospectively reported at least 4 prodromal symptoms, they lacked knowledge of prodromal MI symptoms and often responded to prodromal sensations that they experienced using emotion- and avoidance-based strategies. It was difficult for the women to establish a symptom pattern that was attributable to heart disease. DISCUSSION: The findings of this study may be used as evidence to support interventions that would facilitate women's care seeking for and health care providers' recognition of prodromal MI symptoms. Additional research is necessary to more fully characterize the cognitive processes at play for women of many different sociocultural backgrounds who experience prodromal MI symptoms.

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BACKGROUND: Adherence to prescribed analgesics for patients seriously ill with cancer pain is essential for comfort. OBJECTIVE: The objective of this study was to determine the analgesic adherence in seriously ill patients with cancer and its association with clinical and demographic characteristics. METHODS: This is a cross-sectional study. At home, 202 patients with cancer (mean age, 59.9 ± 14.2 years; 58% female, 48% Black, and 42% White) admitted to hospice/palliative care completed measures on a pen tablet: PAIN Report It, Symptom Distress Scale, mood state item, Pittsburgh Sleep Quality Index item, and Pain Management Index. RESULTS: The mean current pain intensity was 4.4 ± 2.9, and the mean worst pain in the past 24 hours was 7.2 ± 2.7. More than one-half of participants were not satisfied with their pain level (54%) and reported their pain was more intense than they wanted to tolerate for 18 hours or longer in the last 24 hours (51%). Only 12% were not prescribed analgesics appropriate for the intensity of their pain. Adherence rates were variable: nonsteroidal anti-inflammatory drugs (0.63 ± 0.50), adjuvants (0.93 ± 0.50), World Health Organization step 2 opioids (0.63 ± 0.49), and step 3 opioids (0.80 ± 0.40). With setting/clinical/demographic variables in the model, dose intervals of less than 8 hours were associated with less adherence ( P < .001). CONCLUSION: Little progress has been made toward improving analgesic adherence even in settings providing analgesics without cost. Research focused on targeting analgesic dose intervals and barriers not related to cost is needed. IMPLICATION FOR PRACTICE: Dose intervals of 8 hours or longer were significantly associated with higher adherence rates; therefore, use of longer-acting analgesics is one strategy to improve pain control at the end of life.

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AIMS AND OBJECTIVES: The purpose of this study was to explore adult women's unique and shared experiences of prodromal myocardial infarction fatigue. BACKGROUND: Fatigue is the most prevalent symptom experienced by women in the weeks and months before myocardial infarction. However, dimensions of this fatigue, such as timing, distress, intensity, quality, patterns and associated characteristics have not been established through studies of this symptom. A lack of understanding of the characteristics of myocardial infarction fatigue and the context in which it occurs makes clinical decision-making difficult. DESIGN: A qualitative, multiple case study guided by the Theory of Unpleasant Symptoms. METHODS: Women were purposively enrolled from a large hospital in the Midwestern USA. Semi-structured, audio-recorded interviews were conducted during hospitalisation and at 2-3 months postdischarge; women were also provided with a journal. A supplementary interview with family members and electronic health record review also assisted in data triangulation. Analysis was inductive and conducted within and across cases, using coding and categorisation, counting, clustering, visual displays of data and thematic development. The SRQR checklist was used in reporting the study. RESULTS: Ten women, with a median age of 60, participated. Fatigue was described primarily using the terms tiredness and lack of energy, though some women described generalised weakness and cognitive fog. This fatigue was unusual and a notable change from baseline. Many women described significant difficulties performing activities of daily living due to fatigue. CONCLUSIONS: The findings of this study will advance symptom science and an understanding of prodromal myocardial infarction fatigue. Future instrument development or selection of instruments for quantitative work will be aided by this study. RELEVANCE TO CLINICAL PRACTICE: This study provides a clearer picture of prodromal myocardial infarction fatigue experienced by women, aiding healthcare professionals in understanding and identifying this symptom.

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An estimated 1.2 million older adults nationwide currently reside in assisted/supportive living facilities, and research is required to continue to identify best outcomes in for their care. However, challenges exist. The aim of this paper is to address barriers and provide insights related to participant recruitment in assisted and supportive living facilities. Identified barriers included unproductive communication with reception area staff, a perceived lack of interest in research activity, and the inability of Director of Nursing (DON) to provide authorization for research activities. Recruitment insights included productive encounters with gatekeepers, establishing trust with executive administration and healthcare personnel, and research team persistence.

