Publications

Abstract

Primary care providers (PCPs) play a significant role in reducing this global burden in responding to, identifying, and managing the mental health needs of children and adolescents. Services for behavioral health (BH) care needs can be provided by the PCP but might more appropriately be delivered by a psychiatric mental health (PMH) specialist, such as a PMH advanced practice registered nurse (APRN), psychologist, social worker, psychiatrist, or other person trained to manage the BH and mental health needs of children and adolescents. This chapter presents background information and discussion of issues in providing integrated BH and PC services through collaborative treatment models. The most common and researched collaborative and integrated practice models are presented. The team members of an interprofessional team are described. Barriers and facilitators to successful integration of BH and PC are reviewed.

Abstract

The state of modern healthcare is often not conducive to empathy or effective communication because physicians are pressured to see as many patients as they possibly can, sometimes forcing them to forsake emotional connection. However, empathy and communication are among the most vital skills for providing excellent care to patients. Incorporation of empathy and communication have been found to result in fewer malpractice suits, better adherence to treatment plans, fewer errors, and improved outcomes. The components of effective communication include active listening, offering feedback, and being able to apologize for past errors or miscommunication. The challenges associated with patients that are labelled “difficult” are discussed. The neurological processes of empathy are highlighted including the regions of the brain that are implicated. The chapter also frames empathy as a broad concept with emotive, moral, cognitive, and behavioral components, and that compassion is an empathic response that may facilitate feelings of engagement and protect against burnout. Increasingly, medical schools are incorporating training in building empathy and compassion into their curricula.

Abstract

College-age women represent the highest-risk age group for intimate partner violence (IPV) victimization. Bystander prevention approaches (primarily developed to address sexual assault risk on college campuses), have quickly become the mainstay of primary prevention education for gender-based violence in these settings and have been applied to all forms of gender violence in this setting, including IPV. The purpose of this paper is to critically examine the application of bystander approaches to prevention of IPV among college students. A brief overview of the current policy environment mandating prevention education will precede a summary of the conceptual framework underpinning bystander approaches to preventing and responding to sexual violence, followed by an analysis of how IPV does (and does not) fit within that same conceptual framework. The paper concludes with recommendations informal social network-informed approaches to dating violence that improve our theoretical understanding of IPV prevention on college campuses.

Abstract

Although parental HIV disclosure has benefits for parents and children, the disclosure rate among parents remains low. This study aims to qualitatively examine parental concerns regarding disclosure of their HIV status to their children. Eighty parents were enrolled in a randomized controlled trial of a three-session disclosure-support intervention, with forty receiving the intervention and forty receiving treatment as usual. Intervention sessions were audio recorded, and transcriptions were qualitatively coded for content related to concerns of disclosure. Four themes emerged: Intention to disclose, disclosure approach, indicators for disclosure, and fears about disclosure. These themes reveal struggles that parents experience when considering HIV disclosure suggesting that an effective disclosure intervention must help parents assess pros and cons, discuss the emotions of the children after the disclosure, and monitor the impact on children’s lives after disclosure over time. Future research is needed to implement interventions supporting HIV-positive parents’ disclosure decision-making and actions.

Abstract

Background: Cardiovascular disease (CVD) is a growing burden in low-and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana’s Upper East Region. Objective: This study sought to identify non–physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana’s current primary health care structure. Methods: Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings: Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions: Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

