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University Hospital, London Health Sciences Centre, is a 284-bed hospital that serves as the regional stroke center for the Southwestern Ontario region (population 1.6 million), providing care to 450 stroke patients annually. The 55-bed acute-care neuro science unit includes a 6-bed neuro-observation unit and a 5-bed stroke unit. Patients with stroke are cared for in all areas of the 55-bed unit. At the time of the June 2006 workshop, 76 staff registered nurses (61 full-time and regular part-time and 15 casual part-time) worked on the unit; 67 attended the workshop and were invited to participate in the evaluation.
Sixty-six nurses completed or partially completed questionnaires before and immediately after the workshop. At 3 months postimplementation, 24 nurses returned completed or partially completed questionnaires. The mean age of the participants was 36 years (CI = 11.65). Their educational backgrounds included diploma (74%), baccalaureate degree (23%), and master's degree (3%). Six percent of the nurses held the Canadian Nurses Association Certification in Neuroscience Nursing, and 5% had completed a postgraduate neuroscience program. The nurses had a mean of 13 years' nursing experience (SD = 11.74), with 10 of those years in the neurosciences (SD = 9.43). The distribution of full-time, part-time, and casual employment was 60%, 20%, and 20%, respectively. The majority of nurses (63%) reported working more than 50% of the time on the general neuroscience unit, while the remainder usually worked in the neuro-observation or stroke unit. Previous involvement with a best-practice committee was reported by 14% of participants. The demographics of the 24 nurses who returned questionnaires at 3 months were similar to those of the baseline group.
A patient chart audit was performed at 2 weeks, 1 month, and 3 months after implementation of the CNS assessment on 17, 12, and 15 patients, respectively. The charts audited were those of a convenience sample of patients on the acute-care neuroscience unit who had a diagnosis of ischemic stroke (70%), intracerebral hemorrhage (18%), or subarachnoid hemorrhage (12%) and were in hospital on a given day. Forty-four patient charts were audited; the mean age of the subjects was 69 years (range 31-90), and 45% were men. Patient consent was not obtained because the CNS assessment was implemented as a practice change on the neuroscience unit.
Procedure
Nurses were given an information letter and invited to complete 2-3 brief questionnaires immediately before and after the workshop. Each set of questionnaires required 10 minutes to complete. These same nurses also received questionnaires in the mail 3 months after the workshop. The questionnaires were designed to elicit information on participants' demographics, learning experience and evaluation of the workshop, values and perception of BPGs and the CNS assessment, and confidence in performing the CNS assessment. The questionnaires were coded, and a master list was kept in a locked area in the researcher's office. All questionnaires were returned and secured in a locked area off-site. Return of a completed questionnaire constituted consent. The study protocol was approved by the Health Sciences Research Ethics Board at the University of Western Ontario.
Instruments
The Perception of Best Practice and Neurological Assessment Tool is a 6-item questionnaire developed by the investigator to explore nurses' awareness of best practices, perception of accessibility and use of BPGs, and beliefs about the value of BPGs in providing care to neuroscience patients. Five items were added to the instrument at the final 3-month questionnaire to obtain information on nurses' perceptions of using the CNS assessment in practice, including ease of use, usefulness as a communication tool, and ability to identify neurological changes in patients with ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage. For each item, participants were asked to indicate their level of agreement with a statement on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5).
The Self-Evaluation of Performance of Canadian Neurological Scale Assessment Questionnaire was developed by the investigator to measure nurses' confidence in performing the CNS assessment. The instrument consists of 1 item for overall performance of the assessment and 17 items that measure focused components of neurological assessment skills listed as level of consciousness, orientation, speech, motor function in a patient with no comprehensive deficit, motor function in a patient with a comprehensive deficit, and motor function in an uncooperative patient. For each of the 18 items listed, participants were asked to rate their confidence in performance on a 5-point Likert-type scale ranging from not confident at all (1) to very confident (5).
An Evaluation of Workshop Tool was developed to elicit information about the following content and format of the workshop: the PowerPoint presentation, the use of demonstration, the patient video case studies, the opportunity to practice in the laboratory, and whether the workshop met overall learning needs. Participants were asked to indicate their degree of agreement with a series of statements on a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5).
The Learning Experience Tool, based on Bandura's Self-Efficacy Theory, consists of 5 items and is designed to elicit information about the value of different types of learning experiences including participating in the 3-hour workshop, watching the video, observing role models and peers, practicing with patients, and receiving feedback on performance. Respondents were asked to indicate how much each type of learning experience contributed to their confidence in their ability to perform the CNS assessment on a 5-point Likert-type scale ranging from not helpful at all (1) to very helpful (5).
The Patient Chart Audit Tool was designed to obtain information on patient demographics, the need for neurological assessment requiring a validated tool, the appropriateness of the patient for CNS assessment, and whether the CNS or the GCS was used. For patients who were assessed using the CNS, the accuracy of documentation and reporting of significant change also was collected.
Results
Perception of BPGs and the CNS Assessment
Before participating in the workshop, study nurses reported moderate-to-strong awareness of BPGs and the belief that BPGs were valuable. They expressed moderate-to-strong agreement with the statement that they use BPGs in practice and use or will use the CNS to assess stroke patients. However, participants reported only mild agreement with the statement that BPGs were easy to access. Immediately after the workshop, there was an increased awareness of BPGs and a significant increased awareness of BPGs for stroke. Similarly, perception of value and utility of BPGs, ease of access to BPGs, and utility of the CNS assessment significantly increased immediately after the workshop (Table 1).
After 3 months, there was a further increase in awareness of and perception of ease of access to BPGs. There was a decrease in perceived value and use of BPGs and CNS assessment between immediately after and 3 months after the workshop; however, this change was not statistically significant (Table 2).
Three months after the workshop, nurses reported moderately strong agreement that they use the CNS tool in practice (Table 2); however, they reported mild disagreement with statements that the CNS was easy to use, was a useful communication tool, and was useful in identifying changes in awake patients with stroke, intracerebral hemorrhage, or subarachnoid hemorrhage (Table 3). These same nurses reported moderately strong agreement with the statement that, because of a decrease in a patient's level of consciousness, they were required to switch from the CNS to the GCS when assessing patients with subarachnoid hemorrhage.
Confidence in Performing the Canadian Neurological Scale Assessment
Before the workshop, nurses' overall confidence in performing the CNS assessment was moderato (M = 3.36). Nurses were least confident when testing motor function in an uncooperative patient (M = 3.92) and most confident when testing orientation (M = 4.79). Immediately after the workshop, overall confidence in performing the CNS assessment was high (M = 4.38). There remained some variation in confidence in performing components of the assessment (Table 4). At 3 months after the workshop, overall confidence in performing the CNS assessment was moderately high (M = 4.14; Table 5).
There was a significant increase in confidence in overall performance of the CNS assessment from before to immediately after the workshop (p < .0001; Table 4). There was also a significant increase in confidence in performing components of the assessment related to aphasia (p = .0001), motor function in patients with no comprehensive deficit (p < .0001), motor function in patients with a comprehensive deficit (p < .0001), and motor function in uncooperative patients (p < .0001). Confidence in assessing level of consciousness and orientation remained high with no significant change.
There was a slight decrease in confidence in overall performance of the CNS assessment from immediately after to 3 months after the workshop (p = .07; Table 5). There was a decrease in confidence in performing components of the assessment related to aphasia (p = .03), motor function in patients with no comprehensive deficit (p = .05), motor function in patients with a comprehensive deficit (p = .03), and motor function in uncooperative patients (p = .053). Confidence in assessing level of consciousness and orientation remained high with no significant change.
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