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BACKGROUND: Many older people experience chronic pain, so increased comfort and pain relief are important for older residents in assisted and/or supported-living environments. While several studies have found that people using non-pharmacological interventions without taking pain medication experienced significant differences in pain, the effect of non-pharmacological interventions on comfort and chronic pain in older people has not been studied. AIM: To assess differences in comfort and pain among older people in assisted and supported-living facilities who had chronic, non-cancer pain and who used or did not use non-pharmacological interventions. METHOD: A descriptive, comparative, cross-sectional pilot study with a convenience sample of 82 participants from 11 assisted and supported-living facilities. Three questionnaires were used to obtain data on the independent variable of use/non-use of non-pharmacological interventions and the dependent variables of perceived comfort and pain. Multivariate analyses of variance were computed to measure differences between the use/non-use groups, and Roy-Bargmann stepdown analyses were computed to further subdivide and analyse the groups who were using and not using pain medication. RESULTS: No significant differences were found in chronic pain and perceived comfort between participants who did or did not use non-pharmacological interventions if they were not also taking pain medication. However, when participants were also taking pain medication, chronic pain and perceived comfort scores were significantly affected by the use of non-pharmacological interventions. The most common non-pharmacological interventions were exercise, heat therapy, spiritual activity/religion and listening to music. CONCLUSION: Older people using non-pharmacological interventions and taking pain medication had higher perceived comfort scores and lower pain scores than those using pain medication only. Relationships between non-pharmacological interventions and comfort should be explored further. With minor changes, this pilot study design could be used with a larger sample.

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Elders residing in long-term care facilities experience ongoing moderate to severe pain, relief from and increased comfort remain relevant healthcare concerns. However, persistent, noncancer pain may not have been properly addressed due to insufficient attention to research that exists to support the utilization and efficacy of nonpharmacological intervention(s) for elders in long-term care facilities. Our aim of this integrated review was to evaluate the current state of the science on nonpharmacological intervention(s) for pain that are currently utilized in elders who reside in long-term care facilities. Exercise, massage, heat therapy, and relaxation/rest were identified as significant nonpharmacological interventions for persistent pain in elder residents living in long-term care facilities.

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AIMS AND OBJECTIVES: To explore the extant literature for key features of prodromal and acute myocardial infarction fatigue experienced by women, including estimates of severity, narrative descriptors, impacts on activities of daily living and frequency, and to describe what is known from the current evidence base. BACKGROUND: Several studies, conducted across the globe, have investigated prodromal and acute myocardial infarction symptoms experienced by women and suggested that fatigue is prevalent, and they have also sporadically described specific characteristics of fatigue, such as narrative descriptors and severity. However, no review specific to this acute and prodromal fatigue could be located in the literature. DESIGN: Integrative review, guided by Whittemore and Knafl's approach and the Theory of Unpleasant Symptoms. METHODS: We used a comprehensive, systematic approach to searching, screening, selecting, evaluating and analysing the records. Data were collected in February 2017. RESULTS: Twenty-one articles were included in the review, including nine quantitative, six qualitative and six mixed-methods studies, with the majority (14) published in the USA. The average age of participants across the studies was the early 60s. Distress, quality, intensity and timing of prodromal myocardial infarction fatigue were more completely described in the literature than acute myocardial infarction fatigue. CONCLUSIONS: Fatigue is the most common prodromal myocardial infarction symptom experienced by women and is also a common acute symptom. Additional research exploring prodromal and acute myocardial infarction fatigue is necessary. RELEVANCE TO CLINICAL PRACTICE: As healthcare professionals work with women across the healthcare spectrum, recognising fatigue as an important potential myocardial infarction symptom is essential. Not only can women be educated about this symptom and other possible myocardial infarction symptoms, but clinicians can consider fatigue as an important symptom in a constellation of factors when evaluating women's health and the potential for coronary disease and myocardial infarction.

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BACKGROUND: Distress is regarded as the sixth vital sign in cancer care, but few studies describe distress in patients undergoing radiation therapy. OBJECTIVES: The purpose of this study was to assess distress levels among patients with breast or prostate cancer undergoing radiation therapy and investigate which problems contribute to patients' distress levels. METHODS: A retrospective medical record review was conducted for 217 patients with breast or prostate cancer at a midwestern community cancer center. Demographic data, distress scores, and problems or concerns from the patient-completed Distress Thermometer and associated Problem List were collected. Descriptive and bivariate statistics were calculated. FINDINGS: The average distress of patients with breast cancer was significantly higher than that of patients with prostate cancer, and patients with breast cancer reported more problems than those with prostate cancer.