Abstract

Background: Home health care (HHC) is a leading form of home and community-based services for persons with dementia (PWD). Nurses are the primary providers of HHC; however, little is known of nursing care delivery and quality. Objective: The objective of this study was to examine the association between continuity of nursing care in HHC and rehospitalization among PWD. Research Design: This is a retrospective cohort study using multiple years (2010-2015) of HHC assessment, administrative, and human resources data from a large urban not-for-profit home health agency. Subjects: This study included 23,886 PWD receiving HHC following a hospitalization. Measures: Continuity of nursing care was calculated using the Bice and Boxerman method, which considered the number of total visits, nurses, and visits from each nurse during an HHC episode. The outcome was all-cause rehospitalization during HHC. Risk-Adjusted logistic regression was used for analysis. Results: Approximately 24% of PWD were rehospitalized. The mean continuity of nursing care score was 0.56 (SD=0.33). Eight percent of PWD received each nursing visit from a different nurse (no continuity), and 26% received all visits from one nurse during an HHC episode (full continuity). Compared with those receiving high continuity of nursing care (third tertile), PWD receiving low (first tertile) or moderate (second tertile) continuity of nursing care had an adjusted odds ratio of 1.33 (95% confidence interval: 1.25-1.46) and 1.30 (95% confidence interval: 1.22-1.43), respectively, for being rehospitalized. Conclusions: Wide variations exist in continuity of nursing care to PWD. Consistency in nurse staff when providing HHC visits to PWD is critical for preventing rehospitalizations.

Abstract

Objectives: Approximately 7.5 million US adults are homebound or have difficulty accessing office-based primary care. Home-based primary care (HBPC) provides such patients access to longitudinal medical care at home. The purpose of this study was to describe the challenges and adaptations by HBPC practices made during the first surge of the COVID-19 pandemic. Design: Mixed-methods national survey. Setting and Participants: HBPC practices identified as members of the American Academy of Homecare Medicine (AAHCM) or participants of Home-Centered Care Institute (HCCI) training programs. Methods: Online survey regarding practice responses to COVID-19 surges, COVID-19 testing, the use of telemedicine, practice challenges due to COVID-19, and adaptations to address these challenges. Descriptive statistics and t tests described frequency distributions of nominal and categorical data; qualitative content analysis was used to summarize responses to the open-ended questions. Results: Seventy-nine practices across 29 states were included in the final analyses. Eighty-five percent of practices continued to provide in-person care and nearly half cared for COVID-19 patients. Most practices pivoted to new use of video visits (76.3%). The most common challenges were as follows: patient lack of familiarity with telemedicine (81.9%), patient anxiety (77.8%), clinician anxiety (69.4%), technical difficulties reaching patients (66.7%), and supply shortages including masks, gown, and disinfecting materials (55.6%). Top adaptive strategies included using telemedicine (95.8%), reducing in-person visits (81.9%), providing resources for patients (52.8%), and staff training in PPE use and COVID testing (52.8%). Conclusions and Implications: HBPC practices experienced a wide array of COVID-19–related challenges. Most continued to see patients in the home, augmented visits with telemedicine and creatively adapted to the challenges. An increased recognition of the need for in-home care by health systems who observed its critical role in caring for fragile older adults may serve as a silver lining to the otherwise dark sky of the COVID-19 pandemic.

Abstract

Background It is essential to provide safe healthcare in complex, difficult, and quickly changing conditions. The quality of healthcare services directly influences the safety of both the patients and staff. Understanding healthcare staff attitudes toward safety in the healthcare delivery context is foundational for building a culture of safety. Aim of the work To adapt, via a structured translation methodology, the Safety Attitudes Questionnaire- Short Form (SAQ-SF), which assesses how employees of the health care sector perceive the safety climate in their workplace, to the Polish context. Methods Using a content validation approach to structure the translation process, we tested and psychometrically analysed the translated SAQ-SF. The sample comprised 322 employees of a district hospital (second referral level, which ensures 24/7 emergency care services) in Poland. Results The reliability of the sub-scales of the Polish version of the SAQ-SF ranged from 0.66 to 0.95. The discriminatory power of particular SAQ items ranged between 0.02 and 0.90. For 6 out of the 8 scale dimensions, the questions with the highest factor loadings were those measuring the same dimensions of the safety climate, according to the original scale. Conclusions The Polish version of the SAQ-SF (SAQ-SF-PL) meets the criteria of psychometric and functional validation as well as demonstrates good reliability as a measure of patient safety culture in the Polish context. The SAQ-SF-PL is an instrument that enable a valid and reliable assessment of patient safety climate in the Polish healthcare facilities and identify opportunities for improvement. International comparisons will also become easier.

