Background Nurses in skilled nursing facilities (SNFs) play a key role in initiating/transitioning care for the >5 million patients who transition from hospitals-to-SNFs annually. Although hospital discharge processes are well studied, little is known about the SNF nursing processes or the SNF-based consequences of variation in transitional care quality. Objective To examine how SNF nurses transition the care of patients admitted from hospitals, the barriers they experience, and the outcomes associated with variation in the quality of transitions. Design Qualitative study using grounded dimensional analysis, focus groups and in-depth interviews. Setting 5 Wisconsin SNFs. Participants 27 registered nurses. Results SNF nurses rely heavily on written hospital discharge communication to effectively transition patients into the SNF. Nurses cited multiple inadequacies of hospital discharge information, including regular problems with medication orders (including the lack of opioid prescriptions for pain), little patient psychosocial/functional history, and inaccurate information regarding current health status. These communication inadequacies necessitated repeated phone clarifications, created care delays (including delays in pain control), increased SNF staff stress, frustrated patients/family members, directly contributed to negative SNF facility image, and increased a patient's rehospitalization risk. SNF nurses identified a specific list of information/components that they need to facilitate a safe, high-quality transition. Conclusion Nurses note multiple deficiencies in hospital-to-SNF transitions, with poor quality discharge communication being identified as the major barrier to safe and effective transitions. This information should be used to refine and support the dissemination of evidence-based interventions which support transitions of care, including the Interventions to Reduce Acute Care Transfers II (INTERACT) program.

Context Pain, fatigue and sleep disturbance commonly co-occur in patients receiving treatment for advanced cancer. Objectives A pilot randomized controlled trial was conducted to assess initial efficacy of a patient-controlled cognitive-behavioral (CB) intervention for the pain, fatigue, sleep disturbance symptom cluster. Methods Eighty-six patients with advanced lung, prostate, colorectal, or gynecologic cancers receiving treatment at a comprehensive cancer center were stratified by recruitment clinic (chemotherapy, radiation therapy) and randomized to intervention or control groups. Forty-three patients were assigned to receive training in and use of up to 12 relaxation, imagery, or distraction exercises delivered via MP3 player for two weeks during cancer treatment. Forty-three patients were assigned to a waitlist control condition for the same two-week period. Outcomes included symptom cluster severity and overall symptom interference with daily life measured at baseline (Time 1) and two weeks later (Time 2). Results Eight participants dropped out; 78 completed the study and were analyzed (36 intervention, 42 control). Participants used the CB strategies an average of 13.65 times (SD= 6.98). Controlling for baseline symptom cluster severity and other relevant covariates, symptom cluster severity at Time 2 was lower in the intervention group (MAdj=2.99, SE=0.29) than in the waitlist group (MAdj=3.87, SE=0.36), F(1,65)=3.57, P=0.032. Symptom interference with daily life did not differ between groups. No significant adverse events were noted with the CB intervention. Conclusion Findings suggest that the CB intervention may be an efficacious approach to treating the pain, fatigue, sleep disturbance symptom cluster. Future research is planned to confirm efficacy and to test mediators and moderators of intervention effects.

Objective To identify symptom clusters in older breast cancer survivors and examine whether symptom clusters are related to demographic, health, and quality of life variables. Design Symptom bother measures were analyzed using factor analysis to identify possible symptom clusters and the resulting clusters were then correlated with quality of life measures. Setting The randomized clinical trail from which the data used for these analyses were drawn took place over the phone between the participant and a trained research nurse. Sample Data from 192 older breast cancer survivors (mean age = 70) who had participated in a randomized clinical trial testing a symptom management intervention were used for this study. Methods This was a secondary data analysis of the baseline measures of demographics, health history, symptom bother, and physical, mental, and existential dimensions of quality of life. Exploratory and confirmatory factor analyses were conducted as well as MIMIC modeling and partial correlation analyses to assess the relationships amongst clusters and demographic, health history, and quality of life measures. Main research variables The main research variables were self-reported symptom bother, demographics such as age and education level, health history and quality of life. Findings Seven clinically distinct symptom clusters tapping 36 different symptoms in older breast cancer survivors were found, and these symptom clusters were significantly related to multiple dimensions of quality of life. Conclusions Older breast cancer survivors experience multiple, concurrent symptoms that appear to cluster. Identifying symptom clusters helps to elucidate possible inter-symptom relationships, which may lead to the design of more effective symptom management interventions for older breast cancer survivors. Implications for Nursing Older breast cancer survivors should be assessed for a wide variety of symptoms if clinicians hope to identify and understand inter-symptom relationships. Such an assessment would enable more comprehensive symptom management.