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BACKGROUND: Graduate nursing students in online courses often have limited success in developing the critical thinking (CT) skills essential for advanced roles. This study describes the use of complementary strategies in a graduate-level nursing course to enhance CT in online discussions. METHOD: Using Paul and Elder's framework for understanding the components of CT, the authors designed an asynchronous online course using multiple strategies to promote CT. We used mixed methods to collect descriptive and numerical data and content and repeated measures analyses to identify changes in CT skills and student perceptions across the semester. RESULTS: CT scores increased significantly and aligned with students' perceived improvements in CT. CONCLUSION: Evidence of CT in online discussions increased significantly across the semester with the use of multiple instructional strategies and substantial student and faculty efforts. The findings are a useful benchmark for future studies comparing combinations of strategies to identify those most effective and least arduous. [J Nurs Educ. 2016;55(9):514-521.].

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PURPOSE: We determined commonly experienced symptoms reported by adult patients with cancer admitted to urban, ethnically diverse hospice settings and identified symptom clusters. METHODS: We used hierarchical cluster analysis of 150 patients (41 % male, 20-92 years [M = 59, SD = 13.3], 51 % African American, 37 % Caucasian, 12 % other). Using pen-tablet computers, participants completed the Symptom Distress Scale (SDS), a sleep quality item, and listed analgesics consumed in the previous 24 h. RESULTS: Four symptom clusters were identified: cluster 1 (Pain-Fatigue) consisted of pain frequency, fatigue, and pain intensity; cluster 2 (Ingestion-Elimination) consisted of appetite and bowel problems; cluster 3 (General Well-Being) consisted of insomnia, appearance, and outlook; and cluster 4 (Respiratory-Nausea-Concentration) consisting of breathing, cough, nausea frequency, nausea intensity, and concentration. There were no significant differences between Caucasians and African Americans on total SDS scores, analgesic consumption, sleep quality, or most cluster scores. CONCLUSION: This is the first symptom cluster analysis in a US sample with a sizeable proportion of minority hospice/palliative care patients with cancer. Further research to determine the stability of identified symptom clusters over time and discovery of the biological interactions of symptoms within the cluster may lead to symptom management therapies designed for the alleviation of all clustered symptoms.

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BACKGROUND: The 13-item Symptom Distress Scale (SDS) is a widely used symptom measurement tool, yet a systematic review summarizing the symptom knowledge generated from its use in patients with advanced cancer is nonexistent. OBJECTIVES: This was a systematic review of the research literature in which investigators utilized the SDS as the measure of symptoms in patients with advanced cancer. METHODS: We searched PubMed, CINAHL, EMBASE, and Web of Science for primary research studies published between 1978 and 2013 that utilized the SDS as the measurement tool in patients with advanced cancer. Nine hundred eighteen documents were found. Applying inclusion/exclusion criteria, 21 articles and 2 dissertations were included. RESULTS: The majority of investigators utilized descriptive, cross-sectional research designs conducted with convenience samples. Inconsistent reporting of SDS total scores, individual item scores, age ranges and means, gender distributions, cancer types, cancer stages, and psychometric properties made comparisons difficult. Available mean SDS scores ranged from 17.6 to 38.8. Reports of internal consistency ranged from 0.67 to 0.88. Weighted means indicated fatigue to be the most prevalent and distressing symptom. Appetite ranked higher than pain intensity and pain frequency. CONCLUSIONS: The SDS captures the patient's symptom experience in a manner that informs the researcher or clinician about the severity of the respondents' reported symptom distress. IMPLICATIONS FOR PRACTICE: The SDS is widely used in a variety of cancer diagnoses. The SDS is a tool clinicians can use to assess 11 symptoms experienced by patients with advanced cancer.