Abstract

Discussion of culture is complex and, within a mental health context, may prove to be complicated and controversial. This chapter defines culture, acculturation, and marginalization, explores cultural factors that advanced practice registered nurses (APRNs) must understand. It addresses the complex needs of immigrant, refugee, displaced, and culturally vulnerable youth living in challenging in country environments or who are crossing numerous global geographic boundaries. Cultural factors have an impact on the mental/behavioral health of immigrant and refugee children and the children of immigrant parents. The chapter also includes practice, education, and research implications along with recommendations for APRNs working with immigrant, refugee, displaced, and culturally vulnerable populations, and concludes with a case exemplar to illustrate key considerations.

Abstract

Purpose: Telehealth’s uptake has increased substantially in recent years, with an especially large jump in 2020 due to the emergence of COVID-19. This article provides background on and explores “telepresence” in healthcare literature. Telepresence strongly impacts the patient experience, but it is poorly defined in current research. The aim was to conceptually define telepresence using qualitative methods. Design: Dimensional analysis was used to analyze telepresence in clinical literature and create a clearer definition of telepresence as a concept. Multiple databases were searched for articles related to telepresence. Thirteen international articles related to telepresence were selected for analysis. Methods: Dimensional analysis allowed for multiple viewpoints to be explored within each distinct context and perspective. Findings: Twenty-five dimensions were discovered within the articles, which were synthesized to seven core dimensions of telepresence: connection, technological mediation, experienced realism, trust, being supportive, collaboration, and emotional consequence. Conclusions: Telepresence is highly impactful on the patient’s experience of telehealth care visits. The conceptual map produced by this dimensional analysis provides direction for clinicians to improve their ability to be present with patients during telehealth care. Potential implications include a starting point for future qualitative research, and the use of this dimensional analysis to inform clinical guidelines, improve clinician training, and assist in the development of new care models. Clinical Relevance: A telepresence definition brings clarity to an ill-defined concept. COVID-19 magnifies the need for a better understanding of telepresence, which allows clinicians to improve telehealth encounters.

Abstract

Background: Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS). Objective: We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity. Methods: We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences. Results: There were 186 minority older adults (community = 75%, NH = 25%) and 357 White older adults (community = 50%, NH = 50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community. Conclusion: Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

Abstract

Physicians suffer from mental health issues, particularly depression, at higher rates than the general population, due to many of the same factors that contribute to burnout. However, there is a stigma within the profession that prevents them from getting help. This stigma can be based on feedback from self, colleagues, hospitals/medical systems, and licensing boards. Self-criticism by physicians may lead to self-stigmatization. Colleagues may be afraid to broach the topic of mental health and fail to refer their peers to professional help. Hospitals/medical systems often label physicians suffering from mental health issues as ”unprofessional.” Lastly, licensing boards may discriminate against physicians who disclose prior psychiatric history. Major depressive disorder is the most common diagnosis among physicians. Anxiety disorders have been less well-studied but are likely also to be a major problem. Approximately 300 to 400 physicians are estimated to die from suicide each year, and untreated mental health conditions are a significant risk factor. Action at individual, institutional, and organizational levels is necessary to combat the stigma of mental illness.

Abstract

Nurse practitioners (NPs) are educated to provide high-quality patient- and family-centered care to underserved, culturally diverse, medically complex populations. Nurse practitioner faculty plan curricular activities that challenge NP students to critically assess individuals and populations with the goal of preparing NP students to be "practice-ready" upon graduation. Nurse practitioner clinical training occurs in practice settings with NP preceptors, with specific areas of clinical expertise. However, there is a lack of NP clinical preceptors educationally prepared to clinically teach and evaluate NP students. This article presents the design, implementation, evaluation, and outcomes from a 3-year grant funded by the United States Human Resources and Administration Services that featured a web-based Primary Care Nurse Practitioner Preceptor Development Program. Ninety percent of NPs who precepted NP students completed all web-based learning modules. Preceptors with educational preparation via online modules to guide NP student learning in clinical settings are a critical resource for faculty to prepare NP students to be practice-ready upon graduation. This web-based learning platform for online NP preceptor education may be a successful approach for expanding and improving the NP preceptor pool nationwide.