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INTRODUCTION: 79% of ED patients present with pain, yet little is known regarding how unresolved pain affects patients' functional status. METHODS: This prospective, descriptive, 7-day pilot-study investigated how unrelieved pain affects functional status. Participants self-entered demographic data at ED discharge while research-team members collected triage scores, pain intensity scores, pain treatments, pain reassessments, discharge pain intensities, and prescriptions. Seven-day pain diaries were completed. At follow-up participants completed four PROMIS questionnaires. RESULTS: We approached 96 patients at ED discharge enrolling 25 (26%); 12 (48%) completed the entire study; 64% were female, 19-66 years (38.12 ± 14.23). Pain intensity at discharge was 7.25 ± 1.3 (4-10). Pain intensity 24 hours after discharge was 5.71 ± 3.12 and 7 days later was 2.50 ± 1.35. Participants rated their health (1 = poor, 5 = excellent) as good (3.33 ± 0.99), and reported moderate fatigue (2.83 ± 0.58) (1 = none, 5 = very severe). T-Scores for Pain Behavior (60.5 ± 2.8), Pain Interference (66.6 ± 6.0), and Sleep Disturbance (56.5 ± 10.0) were worse than the general public. DISCUSSION: Patients are discharged with unrelieved pain affecting their lives. Research investigating pain assessment and treatment along with detailing patients' daily pain intensity and satisfaction, self-management of pain, and functional status is warranted. Demonstrating these relationships may lead to interventions designed to quickly alleviate decreased functional status so patients may return to their previous health status.

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INTRODUCTION: Research focused on improving the outcome of patients with pain is an important aspect of emergency care, yet little information has been published to quantify pain severity, patient improvement, and return to independent function after ED discharge. Because of the paucity of available clinical data, this pilot study was designed to determine the acceptability and feasibility of using electronic data collection procedures. Specifically, we examined the willingness of discharged ED patients to use portable touch-screen computers as an alternative to traditional "paper and pencil" or telephone data collection methods to report postdischarge pain. METHODS: Participants in this prospective pilot study all reported acute pain that was unresolved at the time of ED discharge. Descriptive data were self-entered on touch-screen computers at ED discharge and 7 days later in subjects' homes. Participants completed 4 Patient-Reported Outcomes Measurement Information System (PROMIS Network, Silver Spring, MD), questionnaires and the computer acceptability scale (CAS), using the Assessment Center platform program (National Institute of Health, Bethesda, MD) for instrument administration, data storage, and information retrieval. Determinants of study success were willingness of the participants to use touch-screen computers, questionnaire completion time, and completeness of the data. RESULTS: Participants (N = 25) used touch-screen computers to complete 18 questions at the time of ED discharge. The mean completion time was 3.54 (± 1.13) minutes. Participants averaged 5.83 (± 2.00) minutes to complete the follow-up questionnaires. Ninety-two percent of subjects reported that the touch-screen computer was easy to use. We encountered no issues with data management using the Assessment Center platform. DISCUSSION: Touch-screen computers are a feasible and acceptable approach to collecting information about how patients self-manage unresolved pain after discharge from an emergency department. This methodology offers an alternative to traditional data collection methods. These data can inform researchers as they design future studies and assist emergency nurses who are responsible for planning quality improvement initiatives.

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AIMS AND OBJECTIVES: To identify barriers and facilitators to nurses' decisions regarding activation of rapid response teams (RRTs) in hospitals. BACKGROUND: Hospitalised patients in the United States who experience cardiopulmonary arrest seldom recover. Most of these patients show signs of clinical deterioration prior to cardiopulmonary arrest. RRTs have been shown to decrease the incidence of cardiopulmonary arrest by bringing needed resources to unstable patients. Despite the evidence in support of the activation of RRTs, nurses do not always use this resource. Nurses' decisions to activate or not to activate the RRT are not clearly understood. DESIGN: We used a qualitative design for this study. METHODS: A purposive sample of 15 medical/surgical nurses was recruited from a small medical centre in the Midwest. Researchers used semistructured, open-ended questions to elicit subject responses regarding facilitators and barriers to activating RRTs. RESULTS: Themes emerged and were categorised as facilitators and barriers to calling the RRT. Facilitators and barriers were then subdivided into distinct subthemes: RRT characteristics and unit culture. The expertise of the RRT members and support and encouragement from nursing unit colleagues and leaders emerged as two potential facilitators. Communication of the RRT members and calling the physician first emerged as two potential barriers. We also identified educational factors that were not clearly facilitators or barriers to calling the RRT. CONCLUSIONS: Further study is needed using quantitative designs with larger sample sizes. RELEVANCE TO CLINICAL PRACTICE: Nurses can build upon knowledge of facilitators and barriers related to RRT characteristics and nursing unit culture.

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