Abstract

Background: Diet and nutrition management is an integral component of Crohn disease (CD) management. This type of management is highly variable and individualized and, thus, requires personalized approaches. Consumer health information technology (CHIT) designed to support CD management has typically supported this task as everyday life work and, not necessarily, as illness work. Moreover, CHIT has rarely supported the ways in which diet and nutrition management requires coordination between multiple forms of patient work. Objective: The purpose of this study was to investigate diet and nutrition management as biform work, identify components of articulation work, and provide guidance on how to design CHIT to support this work. Methods: We performed a qualitative study in which we recruited participants from CD-related Facebook pages and groups. Results: Semistructured interviews with 21 individuals showed that diet and nutrition management strategies were highly individualized and variable. Four themes emerged from the data, emphasizing the interactions of diet and nutrition with physical, emotional, information, and technology-enabled management. Conclusions: This study shows that the extent to which diet and nutrition management is biform work fluctuates over time and that articulation work can be continuous and unplanned. The design guidance specifies the need for patient-facing technologies to support interactions among diet and nutrition and other management activities such as medication intake, stress reduction, and information seeking, as well as to respond to the ways in which diet and nutrition management needs change over time.

Abstract

The ever-evolving composition of the U.S. population prompts healthcare systems to adapt in order to provide care to diverse populations. Health disparities exist, and it is part of our responsibility as medical professionals to reflect on how the sociocultural determinants of health affect outcomes and uncover our unconscious or implicit biases to work towards health equity. The author defines this process as cultural praxis, drawing from Freire’s theory on developing a critical consciousness and understanding cultural humility. Physicians must also understand the systematic problems that lead to inequities in healthcare; the author defines this as structural competence. As in professional identity formation, development of a critical consciousness is an ongoing process that requires reflection, and cultural praxis is more than a set of competencies to be satisfied. This discusses strategies for developing cultural praxis, and provide reflective opportunities in scenarios in which cultural praxis is particularly important, such as in end-of-life care.

Abstract

Background: The COVID-19 pandemic has resulted in a profound transformation of health care delivery toward telemedicine models. Purpose: We present the structure of a nurse-led telephonic palliative program and operational metrics to influence further development of tele-palliative programs. Methods: The nurses engage with seriously ill patients for 6 months with the goal of discussing advance care planning (ACP) and addressing self-identified issues related to their illness. Findings: Of the first 100 program graduates, 78% were actively engaged and 51% named a health care agent and/or engaged in ACP. Of the 18 patients who died during the study, 13 (72%) were enrolled in hospice services. Discussion: Our preliminary results indicate that seriously ill patients are willing to engage with nurses and to participate with discussions on ACP. Conclusion: Given the gaps in health care exposed by the COVID-19 pandemic, this innovative program serves as an important model for bringing palliative care directly to patients.

Abstract

In this chapter, the revised Network Episode Model (NEM) as the basis for a situation-specific theory that provides an explanation of how Malawian women come to make a decision about and act to obtain cervical cancer screening. The situation-specific theory takes into account the uniqueness of Malawian women's individual factors, interpersonal relationships factors, and sociocultural factors. The theory emphasizes the need to attend to the unique factors that influence cervical cancer screening behaviors of women in their unique situations.

Abstract

Patients with diabetes mellitus may experience painful and nonpainful diabetic peripheral neuropathy (DPN). This article offers an overview of DPN and the clinical assessment and management of patients with DPN, as well as the nurse's role in supporting these patients.

Abstract

Objectives: Despite increased risk for chronic disease, there is limited research that has examined disparities in multimorbidity among sexual minority adults and whether these disparities differ by age. Methods: Data were from the 2014–2018 Behavioral Risk Factor Surveillance System. We used sex-stratified multinomial logistic regression to examine differences in multimorbidity between sexual minority and heterosexual cisgender adults and whether hypothesized differences varied across age-groups. Results: The sample included 687,151 adults. Gay, lesbian, and bisexual adults had higher odds of meeting criteria for multimorbidity than same-sex heterosexual adults. These disparities were greater among sexual minority adults under the age of 50 years. Only other non-heterosexual men over the age of 50 years and lesbian women over the age of 80 years were less likely to have multimorbidity than their same-sex heterosexual counterparts. Discussion: Health promotion interventions to reduce adverse health outcomes among sexual minorities across the life span are needed.

Abstract

BACKGROUND: There is limited research on hypertrophic cardiomyopathy (HCM), which is the most common inherited cardiac disorder, in diverse populations, including Black individuals. Current literature lacks comprehensive data on HCM disease expression, comorbidities, and outcomes in this historically disadvantaged group. The purpose of this study was to examine structural HCM characteristics, comorbidities, and outcomes in a Black and White cohort with HCM. METHODS AND RESULTS: The study was a subgroup analysis from a longitudinal, prospective study on HCM, with supplemental chart review. The sample included adults (≥18 years) with a clinical diagnosis of HCM, who self-identified as Black/African American or White. The study sample comprised 434 individuals; 57 (13.1%) were Black, and 180 (41.5%) were women. Black patients were younger than White patients, 54.6 (13.4) versus 62.5 (14.8) years, P=0.001. Black patients were more likely to have sub-basal and diffuse hypertrophy, 22 (38.6%) versus 56 (14.9%), P<0.001, 6 (10.5%) versus 15 (4%), P=0.017, mid-LV obstruction, 7 (12.3%) versus 21 (5.5%), P=0.025, and cardiac fibrosis ≥15%, 10 (22.2%) versus 19 (8.8%), P=0.009, than White patients. Black patients were more likely to experience appropriate implantable cardioverter defibrillator interventions, 5 (38.5) versus 5 (6.8), P<0.001 and were more likely to have ≥2 sudden death risk factors. Comorbidities were largely similar between groups, though more Black participants had Class II obesity, 12 (21.8) versus 30 (8.1), P<0.001. Both groups had similar rates of genetic testing usage. CONCLUSIONS: This study underscores the need for continued research of HCM in Black populations, including tailored approaches to diagnosis and precise evaluation of cardiac anatomy.

Abstract

Background: Disparities in breastfeeding patterns by race and ethnicity in the United States have been documented, and Latinx ethnicity is often associated with higher rates of breastfeeding initiation and longer breastfeeding duration compared to other U.S. racial and ethnic groups. Despite marked differences in infant feeding practices in Latinx countries of origin, U.S. breastfeeding data are routinely presented with Latinx as a single category. Objective: To analyze breastfeeding duration of New York City Latinx mothers by birth region. Methods: Using data from the 2016 New York City Work and Family Leave Survey (WAFLS) surveying residents who gave birth in 2014, we conducted a survival analysis of breastfeeding duration in a sample of Latinx-identifying mothers (n = 271), who reported having ever breastfed their child. Kaplan-Meier survival curves for time to breastfeeding cessation were created for four birth regions (United States, Caribbean, Mexico/Central America, and South America) and compared using the log-rank test. Adjusted hazard ratios (AHRs) were calculated using Cox regression. Results: Survival curves and median breastfeeding duration were significantly different between the four regions. AHR models found that non-Caribbean birthplace was significantly associated with a lower risk of early breastfeeding cessation. Being partnered at the time of childbirth and neonate hospitalization of 6 days or longer was associated with a greater risk of earlier breastfeeding cessation. Conclusion: The significant differences reinforce the need to separate breastfeeding findings by birth region in the Latinx population. Within-group differences are lost in combined analyses and reinforce conclusions that Latinx mothers have optimal breastfeeding behaviors.